Example Instrument: Survey for Creative Concept Testing

Form Approved

OMB No. 0920-0910

Exp. Date XX/XX/XXXX

National Tobacco Education Campaign

Online Questionnaire for Creative Concept Testing

Public reporting burden of this collection of information is estimated to average 13 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0910).

{PREAMBLE SHOWN DURING SCREENER}

{Demographics}

{Base: All respondents}

DEMO1. What is your gender?

1. Male

2. Female

3. Prefer not to answer

DEMO3. Ethnicity

{PREAMBLE}

Please indicate your race or ethnic background. Are you….?

SELECT ONE

1. Hispanic or Latino

2. Not Hispanic or Latino

DEMO4. Race

SELECT ONE OR MORE

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Native Hawaiian or Other Pacific Islander

5. Asian

DEMO5a. Do you speak a language other than English at home?

1. Yes 

2. No

{Base: If DEMO5a=01}

DEMO5b. How well do you speak English?

01     Very well

02     Well

03     Not well

04     Not at all

 

DEMO6. Do you consider yourself to be (Select all that apply)?

01 Heterosexual/straight

02 Lesbian

03 Gay

04 Bisexual

05 Transgender

06 Something else – please specify ______________

{Base: All respondents}

SES1. What is the highest level of education you have completed or the highest degree you have received? If you received your education in another country, please indicate the equivalent level below.

1. Less than high school

2. Completed high school

03 Completed General Education Diploma (GED)

04 Job-specific training program(s) after high school

5. Some college, but no degree

6. Associate Degree

7. College (such as B.A., B.S.)

8. Some graduate school, but no degree

9. Graduate degree (such as MBA, MS, M.D., Ph.D.)

10. Prefer not to answer

{Base: All respondents}

SES2. Which of the following income categories best describes your total 2016 household income before taxes?

1. Less than $15,000

2. $15,000 to $19,999

3. $20,000 to $24,999

4. $25,000 to $29,999

5. $30,000 to $34,999

6. $35,000 to $49,999

7. $50,000 to $74,999

8. $75,000 to $99,999

9. $100,000 or more

10. Prefer not to answer

{Base: All respondents}

SES3. Which statement best describes your current employment status?

01 Working – as a paid employee

02 Working – self-employed

03 Not working – on temporary layoff from a job

04 Not working – looking for work

05 Not working – retired

06 Not working – disabled

07 Not working – other

08 Prefer not to answer

{Base: All respondents}

ADQ1. Has a doctor, nurse, or other health professional EVER told you that you have any of the following? (Select all that apply)

1. Anxiety disorder

2. Depression

3. Other mental health condition (specify) ____________________________________

04 None of these {Single select, anchor}

{Base: If ADQ1=04}

ADQ2. Even if a doctor, nurse, or other health professional has not told you that you have any of the following, have you ever considered yourself to have any of the following? (Select all that apply)

1. Anxiety disorder

2. Depression

3. Other mental health condition (specify) ____________________________________

4. None of these {Single select, anchor}

Strata	Definition	Criteria
LOW SES Smokers	Smokers who use only conventional cigarettes and are low-SES	Low SES is based on an index reflecting three dimensions of SES: education, income, and employment. Low-SES if: SES1 = 01, 02, 03, 04 SES2 = 01, 02, 03 SES3 = 03, 04, or 07 The SES index is a composite score of the three items above ranging from 0-3 and is reflected in the dataset as the variable “ses index”. Respondents scoring 0 or 1 are classified as low SES while respondents scoring 2 or 3 are classified as “not low” SES.

{Section: Attitudes and Behaviors}

{Overall Health Impression}

{Base: All respondents}

OH1. How would you rate your health in general?

1. Excellent

2. Very Good

3. Good

4. Fair

5. Poor

{Smoking Behavior}

{PREAMBLE}

The next questions are about traditional cigarettes, which are any form of tobacco wrapped in paper. Traditional cigarettes typically come in packs of 20, and some brand examples include Marlboro, Newport, Camel, Lucky Strike and Pall Mall.

{Base: Respondents who SMOKE EVERY DAY (IF SCREENER.TS2 = 01)}

TS1a. On average, how many traditional cigarettes do you now smoke a day?

{{1 PACK = 20 CIGARETTES}

{{RANGE 1-100}

{Numeric response}

{Base: Respondents who SMOKE ON SOME DAYS (IF SCREENER.TS2 = 02)}

TS1b. On average, on days that you do smoke, how many traditional cigarettes do you now smoke a day?

{{1 PACK = 20 CIGARETTES}

{{RANGE 1-100}

{Numeric response}

{Base: Respondents who SMOKE EVERY DAY (IF SCREENER.TS2 = 01)}

TS2. When do you typically smoke your first traditional cigarette after waking up?

1. Within 5 minutes

2. Within 6-30 minutes

3. Within 31-60 minutes

4. After 60 minutes

{Base: All respondents}

TS3. How old were you the first time you smoked part or all of a traditional cigarette, even one or two puffs?

_ _ _ age in years

777 Don’t know/not sure

999 Prefer not to answer

{E-Cigarette Use}

{PREAMBLE} The next questions are about electronic vapor products. These are devices that usually contain a nicotine-based liquid that produces an aerosol that is inhaled by the user. You may also know them as e-cigarettes, vape-pens, hookah-pens, electronic hookahs (e-hookahs), electronic cigars (e-cigars), electronic pipes (e-pipes), e-vaporizers, or tank systems. Some brand examples are blu, NJOY, Vuse, MarkTen, and Starbuzz. For the rest of this survey we will call all of the products in this category “e-cigarettes”.

{Base: Dual-users ONLY}

TS4a. Does the e-cigarette you usually use contain nicotine?

1. Yes

2. No

3. Don’t Know

4. Prefer not to answer

{Base: Dual users ONLY}

TS5. How old were you the first time you used an e-cigarette, even one or two puffs?

_ _ _ age in years

777 don’t know/not sure

999 prefer not to answer

{Base: Dual users ONLY}

TS5b. How old were you when you started using e-cigarettes, in addition to cigarettes? That is, how old were you when you started using both at the same time?

_ _ _ age in years

777 don’t know/not sure

999 prefer not to answer

{Base: Dual users ONLY}

EU51. Which do you use more, e-cigarettes or traditional cigarettes?

1. I use e-cigarettes more than I smoke traditional cigarettes

2. I smoke traditional cigarettes more than I use e-cigarettes

3. I use both equally

{Quit Attempts}

{Base: All respondents}

QA1. During the past 3 months, how many times have you stopped smoking traditional cigarettes for one day or longer because you were trying to quit smoking traditional cigarettes for good?

_____ Number of times

{Base: If QA1 > 0}

QA2. When you last tried to quit smoking traditional cigarettes, did you do any of the following?

1. YES

2. NO

{ANSWER ALL, RANDOMIZE ORDER}

QA3_A. Give up traditional cigarettes all at once

QA3_B. Gradually cut back on traditional cigarettes

QA3_C. Substitute some of your traditional cigarettes with e-cigarettes such as vape-pens, hookah pens, electronic hookahs (e-hookahs), electronic cigars (e-cigars), electronic pipes (e-pipes), or e-vaporizers

QA3_D. Switch completely to e-cigarettes, vape-pens, hookah-pens, electronic hookahs (e-hookahs), electronic cigars (e-cigars), electronic pipes (e-pipes), or e-vaporizers

QA3_E. Switch to some other brand of traditional cigarettes

QA3_F. Use nicotine replacement products like the nicotine patch, nicotine gum, nicotine lozenges, nicotine nasal spray, or nicotine inhaler

QA3_G. Use medications like Wellbutrin, Zyban, buproprion, Chantix, or varenicline

QA3_H. Get help from a telephone quit line

QA3_I. Get help from a website such as Smokefree.gov

QA3_J. Get help from a doctor or other health professional

QA3_K. Get help from a pharmacist

{Base: All respondents}

QA4. How much do you want to quit smoking traditional cigarettes for good? Would you say you want to quit…

1. Not at all

2. A little

3. Somewhat

4. A lot

{Base: All respondents}

QA5. Do you plan to quit smoking traditional cigarettes for good….

1. In the next 7 days

2. In the next 30 days

3. In the next 6 months

4. In the next 1 year

5. More than 1 year from now

6. I am not planning to quit

7. Not sure/uncertain

{Base: All respondents}

QA8a. If you were to look for information on quitting smoking traditional cigarettes... which of the following would you use? Select all that apply.

1. Online resource, like a website

2. 1-800-QUIT NOW

3. Family or Friends

4. Doctor or Clinic

5. Other specify________________________

{Psychographic/Attitudinal}

{Base: All respondents}

P1. Please rank the top two reasons why you smoke traditional cigarettes where “1” is the main reason and “2” is the second reason.

{RANDOMIZE}

1. Smoking traditional cigarettes is a social thing to do

2. Smoking traditional cigarettes is something to do at parties or other gatherings

3. I’m addicted to smoking traditional cigarettes

4. Smoking traditional cigarettes goes well with/after meals

5. I like the taste of traditional cigarettes

6. Smoking traditional cigarettes helps me relax

7. Smoking traditional cigarettes goes well when I’m drinking alcohol

8. Smoking traditional cigarettes helps me stay awake, alert, or focused

9. Smoking traditional cigarettes helps when I’m stressed

10. Smoking traditional cigarettes excites me

11. Smoking traditional cigarettes is something to do when I’m bored

12. Smoking traditional cigarettes helps me lose weight / not gain weight

13. I have tried to quit smoking traditional cigarettes and cannot

14. Smoking traditional cigarettes is something I can do with others at the work place

15. Other specify__________________ {ANCHOR}

{Base: All respondents}

P5a. Are you afraid of dying from a tobacco-related disease?

1. Yes

2. No

{Base: All respondents}

P5c. Do you think you will die from a tobacco-related disease?

1. Yes

2. No

{Base: All respondents}

P5b. Are you afraid of living with a tobacco-related disease?

1. Yes

2. No

{Base: All respondents}

P5d. Do you think you will get a tobacco-related disease?

3. Yes

4. No

{Base: All respondents}

P6. Please tell us if you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree with the following statements.

{5-Point Agree Scale}

{RANDOMIZE}

P6_10. I get upset when I think about me smoking traditional cigarettes.

P6_11. I am disappointed in myself because I smoke traditional cigarettes.

P6_12. I get upset when I hear or read about illnesses caused by smoking traditional cigarettes.

P6_13. Warnings about the health risks of smoking traditional cigarettes upset me.

P6_14. Smoking traditional cigarettes will severely lower my quality of life in the future.

P6_16. Smokers should take warnings about traditional cigarette smoking and lung cancer seriously.

P6_17. Smoking cigarettes is pleasurable.

P6_18. Smoking cigarettes relieves tension.

P6_19. Smoking helps me concentrate and do better work.

{Base: All respondents}

D21a. Do you believe traditional cigarette smoking can cause…

1. Yes

2. No

D21_1. Lung cancer

D21_2. Cancer of the mouth or throat

D21_3. Heart disease

D21_4. Diabetes

D21_5. Emphysema

D21_6. Stroke

D21_7. Hole in throat (stoma or tracheotomy)

D21_8. Buerger’s Disease

D21_9. Amputations (removal of limbs)

D21_10. Asthma

D21_11. Gallstones

D21_12. COPD or chronic bronchitis

D21_13. Periodontal or gum disease

D21_14. Premature birth

D21_15. Colorectal cancer

D21_16. Macular degeneration or blindness

D21_17. Depression

D21_18. Anxiety Disorder

D21_19. Colon cancer

D210. Please tell us if you agree or disagree with the following statement:

Smoking can cause immediate damage to your body, which can lead to long-term health consequences.

1. Strongly Agree

2. Agree

3. Neither Agree nor Disagree

4. Disagree

5. Strongly Disagree

D211. Please tell us if you agree or disagree with the following statement:

Smoking traditional cigarettes can cause medical complications and diseases that require surgeries and medical procedures to treat.

1. Strongly Agree

2. Agree

3. Neither Agree nor Disagree

4. Disagree

5. Strongly Disagree

{Base: All respondents}

P7a. Does cutting down on traditional cigarettes without quitting completely decrease your risk of getting a tobacco-related disease?

1. Yes

2. No

{Base: All respondents}

P7b. Does replacing some traditional cigarettes by using an e-cigarette decrease your risk of getting a tobacco-related disease?

1. Yes

2. No

{Base: All respondents}

P8. Are you aware of any advertising or tobacco education campaigns against smoking, tobacco products, or tobacco companies that are now taking place?

1. Yes

2. No

{Base: If P8=01}

P9. Please comment on what you remember about these ads or tobacco education campaigns against smoking, tobacco products, or tobacco companies.

{OPEN END}

{Additional Demographic Information}

{Base for this section is all respondents}

DEMO7. Have you ever served on active duty in the U.S. Armed Forces, military Reserves, National Guard, or other military uniformed services?

1. Yes, now on active duty

2. Yes, was on active duty during the past 12 months, but not now

3. Yes, was on active duty but not during the past 12 months

4. Am now with the Reserves or National Guard

5. No, never served in the military

DEMO8. How many children (under age 18) live in your household:

1. None

2. 1-2 children

3. 3-4 children

4. 5 or more children

DEMO9. What is your marital status?

1. Now married

2. Living with my partner

3. Widowed

4. Divorced

5. Separated

6. Never married

7. Prefer not to answer

{Technology/Media}

{Base: All respondents}

T1. Think about the last time you went online to look for information...How did you begin looking?

01 At a search engine such as Google, Bing, or Yahoo

02 At a site that specializes in information, like WebMD

03 At a more general site like Wikipedia, that contains information on all kinds of topics

04 At a social network site like Facebook

05 Other specify________________________

{Base: All respondents}

T2. Do you currently own a cell phone?

1. Yes

2. No

3. Prefer not to answer

{Base: If T2_01=01}
T3. Some cell phones are called "smartphones" because of certain features they have, such as Internet access and the ability to download apps. Do you own a smartphone, such as an iPhone, Android, Blackberry, or Windows phone?

1. Yes, I own a smartphone

2. No, I do not own a smartphone

3. Prefer not to answer

{Section: Creative Concept Testing}

{Display of Creative Concept}

{Programmer Instructions: Each respondent reviews 1 creative concept with audio; randomize creative concepts to respondents to ensure that creative concepts are equally viewed.}

{Preamble}

We would now like to show you an ad and then gather your reactions to that ad. These are not actual ads - they are just ideas of what future ads or commercials could look like.

Please make sure the volume on your computer is turned up, so that you can both see and hear the video. Please click the “forward” arrow to continue. {Each respondent will review one TV ad}

{Programmer instruction: Display selected creative concept by itself for 15 seconds before showing the “next” button”}

{Unaided Response}

{Base: All respondents}

M1. Based on what you read, saw, and heard, what are the first three words that come to mind about the ad you just saw?

{OPEN END}

{Base: All respondents}

M2. What do you believe is the main message of the ad you just saw?

{OPEN END}

{Aided Response (Monadic)}

{Programmer instruction: For the rest of the questions in this section, display the selected treatment description. Rotate the rest of the questions as indicated}

{Base: All respondents}

M3. People sometimes have different emotional reactions when they see ads like the one above.

On a scale from 1 to 5, where 1 indicates not feeling any emotion, and 5 indicates feeling emotion with extreme intensity, please indicate how much this ad made you feel:

1. I did not feel this emotion

2. Slight emotion

3. Moderate emotion

4. Very intense emotion

5. Extreme and intense emotion

{RANDOMIZED}

M3_1. Angry

M3_2. Afraid

M3_3. Ashamed

M3_4. Sad

M3_5. Hopeful

M3_6. Understood

M3_7. Surprised

M3_8. Trusting

M3_9. Motivated

M3_10. Regretful

{Base: All respondents}

M4. On a scale from 1 to 5, where 1 indicates that you strongly disagree, and 5 indicates that you strongly agree, please indicate how much you disagree or agree with the following statements.

1. Strongly disagree

2. Somewhat disagree

3. Neither agree nor disagree

4. Somewhat agree

5. Strongly agree

{RANDOMIZED}

M4_1. This ad is convincing

M4_2. This ad grabbed my attention

M4_3. This ad was easy to understand

M4_4. I learned something new from this ad

M4_5. I trust the information in this ad

M4_6. This ad is believable

M4_7. I would talk to someone else about this ad

M4_8. This ad is annoying

M4_9. This ad is worth remembering

M4_10. This ad is powerful

M4_11. This ad is informative

M4_12. This ad is meaningful

M4_13. I can identify with what this ad says

{Base: All respondents}

M5a. Is there anything about the ad that is confusing, unclear, or hard to understand?

1. Yes

2. No

{Base: If M5a = 01}

M5b. What was confusing, unclear, or hard to understand? Please be as specific as possible.

{Open End}

{Base: All respondents}

M6a. Does this ad make you want to quit smoking traditional cigarettes?

1. Yes

2. No

{Base: Dual users ONLY}

M6b. Does this ad make you want to quit using e-cigarettes?

1. Yes

2. No

{Base: All respondents}

M6c. Does this ad make you think that cutting down on traditional cigarettes is not worth the effort?

1. Yes

2. No

{Base: M6a = 02}

M7. Why doesn’t the ad make you want to quit smoking traditional cigarettes? Please be as specific as possible.

{Open End}

{Base: M6a = 01}

M8. What about the ad made you want to quit smoking traditional cigarettes? Please be as specific as possible.

{Open End}

{Base: All respondents}

M30. On a scale of 1 (not at all) to 5 (extremely), how much did the ad focus on the benefits of quitting smoking traditional cigarettes?

1. Not at all

2. Slightly

3. Moderately

4. Very

5. Extremely

{Base: All respondents}

M31. On a scale of 1 (not at all) to 5 (extremely), how much did the ad focus on the consequences of continuing to smoke traditional cigarettes?

1. Not at all

2. Slightly

3. Moderately

4. Very

5. Extremely

{Base: All respondents}

M32. Please rate the overall tone of the ad on a scale from 1 (extremely negative) to 5 (extremely positive).

1. Extremely negative

2. Somewhat negative

3. Neither positive nor negative

4. Somewhat positive

5. Extremely positive

{General Thank You Message}

Thank you for your participation in this study. We appreciate your enthusiasm for our study and hope you will join us on future surveys!

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