Smoker Suvey - Wave D

Status: Original and derived artifacts are available for this document.

Download: docx | pdf | html

SMOKER WAVE A-I SURVEY, version 12/5/2018


SUBJECTS FOR QUESTIONNAIRE
SECTION A:	INTRODUCTORY QUESTIONS SECTION B:	TOBACCO USE QUESTIONS SECTION C:	SMOKING CESSATION
SECTION D:	ATTITUDES AND BELIEFS RELATED TO CESSATION SECTION E:	SECONDHAND SMOKE
SECTION F:	MEDIA USE AND AWARENESS SECTION G:	CLOSING QUESTIONS

SECTION A: INTRODUCTORY QUESTIONS A5.
SECTION B: TOBACCO USE QUESTIONS



The next few questions are about tobacco use and smoking cessation.
B1.
On the average, about how many cigarettes a day do you now smoke?

 	Number of cigarettes


B2.
On the days that you smoke, how soon after you wake up do you usually have your first cigarette? Would you say…

    1. Within 5 minutes
    2. 6-30 minutes
    3. From more than 30 minutes to 1 hour
    4. After more than 1 hour


The next few questions ask about your attempts to quit smoking regular cigarettes at different times over the past year. In answering, please think specifically about the timeframe for each question.
C2.
During the past 3 months, how many times have you stopped smoking for one day or longer because you were trying to quit smoking cigarettes for good?

 	Number of times


C2a.
During the past 6 months, that is since [FILL LAUNCH DATE], how many times have you stopped smoking for one day or longer because you were trying to quit smoking cigarettes for good?

 	Number of times


C1.
During the past 12 months, that is, since [DATE FILL], how many times have you stopped smoking for one day or longer because you were trying to quit smoking cigarettes for good?

 	Number of times






C3c.







C4.
When you last tried to quit smoking, did you do any of the following?


1. Yes
2. No






C4_1. Give up cigarettes all at once
C4_2. Gradually cut back on cigarettes
C4_3. Switch completely to vaping (using e-cigarettes, vape pens, JUULs, mods, or other personal vaporizers)
C4_4.  Substitute smoking some of your regular cigarettes with vaping (using e-cigarettes, vape pens, JUULs, mods, or other personal vaporizers)
C4_5. Switch to mild or some other brand of cigarettes
C4_6. Use nicotine replacements like the nicotine patch, nicotine gum, nicotine lozenges, nicotine nasal spray, or nicotine inhaler
C4_7. Use medications like Wellbutrin, Zyban, buproprion, Chantix, or varenicline
C4_8. Get help from a telephone quit line
C4_9. Get help from a website such as Smokefree.gov or CDC.gov/Tips
C4_10. Get help from a doctor or other health professional
C4_11. Get help from a pharmacist
C4_12. Use a mobile App to help you quit smoking
C4_13. Use a texting program to help you quit smoking


































C5.



















C6a.
Do you want to quit smoking cigarettes for good?

    1. Yes
    2. No


C7b.
How much do you want to quit smoking? Would you say you want to quit…

    1. Not at all
    2. A little
    3. Somewhat
    4. A lot
C9.
Do you plan to quit smoking 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, or
    5. More than 1 year from now?
    6. I do not plan to quit smoking cigarettes for good
    7. Not sure/Uncertain


C10.
If you decided to give up smoking altogether in the next 12 months, how likely do you think you would be to succeed? Would you say…

    1. Extremely Likely
    2. Very Likely
    3. Somewhat Likely
    4. Very Unlikely
    5. Extremely Unlikely


C11.
How much do you think your health would improve if you were to quit smoking?

    1. Not at all
    2. A little
    3. Somewhat
    4. A lot




C14.
Among close friends, do…

    1. All of them smoke?
    2. Most of them smoke?
    3. Most of them not smoke?
    4. None of them smoke?




Electronic Vapor Product Questions


The next questions are about vaping (using e-cigarettes, vape pens, JUULs, mods, other personal vaporizers). Vaping products are battery-powered and produce vapor instead of smoke. They typically use a nicotine liquid, although the amount of nicotine can vary and some may not contain any nicotine at all. Some common brands are JUUL, Vuse, MarkTen, Logic, and Blu.

These questions concern electronic vaping products for nicotine use. The use of electronic vaping products for marijuana use is not included in these questions.




B8.
Have you ever vaped, even one time?

    1. Yes
    2. No


B8a.
During the past 30 days, on how many days did you vape?

    1. 0 days
    2. 1 or 2 days
    3. 3 to 5 days
    4. 6 to 9 days
    5. 10 to 19 days
    6. 20 to 29 days
    7. All 30 days


B9.
Do you now vape…

    1. Every day
    2. Some days
    3. Not at all


B9a.

On the days that you vape, how often do you vape?

    1. Rarely
    2. Sometimes
    3. Often
    4. Very Often




B9a.
Do you usually vape with disposable devices, rechargeable devices that use pods or cartridges, or rechargeable devices that use large refillable tanks?

Please indicate the type of device that you vape the most.


    1. Disposable devices that are not rechargeable or refillable
    2. Rechargeable devices that use pods or cartridges, like JUULs
    3. Rechargeable devices that have large refillable tanks
    4. Unknown device type




B9b_1.
When you vape, does the liquid/contents usually contain nicotine?

    1. Yes
    2. No



B10.	Are any of the following a reason why you first tried vaping/currently vape?
1. Yes	2. No

B10_1. I can vape when or where smoking cigarettes is not allowed
B10_2. Vaping might be less harmful to me than smoking cigarettes
B10_3. I like the flavors
B10_4. Vaping can help me quit or cut back on smoking cigarettes
B10_5. Vaping helps me deal with cravings to smoke
B10_6. A friend or family member suggested I vape as a way to quit smoking
B10_7. A friend or family member shared/shares their vaping device with me
B10_8. Vaping is popular among people my age


B13.
In your opinion, regularly vaping and smoking cigarettes is…

1.Much less harmful to one’s health than only smoking cigarettes
2. Slightly less harmful to one’s health than only smoking cigarettes
3. Equally harmful to one’s health as only smoking cigarettes
4. Slightly more harmful to one’s health than only smoking cigarettes
5. Much more harmful to one’s health than only smoking cigarettes.






QUITLINE USE AND AWARENESS

Now, we are going to ask you some additional questions about regular cigarettes.


C18.
A telephone quitline is a free telephone-based service that connects people who smoke cigarettes with someone who can help them quit. Are you aware of any telephone quitline services that are available to help you quit smoking?

    1. Yes
    2. No


C20.
Have you heard of 1-800-QUIT-NOW?

    1. Yes
    2. No


C20a.
Have you called 1-800-QUIT-NOW or any other telephone quit line in the past 3 months since [FILL DATE]?

    1. Yes
    2. No


C22.
In the past 3 months, did you receive any of the following medications for free from the 1-800-QUIT-NOW smokers’ quitline: nicotine patches, gum, lozenges, nasal spray, inhaler, or pills such as Wellbutrin, Zyban, buproprion, Chantix, or varenicline?

    1. Yes
    2. No






SECTION D: ATTITUDES AND BELIEFS RELATED TO CESSATION

The next few questions will ask about your opinions related to smoking, tobacco use, and cessation.

   D8.
Please tell us if you strongly disagree, disagree, agree, or strongly agree with the following statements.

    1. Strongly disagree
    2. Disagree
    3. Agree
    4. Strongly agree



I am eager for a life without smoking.


Concerns About Health


Please tell us if you strongly disagree, disagree, agree, or strongly agree with the following statements.

    1. Strongly disagree
    2. Disagree
    3. Agree
    4. Strongly agree
D10.
I get upset when I think about my smoking.
D11.
I am disappointed in myself because I smoke.
D12.
I get upset when I hear or read about illnesses caused by smoking.
D13.
Warnings about the health risks of smoking upset me.








Risk Perception

Please tell us if you strongly disagree, disagree, agree, or strongly agree with the following statement.


D20.
How likely do you think you are to develop a smoking-related disease as a result of smoking?

    1. Strongly Agree
    2. Agree
    3. Disagree
    4. Strongly Disagree



































D21.
Do you believe cigarette smoking is related to

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



SECTION E: SECONDHAND SMOKE

E1.
Other than yourself, does anyone who lives in your home smoke cigarettes now?

    1. Yes
    2. No




SECTION F: MEDIA USE AND AWARENESS

F1.
On an average day, how much television do you watch?

    1. None
    2. Less than one hour
    3. About 1 hour
    4. About 2 hours
    5. About 3 hours
    6. About 4 hours
    7. 5 hours or more


F2.
On an average day, how many hours do you listen to the radio?

    1. None
    2. Less than one hour
    3. About 1 hour
    4. About 2 hours
    5. About 3 hours
    6. About 4 hours
    7. 5 hours or more
F3.
On an average day, how many hours do you use the Internet for personal reasons?

    1. None
    2. Less than one hour
    3. About 1 hour
    4. About 2 hours
    5. About 3 hours
    6. About 4 hours
    7. 5 hours or more




F13.
Have you heard of the Website www.cdc.gov/Tips?

    1. Yes
    2. No


F13a.
Have you visited www.cdc.gov/Tips in the past 5 months, since [FILL DATE]?

    1. Yes
    2. No


F14.
In the past 5 months, that is since [FILL DATE], have you seen or heard advertisements for medications or products to help people quit smoking such as Chantix, nicotine patches, or nicotine gums?

    1. Never
    2. Rarely
    3. Sometimes
    4. Often
    5. Always
F17.
In the past [FILL # MONTHS PLANNED CAMPAIGN DURATION], that is since [FILL DATE], have you seen or heard of any ads on television or radio with the following themes or slogans?



1. Yes
2. No

F17_1.
TIPS FROM FORMER SMOKERS



F17_2.
TRUTH



F17_3.
BECOME AN EX



F17_4.
EVERY CIGARETTE IS DOING YOU DAMAGE



F17_5.
TOBACCO FREE LIVING



F17_6.
THE REAL COST









F19_1.

F19_2.








F19_3.








F20.














Exposure and Reaction to TV Ads


Now, we would like you to view a series of advertisements that have been shown on television and online in the U.S. Please make sure your computer’s volume is set to an appropriate level. You may be prompted by your computer to download a program enabling video playback. If the videos do not work, you’ll still be able to see images and descriptions of the advertisements. When you are ready, please click on the link below to view the first advertisement.
There is a total of [FILL # TOTAL ADS] ads to view. After you view each ad, there will be a few questions that ask about your opinions of the ad.
F21_x.
Were you able to view this video?

    1. Yes
    2. No



F23_x.
Now we would like to show you some screen shots from a television advertisement that has been shown in the U.S. Once you have viewed the images displayed below, please click on the forward arrow below to continue with the survey.


F24_x.
Have you seen this ad on television or online in the past [FILL # MONTHS SINCE CAMPAIGN LAUNCH] months, since [CAMPAIGN LAUNCH DATE]?

    1. Yes
    2. No


F24a_x_TV.
In the past [FILL # MONTHS SINCE CAMPAIGN LAUNCH] months, how frequently have you seen this ad on television?

    1. Never
    2. Rarely
    3. Sometimes
    4. Often
    5. Very often


F24a_x_ COMPUTER
.
In the past [FILL # MONTHS SINCE CAMPAIGN LAUNCH] months, how frequently have you seen this ad on a laptop or desktop computer?

    1. Never
    2. Rarely
    3. Sometimes
    4. Often



F24a_x_
MOBILE.










F25_x.
Please tell us if you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree with the following statements.

    1. Strongly disagree
    2. Disagree
    3. Neither agree nor disagree
    4. Agree
    5. Strongly agree

F25a_x. This ad is worth remembering. F25b_x. This ad grabbed my attention. F25c_x. This ad is powerful.
F25d_x. This ad is informative. F25e_x. This ad is meaningful to me. F25f_x. This ad is convincing.










F26_x.
On scale of 1 to 5, where 1 means “not at all” and 5 means “very,” please indicate how much this ad made you feel…




1
Not at all
2
3
4
5
Very


F26a_x.
Sad







F26b_x.
Afraid







F26d_x.
Ashamed







F26f_x.
Hopeful







F26g_x.
Motivated







F26h_x.
Understood










For the next few questions, think about all of the advertisements you just viewed and recalled seeing in the past [FILL # MONTHS SINCE CAMPAIGN LAUNCH] months.



Exposure to Radio Ads


Now, we would like you to listen to a radio advertisement that has aired in the
U.S. Please make sure your computer’s volume is set to an appropriate level. You may be prompted by your computer to download a program enabling audio playback. If you cannot hear the audio, you’ll still be able to read a description of the advertisement. There is a total of [FILL # TOTAL RADIO ADS] radio ads to listen to. When you are ready, please click on the link below to listen to the ad. After you listen to the ad, there will be a few questions that ask about your recent recall of the ad.
F32_x.
Were you able to listen to this ad?

    1. Yes
    2. No


F34_x.
Now we would like to show you a script from a radio advertisement that has been shown in the U.S. Once you have read the script displayed below, please click on the forward arrow below to continue with the survey.



F35_x.


Exposure to Display, Print, and Out-of-Home


Next, you will see some advertisements that have recently appeared in magazines, on websites, and on signs in areas such as bus shelters, bus interiors, billboards and other public places. There are 3 sets of images to view, followed by a few questions about whether you have seen these ads before. When you are ready to view them, please click “Next.”
F36.
In the past [FILL # MONTHS SINCE CAMPAIGN LAUNCH], since
[CAMPAIGN LAUNCH DATE], have you seen any of these ads in magazines, on Websites, or in public places outside your home?

    1. Yes
    2. No


F37.
Where did you see these advertisements?

1. Yes	2. No

F37_1.	Magazines or print publications
F37_2.	Websites online


F37a.
In the past XX Months, since [DATE], have you seen any of these ads in public places outside your home such as billboards, bus shelters, or bus interiors?

1. Yes
2. No






















AWARENESS OF E-CIGARETTE ADS

F38.
When you go to a convenience store, supermarket, or gas station, how often do you see ads or promotions for vaping products?

    1. I never go to a convenience store, supermarket, or gas station
    2. Never
    3. Rarely
    4. Sometimes
    5. Most of the time
    6. Always









SECTION G: CLOSING QUESTIONS

G1.
How many people are 17 years of age or younger and currently live in your household at least 50% of the time? If none, enter “0.” Include babies and small children. Your answer will help represent the entire U.S. population and will be kept confidential. Thank you!


 	Number of Children




G5.
What is the highest level of school you have completed?


    1. No formal education
    2. 1st, 2nd, 3rd, or 4th grade
    3. 5th or 6th grade
    4. 7th grade or 8th grade
    5. 9th grade
    6. 10th grade
    7. 11th grade
    8. 12th grade, no diploma
    9. High school graduate – high school Diploma or the equivalent (GED)
    10. Some college, no degree
    11. Associate degree
    12. Bachelor’s degree
    13. Master’s degree
    14. Professional or Doctorate degree



G6.
How much is the combined income of all members of YOUR HOUSEHOLD for the PAST 12 MONTHS? Please include your income PLUS the income of all members living in your household (including cohabiting partners and armed forces members living at home). Please count income BEFORE TAXES and from all sources (such as wages, salaries, tips, net income from a business, interest, dividends, child support, alimony, and Social Security, public assistance, pensions, or retirement benefits).

   1.Below $50,000
   2. $50,000 or more
   3. Don’t Know























G6a.
We would like to get a better estimate of your total HOUSEHOLD income in the past 12 months before taxes. Was it…


   1.Less than $5,000
   2. $5,000 to  $7,499
   3. $7,500 to $9,999
   4. $10,000 to $12,499
   5. $12,500 to $14,999
   6. $15,000 to $19,999
   7. $20,000 to $24,999
   8. $25,000 to $29,999
   9. $30,000 to $34,999
   10. $35,000 to $39,999
   11. 40,000 to $49,999



G6b.
We would like to get a better estimate of your total HOUSEHOLD income in the past 12 months before taxes. Was it…


   1. $50,000 to $59,999
   2. $60,000 to $74,999
   3. $75,000 to $84,999
   6. $85,000 to $99,999
   4. $100,000 to $124,999
   5. $125,000 to $149,999
   6. $150,000 to $174,999
   10. $175,000 to $199,999
   11. $200,000 to $249,999
   12. $250,000 or more





G7.
Are you now…


    1. Married
    2. Widowed
    3. Divorced
    4. Separated
    5. Never married







   G7a.
Are you currently living with a partner to whom you are not married?


    1. Yes
    2. No

























G8.











                   G8a.





































G9.
G10.
Please indicate your current military service status (select one).

    1. Active duty
    2. Reserves
    3. National Guard
    4. Veteran or Armed Services Retiree
    5. Veteran or Retiree with a service connected disability
    6. Civilian: NO military service record



G11.
Are you CURRENTLY covered by any of the following types of health insurance or health coverage plans? Mark “yes” or “no” for each type of coverage.

1. Yes	2. No

G11_1.	Insurance through a current or former employer or union
G11_2.	Insurance purchased directly from an insurance company G11_3.	Medicare, for people age 65 and over, or people with certain disabilities
G11_4.	Medicaid, or any kind of government assistance plan for those with low incomes or disability
G11_5.	TRICARE or other military health care
G11_6.	VA (including those who have ever enrolled for or used VA health care
G11_7.	Indian Health Service
G11_8.		Any other type of health insurance or health coverage plan
G15.
Have you been diagnosed by a physician or other qualified medical professional with any of the following medical conditions?

1. Yes	2. No

G15_1.	Acid reflux disease
G15_2.	ADHD or ADD
G15_3.	Anxiety disorder
G15_4.	Asthma, chronic bronchitis, or COPD
G15_5.	Cancer (any type except skin cancer)
G15_6.	Chronic pain (such as low back pain, neck pain, or Fibromyalgia)
G15_7.	Depression G15_8.	Diabetes G15_9.	Heart attack G15_10.  Heart disease
G15_11. High blood pressure G15_12. High cholesterol G15_13. HIV/AIDS
G15_14. Kidney disease G15_15. Mental health condition G15_16. Multiple sclerosis
G15_17. Osteoarthritis, joint pain or inflammation
G15_18. Osteoporosis or osteopenia G15_19. Rheumatoid arthritis G15_20. Seasonal allergies G15_21. Skin cancer
G15_22. Sleep disorders such as sleep apnea or insomnia
G15_23. Stroke
G15_24. Something else
G20.
Do you or anyone in this household connect to the Internet from home?

    1. Yes
    2. No


G21.
Do you live in a metro or non-metro area?

    1. Non-metro (rural)
    2. Suburban
    3. Urban

		

G22.
Using the scale below, please tell us how much you agree or disagree with the following statements.

    1. Strongly agree
    2. Somewhat agree
    3. Neither agree nor disagree
    4. Somewhat disagree
    5. Strongly disagree

G20a.	I usually try new products before other people do.
G20b.	I often try new brands because I like variety and get bored with the same old thing.
G20c.	When I shop I look for what is new.
G20d.	I like to be the first among my friends and family to try something new.
G20e.	I like to tell others about new brands or technology.



G23.
Do you consider yourself to be…
    1. Heterosexual or straight
    2. Gay
    3. Lesbian
    4. Bisexual
    5. Other, please specify

Thank you for completing today’s survey. Your input will greatly help researchers assess the impact of television ads about quitting smoking.

You will be awarded [AMOUNT] bonus points credited to your KnowledgePanel account for completing the survey. A follow-up survey will be sent to you in about [FILL # MONTHS PLANNED CAMPAIGN DURATION]
and you will be awarded [AMOUNT] bonus points for completing that survey.




ADD1.
Those are all of our questions.  Thanks so much for your participation in our survey.  As a token of our appreciation, we would like to send you $[IF SAMPLE = KP WITHDRAWN, $15; IF SAMPLE=ABS, INSERT INCENTIVE VALUE FROM LOOKUP TABLE based on MNO;  IF SAMPLE=ABS and incentive value is missing from lookup table, insert: $20].

Please verify your name and mailing address so that we can put the check in the mail. To ensure that you will be able to deposit or cash the check, please be sure to provide us with your full first AND last name; if you provide incomplete or inaccurate information, you may not be able to deposit the check. This information will not be connected with your survey responses in any way.

Please select the field(s) that you’d like to update. If all of the information is correct, please select “All of the above are correct”.

1.Name (First/Last):
2.Mailing Address:
3.All of the above are correct




ADD1_1.
Please type in the name to whom you’d like us to send the incentive check:

Name ___________________
ADD1_2.

Please type in the address to where we should send the incentive check:

   Street Address:
   City:
   State:
   Zip Code:


ADD2.

Is the contact information below now up-to-date?

   1. Yes
   2. No

CONTACT_A.

Thank you for your participation in this important study! If you entered your address information on the previous question, your check for participation will arrive in the next 4 – 6 weeks.

The CDC will also have the opportunity to do at least one more survey in the future, with additional rewards and prizes for participation.  Would you be willing to participate in another survey for the CDC?

   1. Yes
   2. No


CONTACT_A1.

Is this the address where you would like us to send your next CDC survey invitation?

   1.Yes
   2. No

CONTACT_A2.

Please provide us with the address that you would like us to use to send you your next CDC survey invitation

   Street Address:
   City:
   State:
   Zip Code:


CONTACT_B.

So that you can participate in the future if you choose to do so, please provide your e-mail address and best phone number to reach you below.  Remember, you can decline to do any survey at that time if you do not want to do it.

   My email address is:
   The best phone number to reach me:


CONTACT2_A.

In case we are unable to reach you through the email address or phone number you provided in the previous question, is there an alternate email address or a phone number to be able to reach?

It is very important for us to hear back from you for future surveys that we will be sending out so we can ensure that the researchers have complete data for this new and important study.

   Alternate Email:
   Alternate phone number to reach you: