SMOKER SURVEY
BASE: If DOV_SMOKER=1
OMB_SMOKER [DISP]
Form Approved
OMB No. 0920-1083
Exp. Date 3/31/2023
Extended Evaluation of the National Tobacco Prevention and Control Public Education Campaign Smoker Questionnaire
Public reporting burden of this collection of information is estimated to average 30 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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1083).
BASE: If A3=2 or ((DOV_SURVEY_1R=1 and ALL_S5=2) or (DOV_SURVEY_1R NE 1 and ABS_S3D=2)) (R is a some day smoker)
A5 [N with range 0-30]
The next few questions are about tobacco use and smoking cessation.
During the past 30 days, that is since [DOV_DATE1], on how many days did you smoke cigarettes?
____ Number of days
Scripter: If A3=1 or ((DOV_SURVEY_1R=1 and ALL_S5=1) or (DOV_SURVEY_1R NE 1 and ABS_S3D=1)) (R is an every day smoker), autofill A5=30
BASE: If DOV_SMOKER=1
B1 [N with range 1-200]
On the average, about how many cigarettes a day do you now smoke? Enter '1' if less than 1 cigarette.
____ Number of cigarettes
BASE: If DOV_SMOKER=1
B2 [S]
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
BASE: If DOV_SMOKER=1
C2 [N with range 0-999]
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.
During the past 3 months, that is, since [DOV_DATE2], 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
BASE: If DOV_SMOKER=1
C2a [N with range C2 value-999]
During the past 6 months, that is since [DOV_DATE4], 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
BASE: If DOV_SMOKER=1
C1 [N with range C2a value-999; if C2a is refused, range C2 value-999]
During the past 12 months, that is, since [DOV_DATE3], 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
BASE: If DOV_SMOKER=1
C3c [S]
In the past 12 months, have you used any of the following medications to help you quit smoking: nicotine skin patch, nicotine gum, nicotine lozenges, nicotine nasal spray, a nicotine inhaler, or pills such as Wellbutrin, Zyban, buproprion, Chantix, or varenicline?
1. Yes
2. No
BASE: If C1>0 or C2>0 or C2a>0
C4 [Grid, S Across]
When you last tried to quit smoking, did you do any of the following?
Statements in row (randomize and record response order):
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 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
Answers in columns:
1. Yes
2. No
BASE: If C1>0 or C2>0 or C2a>0
C5 [Grid, S Across]
When you last tried to quit smoking, did any of the following motivate you to try to quit?
Statements in row:
C5_1. A family member or friend encouraged me to try to quit
C5_2. Anti-tobacco television commercials, online ads or videos, radio ads, or other types of advertisements that focus on the health consequences of smoking
C5_3. My doctor or other health professional advised me to quit smoking
C5_4. Workplace restrictions on smoking
C5_5. Cost of cigarettes is too high
C5_6. Concern about COVID-19
C5_7. Other, please specify: [O] _____
Answers in columns:
1. Yes
2. No
Scripter: If C5_5 = “Yes” but nothing is entered in the verbatim, prompt with “Please tell us what else motivated you to quit smoking.”
BASE: If DOV_SMOKER=1
C6a [S]
Do you want to quit smoking cigarettes for good?
1. Yes
2. No
BASE: If C6a=1
C7b [S]
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
Scripter: If C6a=2, autopunch C7b=1 (not at all)
BASE: If C6a=1
C9 [S]
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
5. More than 1 year from now
6. I do not plan to quit smoking cigarettes for good
7. Not sure/Uncertain
Scripter: If C6a=2, autopunch C9=6 (I do not plan to quit smoking cigarettes for good)
BASE: If DOV_SMOKER=1
C10 [S]
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
BASE: If DOV_SMOKER=1
B8 [S]
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. Some examples of vaping products are pictured below.
[SHOW IMAGE “NEW_VAPE_IMAGE.JPG” centered on screen]
Have you ever vaped, even one time?
1. Yes
2. No
BASE: If B8=1
B8a [S]
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
BASE: If B8=1
B9 [S]
Do you now vape…
1. Every day
2. Some days
3. Not at all
BASE: If B9=1 or B9=2
B9a [S]
On the days that you vape, how often do you vape?
1. Rarely
2. Sometimes
3. Often
4. Very often
BASE: If B9=1 or B9=2
B9b [S]
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 e-cigarette that you use the most.
Disposable devices that are not rechargeable or refillable
Rechargeable devices that use pods or cartridges, like JUULs
Rechargeable devices that have large refillable tanks
Unknown device type
BASE: If B9=1 or B9=2
B9b_1 [S]
When you vape, does the liquid/contents usually contain nicotine?
1. Yes
2. No
3. Don’t know
BASE: If B8=1 and B9 not refused
B10 [M]
Are any of the following a reason why you [B9=3: first tried / B9=1 or 2: currently use] electronic vapor products?
Randomize and record response order, with B10_15 always last
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 [B9=3: shared / B9=1 or 2: shares] their vaping device with me
B10_8. Vaping is popular among people my age
B10_9. I [B9=3: was / B9=1 or 2: am] curious about vaping
B10_10. Other, specify: [O] _____ [anchor]
BASE: If B9=1 or B9=2
B13 [Grid; S Across]
In your opinion, regularly vaping and smoking cigarettes is….
Scripter: Show numbers before answer text.
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
BASE: If B9=1 or B9=2
B14
Do you want to quit vaping for good?
1. Yes
2. No
BASE: If DOV_SMOKER=1
C20 [S]
A telephone quitline is a free telephone-based service that connects people who smoke cigarettes with someone who can help them quit. Have you heard of 1-800-QUIT-NOW?
1. Yes
2. No
BASE: If C20=1
C20a [S]
Have you called 1-800-QUIT-NOW or any other telephone quit line in the past 3 months since [DOV_DATE2]?
1. Yes
2. No
BASE: If C20a=1
C22 [S]
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
BASE: If DOV_SMOKER=1
D18_19 [Grid, S across]
The next few questions will ask about your opinions related to smoking, tobacco use, and cessation.
Please tell us if you strongly disagree, disagree, agree, or strongly agree with the following statements.
Randomize and record response order
Statements in row (randomize list):
D15. Using e-cigarettes and vape products can result in serious lung injury or death.
D18. Smoking can cause immediate damage to your body.
D19. Smoking can cause medical complications and diseases that require surgeries and medical procedures to treat.
Answers in columns:
1. Strongly disagree
2. Disagree
3. Agree
4. Strongly agree
BASE: If DOV_SMOKER=1
D21 [GRID, S ACROSS]
Do you believe cigarette smoking is related to:
Statements in row (randomize and record response order):
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
D21_20. COVID-19
Answers in columns:
1. Yes
2. No
BASE: If DOV_SMOKER=1
E1 [S]
Other than yourself, does anyone who lives in your home smoke cigarettes now?
1. Yes
2. No
BASE: If DOV_SMOKER=1
E8a [S]
In your opinion, how likely is it that regularly breathing secondhand tobacco smoke from cigarettes would worsen asthma or cause infections or lung damage among nonsmokers?
1. Extremely likely
2. Very likely
3. Somewhat likely
4. Very unlikely
5. Extremely unlikely
BASE: If DOV_SMOKER=1
F1 [S]
The next few questions are about media use.
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
BASE: If DOV_SMOKER=1
F2 [S]
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
BASE: If DOV_SMOKER=1
F3 [S]
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
BASE: If DOV_SMOKER=1
F13 [S]
Have you heard of the Website www.cdc.gov/Tips?
1. Yes
2. No
BASE: If F13=1
F13a [S]
Have you visited www.cdc.gov/Tips in the past 3 months, since [DOV_DATE2]?
1. Yes
2. No
BASE: If DOV_SMOKER=1
F14 [S]
In the past 3 months, that is since [DOV_DATE2], have you seen or heard advertisements for medications or products to help people quit smoking such as Chantix, Wellbutrin, Zyban, verenicline, bupoprion, nicotine patches, or nicotine gums?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Always
BASE: If DOV_SMOKER=1
F17 [GRID; S ACROSS]
In the past 3 months, that is since [DOV_DATE2], have you seen or heard of any ads on television or radio with the following themes or slogans?
Statements in row (randomize and record response order):
F17_1. Tips from Former Smokers
F17_2. Truth
F17_3. Every Try Counts
F17_4. This Free Life
F17_5. Fresh Empire
F17_6. The Real Cost
Answers in columns:
1. Yes
2. No
BASE: If DOV_SMOKER=1
F20_1 [S]
Have you seen the following Facebook page or group when you have been online in the past 3 months, since [DOV_DATE2]?
[SHOW IMAGE “Tips Facebook.png” centered on screen]
1. Yes
2. No
BASE: If DOV_SMOKER=1
F20_2 [S]
Have you seen the following YouTube channel or page when you have been online in the past 3 months, since [DOV_DATE2]?
[SHOW IMAGE “Tips Youtube.png” centered on screen]
1. Yes
2. No
BASE: If DOV_SMOKER=1
F20_3 [S]
Have you seen the following Twitter page when you have been online in the past 3 months, since [DOV_DATE2]?
[SHOW IMAGE “Tips Twitter.png” centered on screen]
1. Yes
2. No
BASE: If DOV_SMOKER=1
F21 [Grid, S Across]
Sometimes people use the Internet specifically for health-related reasons. In the past 30 days, have you used the Internet for any of the following reasons?
Statements in row (randomize and record response order):
F21_1. Looked for information about quitting smoking
F21_2. Looked for information vaping (e.g., e-cigarettes or other vaping products)
F21_3. Looked for information about nicotine replacement therapies (e.g., patches, gum, lozenges)
F21_4. Downloaded a mobile App to help you quit smoking
F21_5. Signed up for a texting program to help you quit smoking
F21_6. Created an online plan to help you quit smoking
Answers in columns:
1. Yes
2. No
SMOKER AD SECTION STARTS HERE.
BASE: If DOV_SMOKER=1
SMOKER_VID_INTRO [DISP]
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. 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 the "Next" button below to view the first advertisement. Click or tap on each video to begin playback; the “Next” button will appear once the entire video has been shown.
There is a total of [PPETHM<>4 and DOV_PPETHM_ABS<>4 and ABS_NQRACE1_FRESH=1 (non-Hispanic): 7 ads / PPETHM=4 or DOV_PPETHM_ABS=4 or ABS_NQRACE1_FRESH=2-5 (Hispanic): 8 ads] to view. After you view each ad, there will be a few questions that ask about your opinions of the ad.
BASE: If DOV_SMOKER=1
Scripter: Show all respondents ads 1-5:
1=MICHEAL LIES_15SEC
2=REBECCA BOOT_15SEC
3=ASAAD AND LEAH_15SEC
4=TONYA_15SEC
5=CHRISTINE HEAD OF HOUSEHOLD_15SEC
Scripter: Randomly select and show 2 of ads 6-9:
6=DENISE AND BRIAN_15SEC
7=GERI TEXTING_15SEC
8=SHAWN_15SEC
9=SHARON TREADMILL_15SEC
Scripter: If PPETHM=4 or DOV_PPETHM_ABS=4 or ABS_NQRACE1_FRESH=2-5 (R is Hispanic), randomly select and show one of ads 10-12:
10=BRETT & FELICITA_30SEC
11=JESSICA_15SEC
12=ROSE_15SEC
Scripter: Add “_X” to variable names below that map to ad ID# above. For example:
F21_1 indicates “Were you able to view this video” for MICHAEL LIES.
F21_2 indicates “Were you able to view this video” for REBECCA BOOT .
F21_3 indicates “Were you able to view this video” for ASAAD AND LEAH.
Etc.
BASE: If DOV_SMOKER=1
F21_x [S; prompt once]
Were you able to view this video?
1. Yes
2. No
BASE: If F21_x=2 or refused
F23_x [DISP]
Now we would like to show you some screen shots from a television advertisement that has been shown in the U.S. Please click the arrow to the right of each image to move to the next image.
Once you have viewed all the images, please click the "Next" button below to continue with the survey.
BASE: If F21_x=2 or refused
[DISPLAY STORYBOARD IMAGES FOR AD_X]
BASE: If DOV_SMOKER=1
F24_x [S; prompt once]
Have you seen this ad on television or online in the past 6 months, since March 23, 2020?
1. Yes
2. No
BASE: If F24_x=1
F24a_x_TV [S]
In the past 6 months, since March 23, 2020, how frequently have you seen this ad on television?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Very often
BASE: If F24_x=1
F24a_x_COMPUTER [S]
In the past 6 months, since March 23, 2020, how frequently have you seen this ad on a laptop or desktop computer?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Very often
BASE: If F24_x=1
F24a_x_MOBILE [S]
In the past 6 months, since March 23, 2020, how frequently have you seen this ad on a tablet or smartphone?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Very often
Scripter: Show F25_x – F28_3x for 4 randomly selected ads from ads 1-9
BASE: If DOV_SMOKER=1
F25_x [GRID; S Across]
Please tell us if you strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree with the following statements.
Statements in row (randomize and record response order):
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.
Answers in columns:
1. Strongly disagree
2. Disagree
3. Neither agree nor disagree
4. Agree
5. Strongly agree
BASE: If DOV_SMOKER=1
F26_x [GRID; S ACROSS]
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…
Statements in row (randomize and record response order):
F26a_x. Sad
F26b_x. Afraid
F26d_x. Ashamed
F26f_x. Hopeful
F26g_x. Motivated
F26h_x. Understood
Answers in columns:
1. Not at all
2.
3.
4.
5. Very
BASE: If DOV_SMOKER=1
NEXT_AD [DISP]
Now, we would like you to watch another ad.
Scripter: Repeat the sequence of questions (F21_X through F28_3X) for each of the remaining ads per assignment protocol above
BASE: If DOV_SMOKER=1
Now, we would like you to listen to a streaming radio advertisement that you may have heard 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 audio playback. 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.
[RANDOMLY ASSIGN ALL RESPONDENTS TO LISTEN TO ONE OF THE FOLLOWING ADS]
1=Christine Eating Tip.mp3
2=Brian Heart Attack.mp3
3=Roosevelt Heart Tip.mp3
4=Rebecca Tip.mp3
[PLAY RADIO AD CHOSEN]
[ADD “_x” TO VARIABLE NAMES BELOW THAT MAP TO AD ID # ABOVE. FOR EXAMPLE:
F32_1 indicates “Were you able to listen to this ad” for Christine Radio.
F32_2 indicates “Were you able to listen to this ad” for Brian Radio.
F32_3 indicates “Were you able to listen to this ad” for Roosevelt Radio.
F32_4 indicates “Were you able to listen to this ad” for Rebecca Radio.
[sp]
F35_x. Have you heard this ad streaming or online in the past 3 months, since March 23, 2020?
Yes
No
[IF F35_x=1, ASK F35a_x]
[sp]
F35a_x. In the past 3 months, since March 23, 2020 how frequently have you heard this ad streaming or online?
Rarely
Sometimes
Often
Very Often
BASE: If DOV_SMOKER=1
SMOKER_PRINT_WEB1 [DISP]
Next, you will see some advertisements that have recently appeared on websites. There is 1 set of images to view, followed by a question about whether you have seen these ads before. When you are ready to view them, please click “Next.”
BASE: If DOV_SMOKER=1
SMOKER_PRINT_WEB2 [DISP]
[SHOW IMAGE “Tips 2020 Digital Collage.png” centered on screen]
Please click “Next” to proceed to the next set of questions.
BASE: If DOV_SMOKER=1
F36 [S]
In the past 3 months, since March 23, 2020, have you seen any of these ads on websites or other places online?
1. Yes
2. No
BASE: If F36=1
F37 [S]
Did you see these ads on digital devices such as a smartphone or tablet?
1. Yes
SMOKER AD SECTION ENDS HERE.
BASE: If DOV_SMOKER=1
F38 [S]
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
Demographic Section
BASE: All respondents
G1 [N with range 0-10; prompt once]
Next, how many children aged 17 or younger currently live in your household at least 50% of the time? If none, enter “0”.
Include babies and small children.
Type in the number of children 17 years of age or younger.
Custom refusal prompt: Your answer will help represent the entire U.S. population and will be kept confidential. Thank you!
BASE: If OFFPANEL=1
QEDUC [S]
What is the highest level of school you have completed?
1. Some high school or less – no diploma or GED
2. High school graduate – high school diploma or the equivalent (GED)
3. Some college, no degree
4. Associate degree
5. Bachelor’s degree
6. Master’s degree
7. Professional or Doctorate degree
BASE: If QEDUC=15
QEDUCa [S]
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 or 8th grade
5. 9th grade
6. 10th grade
7. 11th grade
8. 12th grade NO DIPLOMA
SCRIPTER: Create data-only variables:
Variable name: PPEDUC [S]
Variable Text: Education - categorical
Response list:
1. No formal education
2. 1st, 2nd, 3rd or 4th grade
3. 5th or 6th grade
4. 7th 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
QEDUC |
QEDUCa |
PPEDUC |
|
1 |
1 |
|
2 |
2 |
|
3 |
3 |
|
4 |
4 |
|
5 |
5 |
|
6 |
6 |
|
7 |
7 |
|
8 |
8 |
9 |
|
9 |
10 |
|
10 |
11 |
|
11 |
12 |
|
12 |
13 |
|
13 |
14 |
|
14 |
Variable name: PPEDUCAT [S]
Variable Text: Education - categorical
Response list:
1. Less than HS
2. HS
3. Some college
4. Bachelor or higher
QEDUC |
PPEDUCAT |
15 |
1 |
9 |
2 |
10-11 |
3 |
12-14 |
4 |
BASE: If OFFPANEL=1ALL RESPONDENTS
QINC [S; prompt once]
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 [only show with the prompt if question is refused initially]
Custom refusal prompt: We realize that this is personal information. We will ONLY ASK the range of your household income, NOT the exact amount.
BASE: QINC=1
QINC2 [S]
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
BASE: QINC=2
QINC3 [S]
We would like to get a better estimate of your total HOUSEHOLD income in the past 12 months before taxes. Was it...
3. $50,000 to $59,999
4. $60,000 to $74,999
5. $75,000 to $84,999
6. $85,000 to $99,999
7. $100,000 to $124,999
8. $125,000 to $149,999
9. $150,000 to $174,999
10. $175,000 to $199,999
11. $200,000 to $249,999
12. $250,000 or more
SCRIPTER: Create data-only variable:
Variable name: PPINCIMP [S]
Variable Text: HH income – profile and imputed
Response list:
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
12. $50,000 to $59,999
13. $60,000 to $74,999
14. $75,000 to $84,999
15. $85,000 to $99,999
16. $100,000 to $124,999
17. $125,000 to $149,999
18. $150,000 to $174,999
19. $175,000 to $199,999
20. $200,000 to $249,999
21. $250,000 or more
QINC2 |
QINC3 |
PPINCIMP |
1 |
|
1 |
2 |
|
2 |
3 |
|
3 |
4 |
|
4 |
5 |
|
5 |
6 |
|
6 |
7 |
|
7 |
8 |
|
8 |
9 |
|
9 |
10 |
|
10 |
11 |
|
11 |
|
3 |
12 |
|
4 |
13 |
|
5 |
14 |
|
6 |
15 |
|
7 |
16 |
|
8 |
17 |
|
9 |
18 |
|
10 |
19 |
|
11 |
20 |
|
12 |
21 |
BASE: If OFFPANEL=1
QMARIT [S]
Are you now...?
1. Married
2. Widowed
3. Divorced
4. Separated
5. Never married
BASE: If QMARIT=2 to 5 or refused
QPRTNR [S]
Are you currently living with a partner to whom you are not married?
1. Yes
2. No
SCRIPTER: Create data-only variable PPMARIT by using the below logic involving responses to QMARIT AND QPRTNR.
Create numeric variable, PPMARIT, range [1,6]
compute PPMARIT=QMARIT.
if (QPRTNR=1 and QMARIT=5) PPMARIT=6 (living with partner)
BASE: If OFFPANEL=1
E100 [S; prompt once]
Do any of the following currently describe you?
Statements in row:
1. Employed full time (35 hours or more per week) for pay with an organization or company
2. Employed part time (less than 35 hours per week) for pay with an organization or company
3. Self-employed full time (35 hours or more per week)
4. Self-employed part time (less than 35 hours per week)
Answers in columns:
1. Yes
2. No
SCRIPTER: Create DOV_EMPLOYED
If E100_1=1 or E100_2=1 or E100_3=1 or E100_4=1 DOV_EMPLOYED=1.
If E100A=2 and E100B=2 and E100C and E100D=2 DOV_EMPLOYED=2.
Else DOV_EMPLOYED=3.
1. Employed
2. Not employed
3. Refused
BASE: If DOV_EMPLOYED=2
E102 [GRID, S Across]
Do any of the following currently describe you?
Statements in row:
1. Looking for work
2. Unable to work due to a disability
3. On temporary layoff from a job
Answers in columns:
1. Yes
2. No
BASE: If OFFPANEL=1
E104 [GRID, S Across]
Do any of the following currently describe you?
Statements in row:
1. Retired
2. A student
3. A stay-at-home spouse or partner
4. Working in an unpaid job, such as an internship or volunteer position
Answers in columns:
1. Yes
2. No
SCRIPTER: Create data-only variable:
Variable name: QWORK [S]
Variable Text: Current employment status
Response list:
1. Working – as a paid employee
2. Working – self-employed
3. Not working – on temporary layoff from a job
4. Not working – looking for work
5. Not working – retired
6. Not working – disabled
7. Not working – other
Values must be assigned in the order below so that codes at the bottom of the table overwrite codes at the top:
E100 |
DOV_EMPLOYED |
E102 |
E104 |
QWORK |
|
3 |
|
|
Refused |
|
2 |
|
|
7 |
|
|
|
E104_2=1 |
7 |
|
|
|
E104_3=1 |
7 |
|
|
|
E104_4=1 |
7 |
|
|
E102_2=1 |
|
6 |
|
|
|
E104_1=1 |
5 |
|
|
E102_1=1 |
|
4 |
|
|
E102_3=1 |
|
3 |
E100_4=1 |
|
|
|
2 |
E100_2=1 |
|
|
|
1 |
E100_3=1 |
|
|
|
2 |
E100_1=1 |
|
|
|
1 |
BASE: If PPWORK=1 or 2 or QWORK=1 or 2
QWORK2 [S]
Altogether, how many jobs do you have?
1. One
2. Two
3. Three
4. Four or more
BASE: If (OFFPANEL=1 and (QWORK=1 or 2)) or ((PPWORK=1 or 2) and XIND1=MISSING)
IND1 [S]
Think about the industry in which you currently work. Which of the following kinds of industries is it?
[Alternate text if QWORK2=2, 3, or 4]
Think about the industry in which you currently work at your MAIN job. Which of the following kinds of industries is it?
11. Agriculture, Forestry, Fishing and Hunting
21. Mining, Quarrying, and Oil and Gas Extraction
22. Utilities
23. Construction
31-33. Manufacturing
42. Wholesale Trade
44-45. Retail Trade
48-49. Transportation and Warehousing
51. Information
52. Finance and Insurance
53. Real Estate and Rental and Leasing
54. Professional, Scientific, and Technical Services
55. Management of Companies and Enterprises
56. Administrative and Support and Waste Management and Remediation Services
61. Educational Services
62. Health Care and Social Assistance
71. Arts, Entertainment, and Recreation
72. Accommodation and Food Services
81. Other Services and Community/Non-Profit Organizations (except Public Administration)
92. Public Administration
93. Armed Forces
94.Utilities, Waste Management, and Remediation Services
95. Administrative and Support Services (such as Call Centers, Security, Landscaping, and Janitorial)
96. Child Day Care Services
97. Repairs and Maintenance
98. Personal Services (including Beauty, Pet Care, and Household)
100. Community/Non-Profit Organizations (including Religious and Political Organizations)
BASE: All respondents
G9 [S]
How many smoking or tobacco related web surveys like this have you completed during the past year?
1. None
2. 1 survey
3. 2 surveys
4. 3 surveys
5. 4 surveys
6. 5 or more surveys
BASE: All respondents
G10 [S]
Please indicate your current military service status.
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
BASE: All respondents
G11 [GRID, S Across]
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.
Statements in row:
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 use VA health care)
G11_7. Indian Health Service
G11_8. Any other type of health insurance or health coverage plan
Answers in columns:
1. Yes
2. No
BASE: All respondents
G15 [GRID; S Across]
Have you been diagnosed by a physician or other qualified medical professional with any of the following medical conditions?
You may choose not to answer the question by simply clicking “Next”.
Statements in row (randomize and record response order, with G15_25 always last):
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. COVID-19
G15_25. Something else [anchor]
Answers in columns:
1. Yes
2. No
BASE: If OFFPANEL=1 and DOV_RECONTACT=1
G20. [S]
Do you or anyone in this household connect to the Internet from home?
1. Yes
2. No
BASE: If OFFPANEL=1 and DOV_RECONTACT=2
G21 [S]
Do you live in a metro or non-metro area?
1. Non-Metro (Rural)
2. Suburban
3. Urban
BASE: If OFFPANEL=0
KP_THANKS [DISP]
Thank you for completing today’s survey. Your input will greatly help researchers assess the factors that impact quitting smoking.
You will be awarded 15,000 bonus points credited to your KnowledgePanel account for completing the survey.
BASE: If OFFPANEL=1 and DOV_RECONTACT=1
ADD0 [S]
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].
On the next screen, we would like to confirm your mailing information so that we may send you the check. This information will only be used to send you the check and will only be retained until November 2019. We’ll never sell or distribute this information. By completing the following information, you consent to the use of your personal information for the purpose described above.
1. I agree
2. No thank you
If ADD0=2, end survey.
BASE: If OFFPANEL=1 and DOV_RECONTACT=1
Scripter: Prompt if refused with custom text: “Complete and accurate information is needed in order to successfully mail your check”
Scripter: Show MP box next to the NAME_FINAL, ADDRESS_FINAL, CITY_FINAL, STATE_FINAL and ZIP_FINAL fields below
ADD1 [M]
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: [Insert NAME_FINAL from lookup table based on MNO. If NAME_FINAL in look up table is blank, insert: "not provided"]
[SPACE]
2. Mailing Address: [If any part of Address in lookup table (ADDRESS_FINAL, CITY_FINAL, STATE_FINAL, or ZIP_FINAL) is blank, insert: "not provided"]
[Insert ADDRESS_FINAL from lookup table based on MNO]
[Insert CITY_FINAL from lookup table based on MNO]
[Insert STATE_FINAL from lookup table based on MNO]
[Insert ZIP_FINAL from lookup table based on MNO]
[SPACE]
3. All of the above are correct [S]
[SPACE]
4. Prefer not to receive an incentive. [S]
BASE: If Add1=1 or name is missing from spreadsheet and DOV_RECONTACT=1
Scripter: Prompt if refused with custom text “Complete and accurate information is needed in order to successfully mail your check.”
ADD1_1 [O]
Please type in the name to whom you’d like us to send the incentive check:
Name (First/Last): [TEXTBOX]
BASE: If ADD1=2 or any part of address (address_final, city_final, state_final, or zip_final) is missing from spreadsheet and recontact=1
Scripter: Prompt if refused with custom text “Complete and accurate information is needed in order to successfully mail your check.”
ADD1_2 [O]
Please type in the address to where we should send the incentive check:
Street Address (If applicable, include unit number): [TEXTBOX]
City: [TEXTBOX]
State: [TEXTBOX]
Zip Code : [TEXTBOX]
BASE: [If ADD1=1-2]
Scripter: Prompt if refused with custom text “Complete and accurate information is needed in order to successfully mail your check.”
ADD2. [S]
Is the contact information below now up-to-date?
Name: [If asked Add1_1, insert name from Add1_1. If asked Add1_1 and Add1_1= refused, insert: Not provided. If not asked Add1_1, insert Name_Final from look up table based on MNO.]
Mailing Address:
[If not asked Add1_2, insert address from look up table based on MNO]
[If asked Add1_2, insert Street Address from Add1_2. If asked Add1_2 and Street Address=refused, insert: Street address: Not provided]
[If asked Add1_2, insert City from Q1_2. If asked Add1_2 and Add1_2_City=refused, insert: City: Not provided], [If asked Add1_2, insert State from Add1_2. If asked Add1_2 and Add1_2_State=refused, insert: State: Not provided] [If asked Add1_2, insert zip code from Add1_2. If asked Add1_2 and Add1_2_zip=refused, insert: Zip Code: Not provided]
1. Yes
2. No
Scripter: if Add2=refused after prompt, record answer as if respondent had selected 2 (no)
Scripter: if Add2=2; Loop back to Add1
BASE: If sample=abs and DOV_RECONTACT=2
ADD0_NEW [S]
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 AND ABS_G20=1 or -1, $20; IF SAMPLE=ABS and ABS_G20=2: $40].
On the next screen, we would like to confirm your mailing information so that we may send you the check. This information will only be used to send you the check and will only be retained until [FILL DATE]. We’ll never sell or distribute this information. By completing the following information, you consent to the use of your personal information for the purpose described above.
1. I agree
2. No thank you
If ADD0_NEW=2, end survey.
BASE: If sample=abs and DOV_RECONTACT=2
Scripter: Prompt if refused with custom text “Complete and accurate information is needed in order to successfully mail your check.”
ADD1_NEW. [O]
Please provide 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.
After you have entered your information, please make sure to click “Next”.
Name (First/Last): [TEXTBOX]
Street Address (If applicable, include unit number): [TEXTBOX]
City: [TEXTBOX]
State: [TEXTBOX]
Zip Code : [TEXTBOX]
Prefer not to receive an incentive. [S]
BASE: If OFFPANEL=1
CONTACT_A [S]
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
BASE: If CONTACT_A=1
CONTACT_A1 [S]
Is this the address where you would like us to send your next CDC survey invitation?
[Insert Address_Final from look up table based on MNO]
[Insert City_final from look up table based on MNO], [Insert State_final from look up table based on MNO] [Insert Zip_final from look up table based on MNO]
1. Yes
2. No
BASE: If CONTACT_A1=2 or refused
CONTACT_A2. [O]
Please provide us with the address that you would like us to use to send you your next CDC survey invitation.
Street Address (If applicable, include unit number): [TEXTBOX]
City: [TEXTBOX]
State: [TEXTBOX]
Zip Code : [TEXTBOX]
Omit KP closing question QF1
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | SSR Questionnaire Template |
| Author | Nukulkij, Poom (GfK) |
| File Modified | 0000-00-00 |
| File Created | 2022-05-16 |