M
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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.
Other, please specify: [O] _____
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C5 smoker
survey); NB5 (nonsmoker survey)
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] _____
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M
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D21 Smoker Survey/ NC1
Nonsmoker Suvey [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
Answers
in columns:
1.
Yes
2.
No
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D21 (smoker survey); NC1
(nonsmoker surveyDo
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
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M
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G15. 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_24 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.
Something else [anchor]
Answers
in columns:
1.
Yes
2.
No
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G15.
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
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