ASQ 7-month Follow-up Questionnaire (English translation

National Quitline Data Warehouse

0856 NQDW Att E4_NQDW_ ASQ_7-Month follow-up questionnaire_ENGLISH

OMB: 0920-0856

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Form Approved

OMB No. 0920-0856

Exp. Date xx/xx/XXXX







Asian Smokers’ Quitline (ASQ)

7-Month Follow-Up Intake Questionnaire (English)











Public reporting burden of this collection of information is estimated to average 7 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 (0920-0856)




Asian Smokers’ Quitline (ASQ)

7-month Evaluation

SERVICE ENGLISH



Hi, this is from the University of California. I'm calling to evaluate the quality of service provided by the Asian Smokers’ Quitline (ASQ). In order to improve the program, I would like to get your feedback on the services that you received. Your feedback will be summarized along with feedback provided by other people who have used the Quitline. You don’t have to answer any questions you don’t want to, and you can end the interview at any time. Also, answering or choosing not to answer questions will not change the quitline services you can or will receive. The call will take just few a minutes, may be monitored or recorded for quality assurance and all of your responses will be kept private. Is that OK?”

1. When you first called, what kind of services did you expect to receive to help you quit smoking?

Shape1

Counseling No expectations

Patches / quitting aids Other _____

Certificate Don’t know

  • Materials/Booklets/Pamphlets Refused

  • Program Information Not Asked












I'd like to ask you some questions about the written materials . . . .


2. Did you receive the materials sent by ASQ?


Yes Don't Know

No / Never received Refused

Not asked


3. Did you read the materials sent by ASQ?


Yes (all or some) Don't Know

No Refused

Not asked


4. Was there anything in particular that you LIKED about the materials?


Yes Don't Know

No / Never received Refused

Not asked



4a. What was it that you liked (about the materials)?

Shape2

Coping Strategies / Alternatives All of it / Everything

Facts / Info Other____

Suggestions / Tips / Advice Don’t Know

County list / other resources Refused

  • Pictures / comics Not Asked










5. Was there anything in particular that you DISLIKED about the materials?

Yes Don't Know/ remember

No Refused

Not asked



5a. What was it you disliked (about the materials)?

Shape3

Didn’t help All of it / Everything

Nothing new Other _____

Too much info / reading Don’t know

Cartoons/comics Refused

Not asked











Now, I would like to ask you some questions regarding ASQ’s counseling services.


6. Did you receive telephone counseling?

Yes Don't Know

No Refused

Not asked


6a. Was there any particular reason for not receiving counseling?

Shape4

No time / busy No reason at all

Counselor didn’t call me Other ______

I didn’t call / I missed counselor’s call Don’t know

  • Didn’t think I needed it /already quit Refused

  • Not ready Not Asked











7. How did you feel about the number of counseling sessions you received, would you say there were too few,

just right or too many?

Too few Don’t know

Just right Refused

Too many Not asked


8. Briefly, how would you describe your counselor? _________________________________________


________________________________________________________________________________


9. How was your counselor in terms of being a good listener, would you say very good, good or not good?

Very good Don’t know

Good Refused

Not good Not asked


10. Was there anything in particular that you LIKED about the counseling?

Yes Don't Know

No Refused

Not asked


10a. What was it that you liked (about the counseling)?

Shape5

Counselor/Someone to talk to/Support All of it / Everything

Information/Advice Other _____

# of Counseling Sessions Don’t know

Counselor Availability Refused

Not asked












11. Was there anything in particular that you DISLIKED about the counseling?

Yes Don't Know

No Refused

Not asked


11a. What was it that you disliked (about the counseling)?

Shape6

# of counseling sessions (high or low) All of it / Everything

Wanted face to face, not phone Other _____

Counselor style / personality Don’t know

Counselor Availability / follow through Refused

Not asked











12. Overall, how comfortable did you feel when talking with ASQ staff? Would you say very comfortable,

comfortable or not comfortable?

Very comfortable Don’t know

Comfortable Refused

Not comfortable Not asked


13. Overall, how satisfied were you with the services you received? Would you say you were very satisfied,

mostly satisfied, somewhat satisfied or not at all satisfied?

Very satisfied Don’t know

Mostly satisfied Refused

Somewhat satisfied Not asked

Not at all satisfied


14. Do you currently smoke cigarettes everyday, some days, or not at all?

Everyday Don’t know

Some days Refused

Not at all Not asked

Smoking


NOT SMOKING ENGLISH


1. When did you quit? Most recent quit date: _______/_______/_______


1a.How long ago did you quit? ______ days/weeks/months/years

2. Since you first called the Asian Smokers’ Quitline (ASQ) on (screen date), how many times have you tried to quit (including this time)?


Number of times: [ ]

Don't remember exactly, at least: [ ]

Number of imposed/unintended quits: [ ]

Refused

Not Asked



3. Out of those times, how many were for 24 hours or more?


Number of times: [ ]

Don't remember exactly, at least: [ ]

Number of imposed/unintended quits: [ ]


Never quit for > 24 hours

Refused

Not Asked



First Quit Attempt


4. When did you first quit for 24 hours or more since (Screen Date)? ______/______/______


a. When did you start smoking on a daily basis after (first attempt date)? ______/______/______


b. How long did you quit for?_____ days/weeks/months/ years

Don’t know

Refused

Not asked

5. (FIRST QUIT ATTEMPT): During the time you quit for (1st quit length), did you have a cigarette (or puff)?


Yes

No

Don’t know

Refused

Not asked

5a. (FIRST QUIT ATTEMPT): When was your first cigarette/puff? ______/______/______


5b. (FIRST QUIT ATTEMPT): How many days in a row did you smoke, including the first day? [________]

(Note to evaluator: if clients states they have smoked EVER SINCE: confirm & go to SMOKING form).

6. (FIRST QUIT ATTEMPT): For this quit attempt, did you use anything like the Nicotine Patch, Gum, Zyban, Chantix or E-cigarettes to help you quit?

Yes

No

Don’t know

Refused

Not Asked



Which ones?




How long did you use them for?




On average, how many did you use per day?




What dosage did you use?



Did you use them BEFORE, DURING and/or AFTER your quit attempt?



Where did you get them?


How much money did you spend on them?





Patch




_______ days/weeks/months


Don’t Know

Refused

Not Asked




NOT ASKED



21mg (step1)

14mg (step2)

7mg (step3)

Other: ____________

D

R

Z




Before

During

After

D

R

Z




Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z



Gum




_______ days/weeks/months


Don’t Know

Refused

Not Asked



_______/day


D

R

Z



2mg 4mg

Other: ____________

D

R

Z



Before

During

After

D

R

Z





Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z




Zyban


_______ days/weeks/months


Don’t Know

Refused

Not Asked



NOT ASKED



NOT ASKED


Before

During

After

D

R

Z




Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z



Chantix/

Varenicline


_______ days/weeks/months


Don’t Know

Refused

Not Asked




NOT ASKED



NOT ASKED



Before

During

After

D

R

Z




Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z




E-cigarettes


_______ days/weeks/months


Don’t Know

Refused

Not Asked




NOT ASKED



High/full/strong (≥ 19mg)

Medium / regular (11-18mg)

Low / Ultra low / light/ ultra-light (1-10mg)

Nicotine, unknown level

No nicotine

D

R

Z



Before

During

After

D

R

Z


Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z




Lozenge


_______ days/weeks/months


Don’t Know

Refused

Not Asked




_______/day


D

R

Z



2mg 4mg

Other: ____________

D

R

Z



Before

During

After

D

R

Z


Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z



Other: ____________________________________

_________



_______ days/weeks/months


Don’t Know

Refused

Not Asked



NOT ASKED



NOT ASKED



Before

During

After

D

R

Z




Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z


D

R

Z









******Last or Only Quit Attempt******

7. Have you had a cigarette, or even a puff, since you quit on (most recent quit date)?


Yes . . . . . When was your first cig./puff? _____/______/______



No

Don’t know

Refused

Not asked


a. What was the situation just before you smoked that cigarette?

_______________________________________________


____________________________________


b. Where did you get the cigarette?

Bought a pack Asked or took from someone

Bought one or a few Other source

Old cigarette pack Don’t know

Someone offered one Refused

Not asked

c. How many days in a row did you smoke, including the first day? _____ day(s).

Ever Since o Don’t know

Refused

Not Asked


d. When was the last time you had a cigarette, or even a puff?

______/______/______


10 was the last time. . . .Go to 11

Don’t know

Refused

Not asked


e. What was the situation just before you smoked that cigarette?

______________________________________________


__________________________________Code: ______



f. Where did you get the cigarette?


Bought a pack Asked or took from someone

Bought one or a few Other source

Old cigarette pack Don't know

Someone offered one Refused Not asked

g. How many days in a row did you smoke, including the first day? ______ day(s).

Ever Since

o Don’t know

Refused

Not Asked


8. Let me confirm… Are you currently smoking cigarettes everyday or some days?


Everyday Don’t know

Some days Refused

Not asked

9a. On average, how many cigarettes do you smoke per day?_______

9b. How many days per week do you smoke? ­­­________

9c. On average how many cigarettes do you smoke per day on the days you smoke? ______


10. How soon after you wake up do you usually smoke your first cigarette?

0-5 mins6-30 mins 31-60 mins More than 60 mins

Don’t know Refused Not asked




11. Since <insert screen date>, did you use anything like the Nicotine Patch, Gum, Zyban, Chantix or E-cigarettes?


IF E ON QUESTION 7c OR 7g & IF CLIENT HAS QUIT ATTEMPT LASTING OVER 24 HRS (that is, there is a value ≥ 1 in Q5): For this quit attempt, did you use anything like the Nicotine Patch, Gum, Zyban, or Chantix to help you quit?


OTHERWISE USE THIS VERSION Did you use anything like the Nicotine Patch, Gum, Zyban, or Chantix to help you quit?


Yes

No

Don’t know

Refused

Not Asked



Which ones?




Are you currently using them?




How long (did you use / have you used) them for?



On average, how many did you use per day?




What dosage did you use?




Did you use them BEFORE your quit attempt?


Where did you get them?



How much money did you spend on them?





Patch




Yes

No

D

R

Z



_______ days/weeks/months


Don’t Know

Refused

Not Asked




NOT ASKED


21mg (step1)

14mg (step2)

7mg (step3)

Other: ____________

D

R

Z



Before

During

After

D

R

Z




Bought

Given to me

Help/Quit line

Insurance

Other: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z


Gum




Yes

No

D

R

Z



_______ days/weeks/months


Don’t Know

Refused

Not Asked



_______/day


D

R

Z



2mg

4mg

Other: ____________

D

R

Z



Yes

No

D

R

Z





Bought

Given to me

Help/Quit line

Insurance

OTHER: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z




Zyban


Yes

No

D

R

Z



_______ days/weeks/months


Don’t Know

Refused

Not Asked



NOT ASKED



NOT ASKED


Yes

No

D

R

Z




Bought

Given to me

Help/Quit line

Insurance

OTHER: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z




Chantix/

Varenicline


Yes

No

D

R

Z



_______ days/weeks/months


Don’t Know

Refused

Not Asked




NOT ASKED



NOT ASKED



Yes

No

D

R

Z




Bought

Given to me

Help/Quit line

Insurance

OTHER: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z





E-cigarettes



NOT ASKED


_______ days/weeks/months


Don’t Know

Refused

Not Asked




NOT ASKED


High/full/strong (≥ 19mg)

Medium / regular (11-18mg)

Low / Ultra low / light/ ultra light (1-10mg)

Nicotine, unknown level

No nicotine

D

R

Z



Yes

No

D

R

Z





Bought

Given to me

Help/Quit line

Insurance

OTHER: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z





Lozenge


Yes

No

D

R

Z



_______ days/weeks/months


Don’t Know

Refused

Not Asked



_______/day


D

R

Z



2mg

4mg

Other: ____________

D

R

Z



Yes

No

D

R

Z





Bought

Given to me

Help/Quit line

Insurance

OTHER: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z




Other: ____________________________________

_________



Yes

No

D

R

Z



_______ days/weeks/months


Don’t Know

Refused

Not Asked



NOT ASKED



NOT ASKED



Yes

No

D

R

Z




Bought

Given to me

Help/Quit line

Insurance

OTHER: _____________

Don’t Know

Refused

Not Asked



$0, Nothing

$1-30

$31-50

$51-100

More than $100

D

R

Z



D

R

Z












12. During this time, did you use any other programs or methods to quit smoking?

(Note to evaluator: these should be separate from quit aids)


Yes… Which one? ­­­­­­­­_______

No

Don't know

Refused

Not asked



13. IF DIDN’T USE ANY QUITTING AID: What was your main reason for deciding not to use any quitting aids?


o Medi-Cal/Insurance plan

o Too expensive

o Side effects

o Do it on my own

o Decided not to quit

o Won’t work for me

o Never received from ASQ

o Delivery took too long

o Other

o Don’t Know

o Refused

o Not Asked


14. Do you currently use any other form of tobacco, such as chew/snuff, cigars or pipes?

Yes

No

Don’t know

Refused


Which ones?

Chew

Cigars

Pipes

Other: ______________


If CHEW/SNUFF: How much tobacco do you use per week?

______________


Don’t know Refused

If CHEW/SNUFF: Is that cans or pouches?

If CIGARS: How many do you smoke per week?

_______________

 

Don’t know Refused


15. If you were to quit today, how confident are you that you could go without smoking for one week, would you say: very confident, confident, or not confident?


How confident are you that you could continue without smoking for one week, would you say: very confident, confident, or not confident?


Very Confident

Confident

Not Confident

Don’t know

Refused

Not asked

16. Briefly what is the most important advice you would offer to someone who‘s trying to quit smoking?

(Was there anything in particular that helped you?)


Advice: ________________________________

None

Don’t know

Refused

Not asked


END EVAL: Those are all the questions I have for you, thank you for your time.

Comments:______________________________________________________________________________


________________________________________________________________________________________


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