Experimental Survey

Experimental Study of Graphic Cigarette Warning Labels

Supporting statement Appendix

Experimental Survey

OMB: 0910-0668

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0910-0668 can be found here:

2012-12-05 - Reinstatement without change of a previously approved collection

Document [pdf]

Download: pdf | pdf

Appendix – Survey Introduction and Questionnaires

Adult Smokers 25 Years Old and Older – Cigarette Pack

[DISPLAY]
Intro1
This study is funded by the U.S. Food and Drug Administration’s (FDA’s) Center for Tobacco Products
(CTP) and conducted by RTI International. For this study, we would like you to complete two surveys –
one now and another in a week or two. Each survey asks about your smoking habits. The content of the
survey may make a few people uncomfortable; however, your participation in this research study is
completely voluntary, and you may skip any questions you do not want to answer. No one will be able to
link your responses to the survey with your identity. Each survey will take about 10 minutes to complete.
If you have any questions about the study, you may call Katherine Kosa of RTI at 1-800-334-8571,
extension 23901. If you have any questions about your rights as a study participant, you may call RTI’s
Office of Research Protection at 1-866-214-2043.
S. Screening Questions
S1.

What is your age?
_________ years
NOT AGE 25+ - NOT ELIGIBLE - terminate
99 I do not wish to answer

[IF S1=99 NOT ELIGIBLE; ELSE GO TO S2]
S 2.

Do you now smoke every day, some days, or not at all?
1 I smoke every day
2 I smoke on some days
3 I do not smoke at all
99 I do not wish to answer

[If S2=1 or S2=2 THEN ELIGIBLE TO CONTINUE; ELSE NOT ELIGIBLE]
B.

SMOKING BEHAVIOR

Have you smoked at least 100 cigarettes in your entire life?
1 Yes
2 No
99 I do not wish to answer

B2.

Are you planning to stop smoking within the next 30 days?
1 Yes
2 No
99 I do not wish to answer

Adult Smokers 25 Years Old and Older – Cigarette Pack

WARM UP

A1.

What is your gender?
1 Male
2 Female
99 I do not wish to answer

A1a. Are you Hispanic or Latino? (Select one.)
1.Yes
2.No
99 I do not wish to answer
A2.

What is your race? Please select one or more.
1
American Indian or Alaska Native
2
Asian
3
Black or African American
5
Native Hawaiian or Other Pacific Islander
6
White
99
I do not wish to answer

A4. Please enter your 5-digit zip code –OR– your city and state.
5-digit zip code: ________________________
–OR–
City: ________________________
State (2 letter abbreviation): ________________________
99
I do not wish to answer
C.

EXPOSURE TO IMAGE/LABEL OCCURS HERE

Next, you will view a pack of cigarettes. This pack of cigarettes is not real but has been made up
for the purpose of this study. After viewing the pack, you will be asked to answer some questions.
NEXT SCREEN, SHOW IMAGE. ALLOW RESPONDENT AS MUCH TIME AS DESIRED TO
VIEW IMAGE(S)
Here is the pack of cigarettes.
REMOVE LABEL IMAGE AND DO NOT ALLOW RESPONDENT TO RETURN TO THE
IMAGE FOR THE REMAINDER OF THE STUDY
D.

WARNING LABELS

Adult Smokers 25 Years Old and Older – Cigarette Pack
i.
j.

Sad
Angry

3
k. Happy
l. Uneasy

D1_b. Think about the pack of cigarettes you just viewed. How much do you agree or disagree with
each of the following statements?
RESPONSE OPTIONS: 1 “Strongly Disagree” 2 “Disagree” 3 “Neither Disagree nor
Agree” 4 “Agree” 5 “Strongly Agree” 99 “I do not wish to answer”
[RANDOMIZE THE FOLLOWING]
a. The pack is worth remembering
b. The pack grabbed my attention
c. The pack is informative
d. The pack is meaningful
e. The pack looks silly
f. The pack is believable
g. The pack is difficult to look at
h. The pack looks cool
D2. How much do you agree or disagree with each of the following statements?
RESPONSE OPTIONS: 1 “Strongly Disagree” 2 “Disagree” 3 “Neither Disagree nor
Agree” 4 “Agree” 5 “Strongly Agree” 99 “I do not wish to answer”
a. I want a cigarette right now.
b. I would do almost anything for a cigarette right now.
D3.

How likely do you think it is that a regular smoker would…?
RESPONSE OPTIONS: 1 “Not at all Likely” 2 “Somewhat Likely” 3 “Moderately Likely”
4 “Very Likely” 5 “Extremely Likely” 99 “I do not wish to answer”
[RANDOMIZE THE FOLLOWING]
a. get cancer
b. have fatal lung disease
c. have heart disease
d. have a stroke
e. become addicted

D4.

How likely do you think it is that regularly breathing second-hand smoke from cigarettes would
cause…?
RESPONSE OPTIONS: 1 “Not at all Likely” 2 “Somewhat Likely” 3 “Moderately Likely”
4 “Very Likely” 5 “Extremely Likely” 99 “I do not wish to answer”
[RANDOMIZE THE FOLLOWING]
a. nonsmokers to get cancer
b. nonsmokers to have fatal lung disease
c. nonsmokers to get heart disease
d. children to have respiratory or breathing problems

ATTITUDES & BELIEFS

E1.

Now, think about your own smoking. Do you think your smoking has affected your health?
1 Yes
2 No
9 I do not wish to answer

Adult Smokers 25 Years Old and Older – Cigarette Pack

E2.

How concerned are you that your smoking has affected your health?
1 Not at all concerned
2 Only slightly concerned
3 Fairly concerned
4 Very concerned
99 I do not wish to answer

E3.

Do you think that your smoking could affect the health of someone else (e.g. spouse, partner,
child, grandchild)?
1 Yes
2 No
99 I do not wish to answer

E4.

How concerned are you that your smoking could affect the health of someone else?
1 Not at all concerned
2 Only slightly concerned
3 Fairly concerned
4 Very concerned
99 I do not wish to answer

E5.

Please tell us how much you agree or disagree with the following statements…
RESPONSE OPTIONS: 1 “Strongly Disagree” 2 “Disagree” 3 “Neither Disagree nor
Agree” 4 “Agree” 5 “Strongly Agree” 99 “I do not wish to answer”
[RANDOMIZE THE FOLLOWING]
a. If I have smoked a pack of cigarettes a day for more than 20 years, there is little health
benefit to me quitting smoking.
b. Many people who smoke live to a ripe old age, so smoking is not all that bad for me.
c. If a woman smokes when pregnant, it will harm her baby.
d. It is hard for a smoker to quit smoking.
e. It is hard for an ex-smoker who quit smoking to stay quit.
f. I do not need help from anyone to quit smoking.
g. I am confident I won’t be smoking a year from now.
h. I should take warnings about cigarette smoking and lung cancer seriously.

CESSATION and INTENTIONS TO QUIT

F1.

During the past 12 months, have you stopped smoking for one day or longer because you were
trying to quit smoking?
1 Yes
2 No
99 I do not wish to answer

F2.

How much do you want to quit smoking?
1 Not at all
2 A little
3 Somewhat
4 A lot
5 No opinion
99 I do not wish to answer

Adult Smokers 25 Years Old and Older – Cigarette Pack

F3.

How likely do you think it is that you will try to quit smoking within the next 30 days?
1 Very unlikely
2 Somewhat unlikely
3 Somewhat likely
4 Very likely
5 No opinion
99 I do not wish to answer

F4.

If you did try to quit smoking within the next 30 days, how likely do you think it is that you
would succeed in quitting?
1 Very unlikely
2 Somewhat unlikely
3 Somewhat likely
4 Very likely
5 No opinion
99 I do not wish to answer

RECALL Questions

H1a.

Do you recall the warning statement on the pack of cigarettes you viewed earlier in the survey?
1 Yes
2 No
99 I do not wish to answer
[IF H1A=1 GO TO H2A; ELSE GO TO H1B]
H2a. Which one of the following warning statements, do you recall seeing on the pack of cigarettes
you viewed earlier in the survey?
[INCLUDE ACTUAL WARNING STATEMENT (without image) VIEWED FOR THAT
RESPONDENT ALONG WITH 4 RANDOMLY SELECTED WARNING STATEMENTS
FROM THOSE NOT VIEWED BY THAT RESPONDENT]
9
Do not recall
99
I do not wish to answer
H1b.

Do you recall seeing a picture on the pack of cigarettes you viewed earlier in the survey?
1 Yes
2 No
99 I do not wish to answer
[IF H1B=1 GO TO H2B; ELSE GO TO I1]
H2b.

Which one of the following pictures, do you recall seeing on the pack of cigarettes you viewed
earlier in the survey?
[INCLUDE ACTUAL IMAGE (2-D view without warning statement) VIEWED FOR
THAT RESPONDENT ALONG WITH 3RANDOMLY SELECTED IMAGES FROM
THOSE NOT VIEWED BY THAT RESPONDENT]
8
There was no picture on the pack I viewed
9
Do not recall
99
I do not wish to answer

Adult Smokers 25 Years Old and Older – Cigarette Pack
I.
I1.

CLOSING QUESTIONS & DEMOGRAPHICS
What type of Internet connection do you have for your home computer or other primary
computer?
1. Highspeed, Broadband, DSL, or Cable
2. Dial up
3. Other
4. Not sure
99 I do not wish to answer

I3.
What is the highest level of school you completed or the highest degree you received?
[ALLOW ONE RESPONSE ONLY]
1
Never attended school
2
Grades K through 8 (Elementary or grade school)
3
Grades 9 through 12 (Some high school)
4
Grade 12 (High school graduate) or GED
5 Some college
6 College graduate
7 Postgraduate/masters/doctorate/law/MD
99
I do not wish to answer
I5.

What was your annual household income from all sources in 2009? Was it…?
1. Less than $25,000
2. Between $25,000 and $49,999
3. Between $50,000 and $74,999
4. More than $75,000
99. I do not wish to answer
END OF SURVEY

"Thank you for taking our survey. If you'd like to learn more about the dangers
of smoking or to get information about quitting smoking please visit: www.smokefree.gov."

Young Adult Smokers Between 18 and 24 Years Old

What is your age?
_________ years
NOT AGE 18-24 - NOT ELIGIBLE - terminate
99 I do not wish to answer
[IF S1=99 NOT ELIGIBLE; ELSE GO TO S2]
S2.

Do you now smoke every day, some days, or not at all?
1 I smoke every day
2 I smoke on some days
3 I do not smoke at all
99 I do not wish to answer
[If S2=1 or S2=2 THEN ELIGIBLE TO CONTINUE; ELSE NOT ELIGIBLE]

SMOKING BEHAVIOR

Have you smoked at least 100 cigarettes in your entire life?
1 Yes
2 No
99 I do not wish to answer

B2.

Are you planning to stop smoking within the next 30 days?
1 Yes
2 No
99 I do not wish to answer

A.
A1.

WARM UP
What is your gender?
1 Male
2 Female
99 I do not wish to answer

Young Adult Smokers Between 18 and 24 Years Old

A1a. Are you Hispanic or Latino? (Select one.)
1. Yes
2. No
99 I do not wish to answer
A2.

What is your race? Please select one or more.
1
American Indian or Alaska Native
2
Asian
3
Black or African American
5
Native Hawaiian or Other Pacific Islander
6
White
99
I do not wish to answer

EXPOSURE TO IMAGE/LABEL OCCURS HERE

WARNING LABELS

Young Adult Smokers Between 18 and 24 Years Old

D4.

ATTITUDES & BELIEFS

E1.

Now, think about your own smoking. Do you think your smoking has affected your health?
1 Yes
2 No
99 I do not wish to answer

Young Adult Smokers Between 18 and 24 Years Old

E2.

How concerned are you that your smoking has affected your health?
1 Not at all concerned
2 Only slightly concerned
3 Fairly concerned
4 Very concerned
99 I do not wish to answer

E3.

Do you think that your smoking could affect the health of someone else (e.g. spouse, partner,
child, grandchild)?
1 Yes
2 No
99 I do not wish to answer

E4.

How concerned are you that your smoking could affect the health of someone else?
1 Not at all concerned
2 Only slightly concerned
3 Fairly concerned
4 Very concerned
99 I do not wish to answer

E5.

E6.

Cigarette smoking is…
RESPONSE OPTIONS: 1 “Strongly Disagree” 2 “Disagree” 3 “Neither Disagree nor
Agree” 4 “Agree” 5 “Strongly Agree” 99 “I do not wish to answer”
[RANDOMIZE THE FOLLOWING]
a. Glamorous
b. Rebellious
c. Cool
d. Disgusting
e. Foolish
[IF CURRENT SMOKER = YES GO TO F1; ELSE GO TO H1a]

F.
F1.

CESSATION and INTENTIONS TO QUIT
During the past 12 months, have you stopped smoking for one day or longer because you were
trying to quit smoking?
1 Yes
2 No
99 I do not wish to answer

Young Adult Smokers Between 18 and 24 Years Old

F2.

How much do you want to quit smoking?
1 Not at all
2 A little
3 Somewhat
4 A lot
5 No opinion
99 I do not wish to answer

F3.

How likely do you think it is that you will try to quit smoking within the next 30 days?
1 Very unlikely
2 Somewhat unlikely
3 Somewhat likely
4 Very likely
5 No opinion
99 I do not wish to answer

F4.

RECALL Questions

H1a.

Do you recall seeing a picture on the pack of cigarettes you viewed earlier in the survey?
1 Yes
2 No
99 I do not wish to answer
[IF H1B=1 GO TO H2B; ELSE GO TO I1]

Young Adult Smokers Between 18 and 24 Years Old

H2b.

I.
I1.

"Thank you for taking our survey. If you'd like to learn more about the dangers
of smoking or to get information about quitting smoking please visit: www.smokefree.gov."

Youth Between 13 and 17 Years Old Susceptible to Initiation

[DISPLAY]
Intro1
This study is funded by the U.S. Food and Drug Administration’s (FDA’s) Center for Tobacco Products
(CTP) and conducted by RTI International. For this study, we would like you to complete two surveys –
one now and another in a week or two. Each survey asks teenagers what they think about cigarette
smoking. Over 3,500 teenagers will complete both surveys. Each survey will take about 10 minutes to
complete.
Your participation in this research study is completely up to you. As part of the survey, you will view
some images related to smoking. You may feel uncomfortable looking at some of the images; however,
you’ve probably seen similar images online or in health class. Also, the survey asks questions about your
experiences and thoughts regarding cigarette smoking; however, you may skip any questions you do not
want to answer. During the survey, we do not ask for your name; therefore, your name will not be
connected to your answers. Furthermore, we will not share any information you provide in the survey
with anyone outside the research team, including your parents.

To ensure your answers are kept private, please complete the survey in a place where no one can look
over your shoulder and view your answers. Also, please complete the survey in one sitting and close the
screen when you are done taking the survey.
If you have any questions about the study, you may call Katherine Kosa of RTI at 1-800-334-8571,
extension 23901. If you have any questions about your rights as a study participant, you may call RTI’s
Office of Research Protection at 1-866-214-2043.
S. Screening Questions
S1.

What is your age?
_________ years
NOT AGE 13997 - NOT ELIGIBLE - terminate
99 I do not wish to answer
[IF S1=99 NOT ELIGIBLE; ELSE GO TO S3]
S3. During the past 30 days, how many days did you smoke a cigarette or take one or two puffs?
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
99
I do not wish to answer
[If S3 ≠ 1 or 99 (CURRENT SMOKER=YES) THEN GO TO B1; ELSE GO TO S4]

Youth Between 13 and 17 Years Old Susceptible to Initiation

S4.

Do you think you will smoke a cigarette anytime during the next year?
1 Definitely yes
2 Probably yes
3 Probably not
4 Definitely not
99 I do not wish to answer

S5.

Do you think you will try a cigarette soon?
1 Definitely yes
2 Probably yes
3 Probably not
4 Definitely not
99 I do not wish to answer

S6.

If one of your best friends offered you a cigarette, would you smoke it?
1 Definitely yes
2 Probably yes
3 Probably not
4 Definitely not
99 I do not wish to answer

[IF S4=S5=S6=4 OR 99 THEN NOT ELIGIBLE (CLOSED TO SMOKING); ELSE GO TO A1]
B.

SMOKING BEHAVIOR

Have you smoked at least 100 cigarettes in your entire life?
1 Yes
2 No
99 I do not wish to answer

B2.

Are you planning to stop smoking within the next 30 days?
1 Yes
2 No
99 I do not wish to answer

WARM UP

A1.

What is your gender?
1 Male
2 Female
99 I do not wish to answer

A1a. Are you Hispanic or Latino? (Select one.)
1.Yes
2.No
99 I do not wish to answer

Youth Between 13 and 17 Years Old Susceptible to Initiation
A2.

What is your race? Please select one or more..
1
American Indian or Alaska Native
2
Asian
3
Black or African American
5
Native Hawaiian or Other Pacific Islander
6
White
99
I do not wish to answer

EXPOSURE TO IMAGE/LABEL OCCURS HERE

WARNING LABELS

D1_a. Think about the pack of cigarettes you just viewed. How much did the pack of cigarettes make
you feel…?
RESPONSE OPTIONS: 1 “Not at all” 2 “A little” 3 “Some” 4 “A lot” 5 “Completely” 99 “I
do not wish to answer”
[RANDOMIZE THE FOLLOWING]
g. Amused
a. Depressed
h. Disgusted or grossed out
b. Worried
i. Sad
c. Annoyed
j. Angry
d. Guilty
k. Happy
e. Discouraged
l. Uneasy
f. Hopeful
D1_b. Think about the pack of cigarettes you just viewed. How much do you agree or disagree with
each of the following statements?
RESPONSE OPTIONS: 1 “Strongly Disagree” 2 “Disagree” 3 “Neither Disagree nor
Agree” 4 “Agree” 5 “Strongly Agree” 99 “I do not wish to answer”
[RANDOMIZE THE FOLLOWING]
a. The pack is worth remembering
b. The pack grabbed my attention
c. The pack is informative
d. The pack is meaningful
e. The pack looks silly

Youth Between 13 and 17 Years Old Susceptible to Initiation

f. The pack is believable
g. The pack was difficult to look at
h. The pack looks cool
D2. How much do you agree or disagree with each of the following statements?
RESPONSE OPTIONS: 1 “Strongly Disagree” 2 “Disagree” 3 “Neither Disagree nor
Agree” 4 “Agree” 5 “Strongly Agree” 99 “I do not wish to answer”
a. I want a cigarette right now.
b. I would do almost anything for a cigarette right now.
D3.

D4.

[IF CURRENT SMOKER= YES GO TO E1; ELSE GO TO E5]
E.

ATTITUDES & BELIEFS

E1.

Now, think about your own smoking. Do you think your smoking has affected your health?
1 Yes
2 No
9 I do not wish to answer

E2.

How concerned are you that your smoking has affected your health?
1 Not at all concerned
2 Only slightly concerned
3 Fairly concerned
4 Very concerned
99 I do not wish to answer

E3.

Do you think that your smoking could affect the health of someone else (e.g. spouse, partner,
child, grandchild)?
1 Yes
2 No

Youth Between 13 and 17 Years Old Susceptible to Initiation

99 I do not wish to answer
E4.

How concerned are you that your smoking could affect the health of someone else?
1 Not at all concerned
2 Only slightly concerned
3 Fairly concerned
4 Very concerned
99 I do not wish to answer

E5.

Please tell us how much you agree or disagree with the following statements…
RESPONSE OPTIONS: 1 “Strongly Disagree” 2 “Disagree” 3 “Neither Disagree nor
Agree” 4 “Agree” 5 “Strongly Agree” 99 “I do not wish to answer”
[RANDOMIZE THE FOLLOWING]
a. If I have smoked a pack of cigarettes a day for more than 20 years, there is little health
benefit to me quitting smoking.
b. Many people who smoke live to a ripe old age, so smoking is not all that bad for me.
c. If a woman smokes when pregnant, it will harm her baby.
d. It is hard for a smoker to quit smoking.
e. It is hard for an ex-smoker who quit smoking to stay quit.
f. [If S3 ≠ 1 or 99] I do not need help from anyone to quit smoking.
g. I am confident I won’t be smoking a year from now.
h. I should take warnings about cigarette smoking and lung cancer seriously.

E6.

[IF CURRENT SMOKER = YES GO TO F1; ELSE GO TO H1A]
F.

CESSATION and INTENTIONS TO QUIT

F1.

During the past 12 months, have you stopped smoking for one day or longer because you were
trying to quit smoking?
1 Yes
2 No
99 I do not wish to answer

F2.

How much do you want to quit smoking?
1 Not at all
2 A little
3 Somewhat
4 A lot
5 No opinion
99 I do not wish to answer

Youth Between 13 and 17 Years Old Susceptible to Initiation

F3.

How likely do you think it is that you will try to quit smoking within the next 30 days?
1 Very unlikely
2 Somewhat unlikely
3 Somewhat likely
4 Very likely
5 No opinion
99 I do not wish to answer

F4.

RECALL Questions

H1a.

I.
I1.

CLOSING QUESTIONS & DEMOGRAPHICS
What type of Internet connection do you have for your home computer or other primary
computer?

Youth Between 13 and 17 Years Old Susceptible to Initiation
1.
2.
3.
4.
99

Highspeed, Broadband, DSL, or Cable
Dial up
Other
Not sure
I do not wish to answer

I2.

What grade or year of school are you currently in?
[ALLOW ONE RESPONSE ONLY]
1
4th grade
2
5th grade
3
6th grade
4
7th grade
5
8th grade
6
9th grade
7
10th grade
8
11th grade
9
12th grade
10
Not currently in school
11
Graduated high school or GED
99 I do not wish to answer

END OF SURVEY

"Thank you for taking our survey. If you'd like to learn more about the dangers of smoking or to
get information about quitting smoking please visit: www.smokefree.gov."

Adult Smokers 25 Years Old and Older – Cigarette Advertisement

What is your age?
_________ years
NOT AGE 25+ - NOT ELIGIBLE - terminate
99 I do not wish to answer
[IF S1=99 NOT ELIGIBLE; ELSE GO TO S2]
S2.

Do you now smoke every day, some days, or not at all?
1 I smoke every day
2 I smoke on some days
3 I do not smoke at all
99 I do not wish to answer

[If S2=1 or S2=2 THEN ELIGIBLE TO CONTINUE; ELSE NOT ELIGIBLE]
B.

SMOKING BEHAVIOR

Have you smoked at least 100 cigarettes in your entire life?
1 Yes
2 No
99 I do not wish to answer

B2.

Are you planning to stop smoking within the next 30 days?
1 Yes
2 No
99 I do not wish to answer

WARM UP

A1.

What is your gender?
1 Male
2 Female
99 I do not wish to answer

Adult Smokers 25 Years Old and Older – Cigarette Advertisement

A1a. Are you Hispanic or Latino? (Select one.)
1. Yes
2. No
99 I do not wish to answer
A2.

What is your race? Please select one or more.
1
American Indian or Alaska Native
2
Asian
3
Black or African American
5
Native Hawaiian or Other Pacific Islander
6
White
99
I do not wish to answer

A4.

Please enter your 5-digit zip code –OR– your city and state.

5-digit zip code: ________________________
–OR–
City: ________________________
State (2 letter abbreviation): ________________________
99
I do not wish to answer

EXPOSURE TO IMAGE/LABEL OCCURS HERE

Next, you will view an advertisement for cigarettes. This advertisement is not real but has been
made up for the purpose of this study. After viewing the ad, you will be asked to answer some questions.
NEXT SCREEN, SHOW IMAGE. ALLOW RESPONDENT AS MUCH TIME AS DESIRED TO
VIEW IMAGE(S)
Here is the advertisement for cigarettes.
REMOVE LABEL IMAGE AND DO NOT ALLOW RESPONDENT TO RETURN TO THE
IMAGE FOR THE REMAINDER OF THE STUDY
D.

WARNING LABELS

D1_a. Think about the ad you just viewed. How much did the ad make you feel…?
RESPONSE OPTIONS: 1 “Not at all” 2 “A little” 3 “Some” 4 “A lot” 5 “Completely” 99 “I
do not wish to answer”
[RANDOMIZE THE FOLLOWING]
g. Amused
a. Depressed
h. Disgusted or grossed out
b. Worried
i. Sad
c. Annoyed
j. Angry
d. Guilty
k. Happy
e. Discouraged
l. Uneasy
f. Hopeful

Adult Smokers 25 Years Old and Older – Cigarette Advertisement

D1_b. Think about the ad you just viewed. How much do you agree or disagree with each of the
following statements?
RESPONSE OPTIONS: 1 “Strongly Disagree” 2 “Disagree” 3 “Neither Disagree nor
Agree” 4 “Agree” 5 “Strongly Agree” 99 “I do not wish to answer”
[RANDOMIZE THE FOLLOWING]
a. The ad is worth remembering
b. The ad grabbed my attention
c. The ad is informative
d. The ad is meaningful
e. The ad looks silly
f. The ad is believable
g. The ad is difficult to look at
h. The ad looks cool
D2. How much do you agree or disagree with each of the following statements?
RESPONSE OPTIONS: 1 “Strongly Disagree” 2 “Disagree” 3 “Neither Disagree nor
Agree” 4 “Agree” 5 “Strongly Agree” 99 “I do not wish to answer”
a. I want a cigarette right now.
b. I would do almost anything for a cigarette right now.
D3.

D4.

ATTITUDES & BELIEFS

E1.

Now, think about your own smoking. Do you think your smoking has affected your health?
1Yes
2 No
99I do not wish to answer

Adult Smokers 25 Years Old and Older – Cigarette Advertisement

E2.

How concerned are you that your smoking has affected your health?
1 Not at all concerned
2 Only slightly concerned
3 Fairly concerned
4 Very concerned
99 I do not wish to answer

E3.

Do you think that your smoking could affect the health of someone else (e.g. spouse, partner,
child, grandchild)?
1 Yes
2 No
99 I do not wish to answer

E4.

How concerned are you that your smoking could affect the health of someone else?
1 Not at all concerned
2 Only slightly concerned
3 Fairly concerned
4 Very concerned
99 I do not wish to answer

E5.

CESSATION and INTENTIONS TO QUIT

F1.

During the past 12 months, have you stopped smoking for one day or longer because you were
trying to quit smoking?
1 Yes
2 No
99 I do not wish to answer

F2.

How much do you want to quit smoking?
1 Not at all
2 A little
3 Somewhat
4 A lot
5 No opinion
99 I do not wish to answer

Adult Smokers 25 Years Old and Older – Cigarette Advertisement

F3.

How likely do you think it is that you will try to quit smoking within the next 30 days?
1 Very unlikely
2 Somewhat unlikely
3 Somewhat likely
4 Very likely
5 No opinion
99 I do not wish to answer

F4.

RECALL Questions

H1a.

Do you recall the warning statement in the ad you viewed earlier in the survey?
1 Yes
2 No
99 I do not wish to answer
[IF H1A=1 GO TO H2A; ELSE GO TO H1B]
H2a.

Which one of the following warning statements, do you recall seeing in the ad you viewed earlier
in the survey?
[INCLUDE ACTUAL WARNING STATEMENT (without image) VIEWED FOR THAT
RESPONDENT ALONG WITH 4 RANDOMLY SELECTED WARNING STATEMENTS
FROM THOSE NOT VIEWED BY THAT RESPONDENT]
9
Do not recall
99
I do not wish to answer

H1b.

Do you recall seeing a picture in the ad you viewed earlier in the survey?
1 Yes
2 No
99 I do not wish to answer
[IF H1B=1 GO TO H2B; ELSE GO TO I1]
H2b.

Which one of the following pictures, do you recall seeing in the ad you viewed earlier in the
survey?
[INCLUDE ACTUAL IMAGE (2-D view without warning statement) VIEWED FOR
THAT RESPONDENT ALONG WITH 3RANDOMLY SELECTED IMAGES FROM
THOSE NOT VIEWED BY THAT RESPONDENT]
8
There was no picture in the ad I viewed
9
Do not recall
99
I do not wish to answer

Adult Smokers 25 Years Old and Older – Cigarette Advertisement
I.

CLOSING QUESTIONS & DEMOGRAPHICS

I1.

What type of Internet connection do you have for your home computer or other primary
computer?
1. Highspeed, Broadband, DSL, or Cable
2. Dial up
3. Other
4. Not sure
99 I do not wish to answer

"Thank you for taking our survey. If you'd like to learn more about the dangers of smoking or to
get information about quitting smoking please visit: www.smokefree.gov."

ADULT SMOKERS AGED 25 AND OLDER: SAMPLE SCREEN SHOTS

Insert Graphic
Warning Here

ADULT SMOKERS AGED 25 AND OLDER: SAMPLE SCREEN SHOTS

Insert Graphic Image Here

ADULT SMOKERS AGED 25 AND OLDER: SAMPLE SCREEN SHOTS

FOLLOW-UP – 1 week follow-up of sub-set of respondents who completed
baseline in first week
A.

RECALL Questions

A1a.

Do you recall the warning statement on the pack of cigarettes you viewed during
the initial survey about 1 week ago?
1 Yes
2 No
99 Choose not to answer

[IF A1A=1 GO TO A2A; ELSE GO TO A1B]
A2a.

Which of the following warning statements, if any, do you recall seeing on the
pack of cigarettes you viewed during the initial survey about 1 weeks ago?
[INCLUDE ACTUAL WARNING STATEMENT VIEWED FOR THAT
RESPONDENT ALONG WITH 4 RANDOMLY SELECTED WARNING
STATEMENTS FROM THOSE NOT VIEWED BY THAT RESPONDENT]
9
Do not recall

A1b.

Do you recall the image, if any, on the pack of cigarettes you viewed earlier in the
survey?
1 Yes
2 No
99 Choose not to answer

[IF A1B=1 GO TO A2B; ELSE GO TO END]
A2b.

Which of the following images, if any, do you recall seeing on the pack of
cigarettes you viewed earlier in the survey?
[INCLUDE ACTUAL IMAGE VIEWED FOR THAT RESPONDENT ALONG
WITH 4 RANDOMLY SELECTED IMAGES FROM THOSE NOT VIEWED BY
THAT RESPONDENT]
8
There was no image on the pack I viewed
9
Do not recall

File Type	application/pdf
File Title	Microsoft Word - FDA survey_adults_pack_10-08-10.docx
Author	cchoinie
File Modified	2010-10-08
File Created	2010-10-08