Form 5 12 Week Post Quit Date Questionnaire

SFTXT Attachment 19: 12 week Follow Up Survey

Word Questions Pages 2 to 6

Screenshots Pages 7 to 26

OMB No.: 0925-XXXX

Expiration  Date:  xx/xx/20xx

Collection of this information is authorized by The Public Health Service Act, Section 410 (285) and Section 412 (285a-1). Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private to the extent provided by law.  Names and other identifiers will not appear in any report of the study. Information provided will be combined for all study participants and reported as summaries.  In order to provide feedback on its tobacco cessation services, the National Cancer Institute has asked you to complete this voluntary survey.

Public reporting burden for this collection of information is estimated to average 15 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

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INTRODUCTION:

Thank you for taking time from your busy schedule to take part in this research. Your answers will remain confidential – that is, your personal responses will not be traced to your name.

Make sure you are comfortable and can read the screen from where you sit.

The survey will take about 15 minutes to complete. We ask you to complete the survey in one sitting (without taking any breaks) in order to avoid distractions.

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1. Have you smoked cigarettes at all, even a puff, in the last 7 days?

a. Yes [Ask 2 & 3, then skip to #6]

b. No [SKIP TO Q4]

2. On how many days of the past 7 days did you smoke cigarettes, even a puff? If you’re not sure, give your best guess.

(Input number)

3. In the past 7 days, about how many cigarettes did you smoke on the days you smoked? If you’re not sure, give your best guess.

(Input number)

4. Have you smoked cigarettes at all, even a puff, in the last 30 days?

a. Yes [Skip to #6]

b. No [Go to #5]

5. Have you smoked cigarettes at all, even a puff, since your quit date?

   1. Yes [If Yes, ask #6]

   2. No [If No, skip to #7]

6. What is the total number of cigarettes you have smoked since your quit date? If you’re not sure, give your best guess.

   1. 1-2 cigarettes

   2. 3-5 cigarettes

   3. 5-10 cigarettes

   4. More than 10 cigarettes

7. Since your quit date, have you: (SELECT ALL THAT APPLY)

1. Used dissolvable smokeless tobacco, e.g., sticks, strips, or orbs?

2. Smoked bidis, kreteks, or tobacco in a pipe?

3. Smoked flavored cigarettes?

4. Smoked menthol cigarettes?

5. Smoked flavored cigars?

6. Smoked tobacco out of a water pipe - (also called a "hookah")?

7. Used snus?

8. Used an electronic cigarette?

9. None of the above

8. Since your quit date, did you do any of the following to help you stop smoking? (SELECT ALL YOU HAVE TRIED)

1. I did not try to quit since my quit date

2. Attended a program (i.e., in my community or school)

3. Called a help line or quit line

4. Used nicotine gum

5. Used nicotine patch

6. Used some other medicine to help quit

7. Visited an internet quit site

8. Downloaded a Smartphone application focused on helping people quit smoking

9. Got help from family or friends

10. I tried to quit but did something else

11. I tried to quit but did not do any of these things

9. On a scale from 1 to 10 with 10 being extremely motivated and 1 being not at all motivated, how motivated are you to continue working on quitting smoking right now? (check one)

1	2	3	4	5	6	7	8	9	10
Not at all motivated									Extremely motivated

[NOTE TO PROGRAMMER: If Q5 = no, ask 10a for those who have not smoked since their quit date. If Q5 = yes, ask 10b for those who have continued to smoke after their quit date.]

10a. You just indicated that you have not smoked cigarettes at all, even a puff, since your quit date. Please choose the statement that best describes your level of motivation to stay quit:

1. I really want to stay quit.

2. I am thinking about starting smoking again.

3. I really want to start smoking again.

10b. Please choose the statement that best describes your level of motivation:

1. I don't want to stop smoking

2. I think I should stop smoking but don't really want to

3. I want to stop smoking but haven't thought about when

4. I really want to stop smoking but I don't know when I will

5. I want to stop smoking and hope to soon

6. I really want to stop smoking and intend to in the next 3 months

7. I really want to stop smoking and intend to in the next month

11. Do you think that you will be smoking cigarettes one year from now?

a. Definitely yes

b. Probably yes

c. Probably not

d. Definitely not

Since your quit date of ___, which of the following did you use to help you stay off cigarettes?	Yes	No
12. Surrounded myself with others who support my quitting
13. Anticipated and planned for times when I was tempted to smoke
14. Reminded myself why I want to be smokefree
15. Learned my smoking triggers so I could avoid them
16. Avoided social situations that trigger my smoking
17. Had a plan for how to respond when offered a cigarette
18. Managed my stress so I wouldn’t be tempted to smoke
19. Arranged my daily routines to decrease my temptations to smoke

Think about the last time you had a strong craving. Did you do any of the following?	Yes	No
20. Distracted myself by doing something else
21. Asked a friend for support
22. Used gum or mints to keep my mouth busy
23. Found a smokefree place to go
24. Waited for the craving to pass
25. Exercised or did a physical activity

	Not at all confident				Extremely confident
26. I am confident that I will be able to stay off cigarettes for good.	0	1	2	3	4

If you are trying or have tried to quit smoking, to what extent do you agree/disagree with the following 8 statements for you?

	Strongly Disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
27. There are people or resources I can count on for emotional support	1	2	3	4	5
28. I am pretty much on my own.	1	2	3	4	5
29. There are people or resources who can help me find out the answers to my questions.	1	2	3	4	5
30 I have been overwhelmed by the amount of information on quitting smoking.	1	2	3	4	5
31. The information I get on quitting smoking is easy to understand.	1	2	3	4	5
32. I have found it easy to get the information on quitting smoking that I need.	1	2	3	4	5
33. I have the skills and knowledge needed to quit smoking successfully	1	2	3	4	5
34. The resources (things I can read, people I can talk with) that I have had for quitting smoking have been helpful to me.	1	2	3	4	5

35. During the past month, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some of your usual activities?

a. Yes

b. No

c. Not sure

It seems you have skipped the following questions:

DISPLAY SKIPPED QUESTIONS HERE. INCLUDE “SKIP” AS A RESPONSE OPTION

If you skipped these questions by mistake, please click on the question to complete it now.

If you meant to skip the question, please select “I prefer not to answer” next to the question.

CONCLUSION:

This is the end of the survey. To retrieve your gift card for this survey click here [insert link to claim gift card]. We also will send you an email that will contain the link to the gift card if you would like to claim it at a later time. We will send you an email about 3 months from now asking you to complete the last follow-up survey about your experiences with the program and cessation. Thank you so much for your time.

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