Form 2 Pilot Instrument

APPENDIX E: PILOT INSTRUMENT
OMB No.: 0925-0538
Expiration Date: XX/XX/XXXX

1

START HERE:

1.

Is there more than one person age 18 or older living in this household?
Yes
No

GO TO A1 on the next page

2.

Including yourself, how many people age 18 or older live in this household?

3.

The adult with the next birthday should complete this questionnaire. This way,
across all households, HINTS will include responses from adults of all ages.

4.

Please write the first name, nickname or initials of the adult with the next birthday.
This is the person who should complete the questionnaire.

Si prefiere recibir la encuesta en español, por favor llame 1-888-738-6812

STATEMENT OF PRIVACY: Collection of this information is authorized by The Public Health Service Act, Sections 411 (42 USC 285 a) and 412 (42
USC 285a-1.a and 285a1.3). 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 under the Privacy Act and will only be seen by people authorized to work on this project. The report summarizing the
findings will not contain any names or identifying information. Identifying information will be destroyed when the project ends.
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN: Public reporting burden for 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC
7974, Bethesda, MD 20892-7974, ATTN: PRA (0920-0538). Do not return the completed form to this address.

1

A: Looking For Health Information
A1. Have you ever looked for information about
health or medical topics from any source?
Yes
No

A4. In general, how much would you trust
information about health or medical topics
from each of the following?

GO TO A4 in the next column
a. A doctor ....................................................

A2.

The most recent time you looked for
information about health or medical topics,
where did you go first?

b. Family or friends ................................
c.

Mark X only one.

Books
Brochures, pamphlets, etc.
Public Health organization
Family
Friend/Co-worker
Doctor or health care provider
Internet
Library
Magazines
Newspapers
Telephone information number
Complementary, alternative, or unconventional
practitioner

Government health agencies
(e.g., the Food and Drug
Administration (FDA), National
Institutes of Health (NIH) or
Centers for Disease Control and
Prevention (CDC)) ................................

d. Health organizations or groups
(e.g., the American Cancer
Society, American Lung
Association or others) ...............................
e. Charitable organizations ...........................
f.

Religious organizations and
leaders ......................................................

A5. On a typical weekday, about how many
hours do you…
Hours

a. watch television ..........................................

A3.

Based on the results of your most recent
search for information about health or
medical topics, how much do you agree or
disagree with each of the following
statements?

b. listen to the radio ........................................
c. use the internet for personal reasons ........

A6. During a typical weekend, about how many
hours do you…
Hours

a. It took a lot of effort to get the
information you needed ...........................
b. You felt frustrated during your
search for the information ........................
c.

You were concerned about the
quality of the information ..........................

a. watch television ..........................................
b. listen to the radio ........................................
c. use the internet for personal reasons ........

d. The information you found was
hard to understand ................................

A7. In the past seven days, how many days did
you read a newspaper?
days
2

A10. What information did you look for the most
recent time you looked for information about
electronic cigarettes?
Mark X only one.
Health effects
Using electronic cigarettes to quit or reduce
smoking
List of chemicals in electronic cigarettes
Cost/Coupons
Instructions/Tutorials
Where to buy
Reviews/Ratings of brands
Something else – Specify
Electronic cigarettes

Questions A8-A11 are about electronic cigarettes
or e-cigarettes such as those shown in the image
above. You may also know them as vape-pens,
hookah-pens, e-hookahs, or e-vaporizers. Some A11. In general, how much would you trust
look like cigarettes and others look like pens or
information about the health effects of
small pipes. These are battery-powered, usually
electronic cigarettes from each of the
contain liquid nicotine, and produce vapor
following?
instead of smoke.
A8.

Have you ever looked for information on
electronic cigarettes from any source?
Yes
No

a. A doctor/pharmacist/health care
provider .....................................................
GO TO A11 in the next column

b. Family or friends ................................
c.

A9.

What kinds of information on electronic
cigarettes have you ever looked for from
any source?
MarkX all that apply.
Health effects
Using electronic cigarettes to quit or reduce
smoking
List of chemicals in electronic cigarettes
Cost/Coupons
Instructions/Tutorials
Where to buy
How to get free samples
Reviews/Ratings of brands
Something else – Specify

Government health agencies
(e.g., the Food and Drug
Administration (FDA), National
Institutes of Health (NIH), or
Centers for Disease Control and
Prevention (CDC)) ................................

d. Health organizations or groups
(such as the American Cancer
Society, American Lung
Association or others) ...............................
e. Religious organizations and
leaders ......................................................
f.

Tobacco companies ................................

g. Electronic cigarette companies .................

3

A12. Have you ever looked for any of the
A14. Overall, how confident are you that you
following information about tobacco
could get health information about tobacco
products (e.g. cigarettes, cigars, or chewing
products if you needed it?
tobacco) from any source?
Completely confident
Mark X all that apply.

Health effects
Products that claim to reduce exposure to
certain chemicals or present less risk of disease
Quitting help/information
List of chemicals in tobacco products
Cost/Coupons
Instructions/Tutorials
Where to buy
Information about new kinds of
tobacco products
Never looked for any
GO TO A14
of this information
in the next column
Something else – Specify

Very confident
Somewhat confident
A little confident
Not confident at all

A15. In general, how much would you trust
information about the health effects of using
tobacco from each of the following?

a. A doctor/pharmacist/health care
provider .....................................................
b. Family or friends ................................
c.

A13. If you have looked for information about
tobacco products, what information did you
look for the most recent time you looked?
MarkX all that apply.
Health effects
Products that claim to reduce exposure to
certain chemicals or present less risk of disease
Quitting help/information
List of chemicals in tobacco products
Cost/Coupons
Instructions/Tutorials
Where to buy
Information about new kinds of tobacco products
Something else – Specify

Government health agencies
(e.g., the Food and Drug
Administration (FDA), National
Institutes of Health (NIH), or
Centers for Disease Control and
Prevention (CDC)) ................................

d. Health organizations or groups
(such as the American Cancer
Society, American Lung
Association or others) ...............................
e. Religious organizations and
leaders ......................................................
f.

Tobacco companies ................................

4

B: Using the Internet to Find Information
A16. In the past 30 days, how often have you
seen, heard, or read a message about the
health effects of tobacco use from each
of the following sources?

B1.

Do you ever go on-line to access the
Internet or World Wide Web, or to send and
receive e-mail?
Yes
No

B2.

GO TO C1 on the next page

How often do you access the Internet
through each of the following?

a. Television .................................................
b. News websites (e.g. CNN.com) ...............
c.

Health websites (e.g. WebMD.com) ........

d. Government websites (e.g. FDA.gov)
e. Social Media (such as Facebook or
Twitter) .....................................................
f.

Magazine ..................................................

g. Newspaper ...............................................
h. Radio ........................................................
i.

Billboard ...................................................

j.

Public transportation ................................

k.

Mailings ....................................................

l.

Community event ................................

a. Computer at home ................................
b. Computer at work ................................
c.

Computer at school ................................

d. Computer in a public place
(library, community center,
other) ........................................................
e. On a mobile device (cell
phone/smart phone/tablet) .......................
f.

On a gaming device/ “Smart
TV” ............................................................

g. Other .........................................................

m. Point of sale (such as at or inside
convenience stores, drug stores or
supermarkets) ..........................................

B3. Some people notice information about
health on the Internet, even when they are
not trying to find out about a health concern
they have or someone in their family has.
Have you read such health information on
the Internet in the past 12 months?
Yes
No

B4.

GO TO B5 on the next page

About how often have you read this sort of
information in the past 12 months?
Once a month or more
Less than once a month

5

C: Tobacco Product Use
B5. Sometimes people use the Internet
specifically for health-related reasons.

C1.

Have you smoked at least 100 cigarettes in
your entire life?
Yes
No

In the past 12 months, have you used the
Internet for any of the following reasons?
Yes No

a. Looked for health or medical information
for yourself ...............................................

C2.

b. Looked for health or medical information
for someone else .....................................
c.

Everyday
Some days
Not at all
GO TO C4 below

Looked for information about quitting
smoking ....................................................

d. Participated in an online forum or
support group for people with a similar
health or medical issue ............................

C3.

e. Used a website to help you with your
diet, weight, or physical activity ...............
f.

h. Shared health information on social
media sites, such as Facebook or
Twitter ......................................................
i.

Exchanged support about health
concerns with family or friends.................

j.

Kept track of personal health information
such as care received, test results, or
upcoming medical appointments .............

k.

Watched a health-related video on
YouTube...................................................

Are you seriously considering quitting
smoking cigarettes in the next six months?
Yes
No

Looked for a health care provider ............

g. Downloaded health information to a
mobile device, such as an MP3 player,
cell phone, tablet computer, or electronic
book device ..............................................

Do you now smoke cigarettes every day,
some days or not at all?

C4.

GO TO C5 on the next page

About how long has it been since you
completely quit smoking cigarettes?
Less than 2 weeks
2 weeks to less than 1 month ago
1 month to less than 3 months ago
3 months to less than 6 months ago
6 months to less than 1 year ago
1 year to less than 5 years ago
5 years to less than 15 years ago
15 years ago or more

6

C5.

How much do you agree or disagree with
this statement:
“Smoking behavior is something basic
about a person that they can’t change very
much.”
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree

C6. There are a number of resources that people
use to help them stop smoking such as
telephone quitlines (e.g., 1-800-QUIT-NOW)
or websites (e.g., www.smokefree.gov)
Before being contacted for this survey (and
regardless of whether or not you smoke),
had you ever heard of telephone quitlines
or websites for help with quitting smoking?
Yes
No

C7.

GO TO C9 in the next column

Have you ever called a telephone quitline or
visited a website for help with quitting
smoking?
Yes
No

C8.

How likely would you be to call a quitline or
visit a website for help with quitting smoking
in the future?
Very likely
Somewhat likely
Somewhat unlikely
Very unlikely

Size of cigars, cigarillos, litte filtered cigars and
cigarettes.

C9.

How many cigars, cigarillos, or little
filtered cigars have you smoked in your
entire life? Some popular brands include
Macanudo, Romeo y Julieta, Black and
Mild, Swisher Sweets, Prime Time, and
Cheyenne.
None
1-10
11-20
21-50
51-99
100 or more

C10. Do you now smoke cigars, cigarillos, or little
cigars every day, some days or not at all?
Everyday
Some days
Not at all
GO TO C12 on the next page

C11. Is the size of the cigars, cigarillos, or little
filtered cigars that you usually smoke…
Mark X only one.
Regular or large cigars like Macanudo, Romeo
y Julieta, Arturo Fuente, or others
Medium cigars or cigarillos like Black and
Mild, Swisher Sweets, Dutch Masters, Phillies
Blunts, or others
Little filtered cigars like Prime Time little
filtered cigars, Winchester little filtered cigars, or
others

7

Please refer to the images on the right side of this
page to answer questions C12 - C15.
C12. Before this survey, which of the following
tobacco products have you ever heard of?
Mark X all that apply.

C15. Do you now use chewing tobacco, snus,
snuff, or dip every day, some days or not at
all?
Everyday
Some days
Not at all

Hookah or water pipe filled with tobacco
Electronic Cigarettes or e-cigarettes (such as
VUSE, blu, or Logic), also known as vape-pens,
hookah pens, e-hookahs, or e-vaporizers
Pipe filled with tobacco
“Roll your own” cigarettes
Snus (such as Camel snus, General snus,
Marlboro snus, and Nordic Ice)
I have not heard of any of these tobacco
products
GO TO C14 below

C13. Which of the following tobacco products
have you ever tried even once?

Image 1. Hookah/water pipe

Mark X all that apply.
Hookah or water pipe filled with tobacco
Pipe filled with tobacco
“Roll your own” cigarettes
Snus (such as Camel snus, General snus,
Marlboro snus, and Nordic Ice)
I have never tried any of these tobacco
products
Have you ever used an e-cigarette, even one or two
times?
Yes
No (SKIP next questions)

Image 2. Electronic cigarettes

Do you now use an e-cigarette every day,
some days or not at all?
Everyday
Some days
Not at all

C14. Have you used chewing tobacco, snus,
snuff, or dip, at least 20 times in your entire
life? Some popular brands include Grizzly,
Copenhagen, Skoal, or Redman.
Yes
No

Image 3. Snus

8

C16. Were any of the tobacco products you used
in the past 30 days flavored to taste like
menthol (mint), clove, spice, alcohol (wine,
cognac), candy, fruit, chocolate, or other
sweets?
Yes
No
Don’t know
I have not used any tobacco products in the past
30 days.

C19. How much do you agree or disagree with
the following statements?

a. Nicotine is the main
substance in tobacco that
makes people want to
smoke ..................................
b. The nicotine in cigarettes is
the substance that causes
most of the cancer caused
by smoking ...........................

C17. Of the five closest friends or acquaintances
that you spend time with on a regular basis,
how many of them use any kind of
tobacco?
0
1
2
3
4
5

c. Addiction to nicotine is
something that I am
concerned about ..................

C20. Overall, how addictive do you believe each
of the following is?

a. Cigarette smoking ................................

C18. How soon after you wake up do you usually
use any tobacco product?

b. Cigar smoking ................................

I do not use tobacco products
Within 5 minutes
From 6 to 30 minutes
From 31 to 60 minutes
After 60 minutes
I rarely want to use a tobacco product

d. Using electronic cigarettes or
e-cigarettes (also known as
vape-pens, e-hookahs, or
e-vaporizers) ................................

c.

Smokeless tobacco use ............................

e. Smoking tobacco in a hookah ..................
f.

Smoking “roll your own”
cigarettes ..................................................

g. Smoking a pipe filled with
tobacco .....................................................

9

D: Beliefs about Tobacco Products
D1.

In the past year, how often have you
thought about the chemicals contained in
tobacco products?

D5.

No harm
Little harm
Some harm
A lot of harm

Never
Rarely
Sometimes
Often

D2.

Where do you think the chemicals in
cigarettes and cigarette smoke come from?

How much do you think people harm
themselves when they smoke 10 or more
cigarettes every day?

D6.

How harmful do you think each of the
following is to a person’s health?

Mark X only one.
All the chemicals come from the tobacco leaf
Most of the chemicals come from the tobacco
leaf
The chemicals come equally from the tobacco
leaf and things added to the tobacco
Most of the chemicals come from things added to
the tobacco
All the chemicals come from things added to the
tobacco
I do not believe there are any chemicals in
cigarettes and cigarette smoke

D3.

How long do you think someone has to
smoke cigarettes before it harms their
health?
Less than 1 year
1 year
5 years
10 years
20 years or more

D4.

How much do you think people harm
themselves when they smoke a few
cigarettes every day?

a. Cigarette smoking ................................
b. Cigar smoking ...........................................
c.

Smokeless tobacco use ............................

d. Electronic cigarette use ............................
e. Smoking tobacco in a hookah ..................
f.

Smoking “roll your own” cigarettes ...........

g. Smoking a pipe filled with tobacco ...........

D7.

New types of cigarettes are now available
called electronic cigarettes or e-cigarettes
(also known as vape-pens, hookah pens, ehookahs, or e-vaporizers). These products
deliver nicotine through a vapor. Compared
to smoking cigarettes, would you say that
electronic cigarettes are …
Much less harmful
Less harmful
Just as harmful
More harmful
Much more harmful
I don’t know enough about these products

No harm
Little harm
Some harm
A lot of harm

10

D8.

In your opinion, do you think that some
smokeless tobacco products, such as
chewing tobacco, snus and snuff, are less
harmful to a person's health than
cigarettes?
Yes
No
Don’t know

D9. How much do you think people harm
themselves when they use smokeless
tobacco, such as chewing tobacco, snuff,
dip, or snus, every day?
No harm
Little harm
Some harm
A lot of harm

D10. How much do you think people harm
themselves when they use smokeless
tobacco, such as chewing tobacco, snuff,
dip, or snus, some days but not every day?
No harm
Little harm
Some harm
A lot of harm

D11. Please indicate how much you agree or
disagree with the following statement:

D13. Do you believe that anyone regulates
statements from tobacco companies about
the contents or health effects of their
tobacco products?
Yes
No
Don’t
know

GO TO D15 below

D14. Who do you believe regulates
statements that tobacco companies make
about the contents or health effects of their
tobacco products?
Mark X all that apply.
Centers for Disease Control and Prevention
(CDC)
Federal Trade Commission (FTC)
Food and Drug Administration (FDA)
National Institutes of Health (NIH)
Surgeon General
Tobacco industry/tobacco companies
None of the above

D15. Do you believe that the United States Food
and Drug Administration (FDA) regulates
tobacco products in the U.S.?
Yes
No
Don’t know

“Tobacco is safer to use now than it was
5 years ago.”
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree

D12. In your opinion, do you think that some
types of cigarettes are less harmful to a
person's health than other types?

D16. In your opinion, how qualified is the United
States Food and Drug Administration (FDA)
to regulate tobacco products?
Not at all
A little
Somewhat
Very

Yes
No
Don’t know
11

E: Beliefs About Cigarette Claims
E1.

Do you think a tobacco product that says it has
no additives is less harmful, about the same, or
more harmful than a regular tobacco product?

Compared to a typical cigarette, would you
think that a cigarette advertised as “low
nicotine” would be…

Much less harmful to your health than a typical
cigarette?
Slightly less harmful to your health than a typical
cigarette?

Much less harmful to your health than a typical
cigarette?

Equally harmful to your health as a typical
cigarette?

Slightly less harmful to your health than a typical
cigarette?

Slightly more harmful to your health than a
typical cigarette?

Equally harmful to your health as a typical
cigarette?
Slightly more harmful to your health than a
typical cigarette?
Much more harmful to your health than a typical
cigarette?

Much more harmful to your health than a typical
cigarette?

Do you think a tobacco product that says it is
organic is less harmful, about the same, or more
harmful than a regular tobacco product?
Much less harmful to your health than a typical
cigarette?

Compared to a typical cigarette, would you think
that a cigarette advertised as “low nicotine”
would have…

Slightly less harmful to your health than a typical
cigarette?

Much lower risk of causing lung cancer than a
typical cigarette

Equally harmful to your health as a typical
cigarette?

Slightly lower risk of causing lung cancer than a
typical cigarette

Slightly more harmful to your health than a
typical cigarette?

Equal risk of causing lung cancer than a typical
cigarette
Slightly higher risk of causing lung cancer than a
typical cigarette

Much more harmful to your health than a typical
cigarette?

E4.

Much higher risk of causing lung cancer than a
typical cigarette

E2.

Very likely
Somewhat likely
Somewhat unlikely
Very unlikely

Compared to a typical cigarette, would you
think that a cigarette advertised as “low
nicotine” would be…
Much less addictive than a typical cigarette?

E5.

Slightly less addictive than a typical cigarette?
Equally addictive as a typical cigarette?
Slightly more addictive than a typical cigarette?

How believable is it that a cigarette could
be “low nicotine”?
Not at all believable
A little believable
Somewhat believable
Very believable

If a tobacco product made a claim that it
was less addictive than other tobacco
products, how likely would you be to use
that product?
Very likely
Somewhat likely
Somewhat unlikely
Very unlikely

Much more addictive than a typical cigarette?

E3.

How likely do you think it is that tobacco
products could be made without some of the
chemicals that are harmful to health?

E6.

If a tobacco product made a claim that it
was less harmful to health than other
tobacco products, how likely would you be
to use that product?
Very likely
Somewhat likely
Somewhat unlikely
Very unlikely
12

F: Dietary Supplements
These next questions ask about dietary
supplements such as vitamins, minerals, herbs,
and other supplements that you may take in
addition to your regular diet.

F1.

F3.

MarkX all that apply.

Heart problems/chest pain
Abdominal pain
Headache
Rashes
Allergy/reaction
Nausea
Blood pressure problems
Diarrhea
Cramping/muscle aches
Sleep problems
Dizziness/fainting
Itching
Anxiety/nervousness
Drowsiness
Vomiting
Other symptom -Specify

Please indicate whether or not you have
taken one or more of the following types of
dietary supplement(s) in the past 12
months:
Yes No

a. Multi-vitamins or multi-mineral
supplements, such as One-A-Day,
Mega-Vitamin, or Centrum Silver .............
b. Specialized or single-ingredient vitamins
or minerals, such as calcium, Vitamin B,
or magnesium ..........................................
c.

F2.

Herbs, botanicals, or other supplements
(not including vitamins or minerals), such
as Echinacea, ginkgo, fish oil, garlic pills,
or glucosamine .........................................

In the past 12 months, have you
experienced any health problem that you
thought might be related to any dietary
supplements you took?
Yes
No GO TO F6 on the next page

The last time you had such a problem, what
were the major symptoms of the problem?

F4.

What supplement(s) did you think
was(were) related to your problem?
MarkX all that apply.
Multi-vitamins
“Xenadrine”
Unspecified vitamins/minerals
Iron
Ginko Biloba
Vitamin C
Calcium
“Metabolife”
Vitamin E
Ginseng
“Phen Phen”
St. John’s wort
Vitamin B
Other supplement(s) -Specify

13

F5.

Did you report your problem to any of the
following institutions or professionals?
Yes No

a. The Food and Drug Administration ..........

F10. In your opinion, if a dietary supplement
product says on its package that it "may
produce anticarcinogenic effects in the
body," does this mean the product may
reduce the risk of…

b. The CDC, Centers for Disease Control
and Prevention .........................................
c.

A single type of cancer?
A few or some types of cancer?
All cancers?
Not sure

A health department or poison control
center .......................................................

d. The manufacturer of the dietary
supplement ..............................................
e. Your doctor ..............................................

F6.

Have you given any dietary supplements to
any infant(s), child(ren), or adolescent(s) in
your family in the past 12 months?

F11. In your opinion, if a dietary supplement
product says on its package that it "may
reduce the risk of certain cancers," does
this mean the product may reduce the risk
of:
A single type of cancer?
A few or some types of cancer?
All cancers?
Not sure

Yes
No GO TO F9 in the next column

F7.

If yes, what was the reason for using the
supplement?

G: Beliefs About Cancer
G1.

F8.

How much do you agree or disagree with
each of the following statements?

If yes, please provide the name(s) of the
supplement(s):
a. Cancer is most often caused
by a person's behavior or
lifestyle ......................................................

F9.

If a dietary supplement product says on its
package that it "may produce
anticarcinogenic effects in the
body," does this mean that the product may
do any of the following things?
Not
Yes No Sure

b. It seems like everything causes
cancer .......................................................
c.

There's not much you can do to
lower your chances of getting
cancer .......................................................

d. There are so many different
recommendations about
preventing cancer, it's hard to
know which ones to follow ........................

a. Reduce the risk of cancer .......................
b. Treat cancer .............................................
c.

Completely prevent cancer ......................

d. Cure cancer .............................................

G2.

Which of the following is closest to your
opinion about how cancers can be cured?
All types of cancers can be cured in the same
way.
Some types of cancers, but not all can be cured
in the same way.
Each type of cancer is cured in a different way.
There is no cure for cancer.
14

G3.

Which of the following is closest to your
opinion about people’s ability to avoid
cancers through what they eat or drink?
All cancers can be avoided through what people
eat or drink.
Some cancers, but not all can be avoided
through what people eat or drink.
What people eat or drink does not affect their
ability to avoid cancers.

G4.

Which of the following is closest to your
opinion about how dietary supplements
affect people’s ability to avoid cancer?
All cancers can be avoided through dietary
supplements.
Some types of cancers, but not all can be
avoided through dietary supplements.
Dietary supplements do not affect people’s
ability to avoid cancer.

H: Medical Products and Food Safety
In this section, please think about news reports
you hear about medical products and foods, the
Food and Drug Administration’s (FDA) activities,
and how these affect your choices.

H1. How much attention do you pay to reports
of FDA investigations?
None
A little
A lot

H2.

If the FDA reports that it is investigating an
approved drug, what does it mean to you?
The drug is safe to use

G5.

I am unsure whether the drug is safe to use

Which of the following is closest to your
opinion about treating cancer with dietary
supplements instead of drugs or surgery?
All cancers can be treated with dietary
supplements instead of drugs or surgery.
Some types of cancers, but not all can be
treated with dietary supplements instead of
drugs or surgery.
Cancers cannot be treated with dietary
supplements.

The drug is not safe to use

H3.

Many people take medicine for pain.
How often do you use medicine for pain by
prescription only?
More than four times daily
One to four times daily
Less than one time daily
Not applicable

H4.

How often do you use non-prescription
medicine for pain such as aspirin,
acetaminophen, ibuprofen, or naproxen?
More than four times daily
One to four times daily
Less than one time daily
Not applicable

15

H5. If a prescription drug you take is recalled H7.
and you hear that some people who use the
drug have been hospitalized, would you...
Yes

Not
No Sure

a. Check the number on your pill
bottle to see if it matches the
numbers in the recall notice? ...................

Strongly agree
Agree
Disagree
Strongly disagree
No opinion

b. Stop taking the drug
immediately?. ...........................................
c.

Lasers are in common use in products such
as CDs, DVDs and laser printers. Doctors
use lasers to treat skin conditions. Lasers
are also used in light shows at concerts.
How much do you agree that direct
exposure to lasers may damage your skin
and eyes?

Continue taking the drug but
watch for symptoms reported in
the recall notice? ................................

d. Ask your doctor what to do? ....................

H8.
H6.

If a brand of canned food that you have in
your home was recalled because some
people became seriously ill after eating it,
how likely would you be to…

Would you agree or disagree with the
following statements?

a. The food I buy is safe to
eat .......................................
b. Cosmetics are tested
for safety before they go
on the market .....................
c.

a. Switch brands ................................
b. Ask your doctor what to
do. .............................................................
c. Check the number of the
can to see if it matches
any of the numbers in the
recall notice ................................
d. No longer buy any brand
of that food ................................
e. Pay no attention to the
recall/keep buying and
eating that brand ................................
f. Other -specify ................................

Pet foods are tested for
safety before they go on
the market ..........................

d. The drugs I buy without
a prescription are tested
to see if they are safe
before they go on the
market ................................
e. Vaccines that I get are
tested to see if they are
safe before they go on
the market ..........................
f.

Prescription drugs that I
buy are tested to see if
they are safe before
they go on the market ........

16

H9. Would you agree or disagree with the
following statement?

I4.

Married
Living as married
Divorced
Widowed
Separated
Single, never been married

Medical equipment (including prescription
eyeglasses, hearing aids, blood glucose
kits, thermometers, pregnancy test kits, and
contact lenses) is tested to see if it is
effective before it goes on the market.
Strongly agree
Agree
Disagree
Strongly disagree
No opinion

I5.

What is your age?
Years old

I2.

Employed
Unemployed
Homemaker
Student
Retired
Disabled
Other-Specify

I3.

I6.

Have you ever served on active duty in the
U.S. Armed Forces, military Reserves or
National Guard? Active duty does not
include training in the Reserves or National
Guard, but DOES include activation, for
example, for the Persian Gulf War.
Yes, now on active duty
Yes, on active duty in the last 12 months but
not now
Yes, on active duty in the past, but not in the
last 12 months
No, training for Reserves or National Guard only
No, never served in the military

Were you born in the United States?
Yes
No

What is your current occupational status?
Mark X only one.

What is the highest grade or level of
schooling you completed?
Less than 8 years
8 through 11 years
12 years or completed high school
Post high school training other than college
(vocational or technical)
Some college
College graduate
Postgraduate

I: You and Your Household
I1.

What is your marital status?

I7.

GO TO I8 below

In what year did you come to live in the
United States?
Year

I8.

How well do you speak English?
Very well
Well
Not well
Not at all

I9.

Are you of Hispanic, Latino/a, or Spanish
origin? One or more categories may be
selected.
MarkX all that apply.
No, not of Hispanic, Latino/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino/a, or Spanish
origin

17

I10.

What is your race? One or more categories
may be selected.

I13.

How many children under the age of 18 live
in your household?

Mark X all that apply.

Number of children under 18

White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander

I14.

Own
Rent
Occupied without paying monetary rent

I15.

Including yourself, how many people live in
your household?

Starting with yourself, please mark the sex,
and write in the age and month of birth for
each adult 18 years of age or older living at
this address.
Sex

SELF

Male
Female

Adult 2

Male
Female

Adult 3

Male
Female

Adult 4

Male
Female

Adult 5

Male
Female

Age

Is there at least one telephone inside your
home that is currently working and is not a
cell phone?
Yes
No

Number of people

I12.

Does anyone in your family have a working
cell phone?
Yes
No

I16.
I11.

Do you currently rent or own your home?

I17.

Month Born
(01-12)

Thinking about members of your family
living in this household, what is your
combined annual income, meaning the total
pre-tax income from all sources earned in
the past year?
$0 to $9,999
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $199,999
$200,000 or more

I18.

Do you think of yourself as…
Heterosexual, or straight
Homosexual, or gay or lesbian
Bisexual
Something else – Specify

18

I19.

Do you live in the same household with
someone who uses tobacco products?
Yes
No

I20.

GO TO I21 below

How many people in your household use
tobacco products?
Number of tobacco users

I21.

About how long did it take you to complete
the survey?
Write a number in one box below.
Minutes

I22.

Hours

At which of the following types of addresses
does your household currently receive
residential mail?
MarkX all that apply.
A street address with a house or building
number
An address with a rural route number
A U.S. post office box (P.O. Box)
A commercial mail box establishment (such as
Mailboxes R Us, and Mailboxes Etc.)

19

Thank you!
Please return this questionnaire in
the postage-paid envelope within 2
weeks.
If you have lost the envelope, mail
the completed questionnaire to:
HINTS Study, TC 1046F
Westat
1600 Research Boulevard
Rockville, MD 20850