Adult smokers ages 25 to 54; Wave 1 Questionnaire

Evaluation of the Food and Drug Administration’s Point-of-Sale Campaign

Attachment_02a_POSITEv_Wave_1_questionnaire Clean

Adult smokers ages 25 to 54; Wave 1 Questionnaire

OMB: 0910-0851

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0910-0851 can be found here:

2019-02-27 - No material or nonsubstantive change to a currently approved collection
2018-10-23 - No material or nonsubstantive change to a currently approved collection

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August 2017

Point of Sale Intervention for Tobacco Evaluation (POSITEv)

Wave 1 Questionnaire

Prepared for

Food and Drug Administration

Janine Delahanty, PhD

Health Scientist

Health Communication and Education

U.S. Food and Drug Administration

Janine.Delahanty@fda.hhs.gov

Prepared by

RTI International

3040 E. Cornwallis Road

Research Triangle Park, NC 27709

RTI Project Number 0213772.003.001.005

_________________________________

RTI International is a registered trademark and a trade name of Research Triangle Institute

Section AA: Programming Notes and Instructions

Section A: Informed Consent

Section B: Demographics

Section C: Tobacco Use Behavior

Section D: Tobacco Use Intentions and Self-Efficacy

Section E: Cessation (Intention, Behavior, Motivation)

Section F: Attitudes, Beliefs, Risk Perceptions and Social Norms

Section G: Media Use and Awareness

Section H: Environment

Section AL: Locator Module

Section J: App-based portion of study

SECTION AA: PROGRAMMING NOTES

PROGRAMMING NOTES

All questions should appear on separate pages.
Participants may refuse to answer any question by clicking “next”. When participants refuse to answer a question, show “Prefer not to answer” as an additional response option and provide a prompt to check that option if they want to skip the question. “Prefer not to answer” will not be displayed unless a question is left unanswered.
If response boxes are used, such as in Hatteras, use radio buttons for questions where only one answer is allowed.
If response boxes are used, use check boxes for questions where more than one answer is allowed.
Prefer Not To Answer/Don’t Know/Refused/None of these are not allowed in combination with other responses.
If the questionnaire interface includes a banner across the top of the page, such as in Hatteras, include the variable name on the banner. In Hatteras, the banner also displays the name of the study, the progress bar, a Help button, and a Log out button. If not, do not include the variable name on the screen.
Except where noted, response options should not be labeled with numbers.
Do not display section headings.
Do not display question headings, or headings for question series.
Abbreviations used include ‘R’ for ‘respondent’ and ‘PNTA’ for ‘prefer not to answer’
A back button will not be offered to respondents.
Images displayed should be of equal size to one another.
Timestamp Specs
Overall time for respondents – NAVIGATION INSTRUCTIONS through EXIT1 OR EXIT3
Overall time by section
SECTION A – INFORMED CONSENT
SECTION B – B1 through B5
SECTION C - C1 through C18
SECTION D – D1 through D4
SECTION E – E1 through E20_
SECTION F – F1 through F6
SECTION G – G1 through G12
SECTION H – H1 through ENDCASI2
SECTION AL - AL_INT1 through AL_A2PEM
SECTION J - APP_CONSENT through EXIT1 OR EXIT3

All telephone numbers should only accept exactly 10 digits – all numbers and a mask should appear for formatting: XXX-YYY-ZZZZ. Area codes and prefixes should not begin with 0 or 1. The mask will allow the entry of 0 or 1 and the rest of the digits up to 10. Then when Next is pressed, the check happens and a message says that the number is invalid due to the leading 0 or 1, prefix 0 or 1 or less than 10 digits.

Consent
AL_INT2 (R willing to provide contact info?)
AL_INT3 (R willing to provide a contact?)
AL_INT4 (R willing to provide a second contact?)
Start recording APP_CONSENT

NAVIGATION INSTRUCTIONS

INTERVIEWER, READ: Now I’d like you to read the questions and enter your answers into the laptop yourself. This will allow you to answer the questions in complete privacy. I will not be able to see the answers you type into the computer. You can also skip any question you don’t want to answer by clicking the next button. Let me explain how to use the laptop.

Move laptop so respondent can see the screen and point out the following:

Point to the mouse and say: Please use the mouse to select your answers to the questions.

Point out number keys and say: Please use these keys for questions that ask you to enter a specific number.

Point to “Next” button and say: When you are ready to move to the next question or page, click here. This button will store your answers. Once you have entered your responses and clicked this button, you will not be able to go back and change your answers.

Point to the “Log Out” button and say: The Log Out button will take you out of the survey. Please do not click on it unless you need to stop the survey. This button will save your answers so that you can pick up where you left off when you go back to the survey.

Say: If you have any questions or trouble with the laptop, please ask. If not, click here to begin.”

Point to “Next” button and say “Please answer all of the questions to the best of your abilities.

PROGRAMMER: PROGRAM A NEXT BUTTON AT THE END OF THIS SCREEN

PROGRAMMER: START CASI

SECTION A: INFORMED CONSENT

[INSERT INFORMED CONSENT HERE]

SECTION B: DEMOGRAPHICS

B1 INTRO: Please answer the following general questions about you and your background.

B1. Are you Hispanic, Latino/a, or of Spanish origin?

999 Prefer not to answer

ASK: All respondents

B2. What race or races do you consider yourself to be? Select all that apply.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Other

999 Prefer not to answer

ASK: All respondents

B3. What is the highest level of school you have completed?

8^th grade or less
9^th to 12^th grade but no diploma
Regular high school diploma
GED or alternative credential
Some college (no degree)
Associate’s Degree (for example: AA, AS)
Bachelor’s degree (for example: BA, BS)
Master’s degree (for example: MA, MS, MEng, Med, MSW, MBA)
Professional degree or doctoral degree beyond a bachelor’s degree (for example: MD, DDS, DVM, LLB, JD, PhD, EdD)

999 Prefer not to answer

ASK: All respondents

B4. Are you currently…? Please select the option that best describes you.

Employed for wages
Self-employed
Out of work for 1 year or more
Out of work for less than 1 year
A homemaker
A student
Retired
Unable to work

999 Prefer not to answer

ASK: All respondents

B5 INTRO: The next question is about the total income of your household for the past 12 months. Please include your income plus the income of all members living in your household (including cohabiting partners and armed forces members living at home). Please count income before taxes and from all sources (such as wages, salaries, tips, net income from a business, interest, dividends, child support, alimony, Social Security, public assistance, pensions, or retirement benefits).

B5. Was your total household income in the past 12 months.

Below $35,000
$35,000 or more
Don’t Know

999 Prefer not to answer

ASK: All respondents

SECTION C: TOBACCO USE

INTRODUCTION: The next set of questions are about tobacco products and how often you use them.

C1. Do you consider yourself a smoker?

999 Prefer not to answer

ASK: All respondents

C2. About how long has it been since you last smoked cigarettes? If you smoked a cigarette today please enter 0 days. Please enter days or weeks.

_____ Number of days (Range: 0–7)

_____ Number of weeks (Range: 0–4)

999 Prefer not to answer

PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 7 FOR DAYS. ALLOW A MINIMUM OF 0 AND A MAXIMUM OF 4 FOR WEEKS.

IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN [0 AND 7/ 0 AND 4].” IN LOWERCASE LETTERS

ALLOW R TO ENTER DAYS OR WEEKS. IF DAYS AND WEEKS ARE ENTERED ERROR MESSAGE SHOULD SAY, “PLEASE ENTER A NUMBER OF DAYS OR A NUMBER OF WEEKS, BUT NOT BOTH. IN LOWERCASE LETTERS

IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A NUMBER OF DAYS OR A NUMBER OF WEEKS WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.

ASK: All respondents

C3. Not including today, how many cigarettes did you smoke on the most recent day you smoked? A pack usually has 20 cigarettes in it.

_____ Number of cigarettes (Range: 1–99)

999 Prefer not to answer

PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 99. PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX.

IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN [0 AND 99.” IN LOWERCASE LETTERS

ASK: All respondents

C4. On the days that you smoke, how soon after you wake up do you typically smoke your first cigarette of the day? Please enter the number of minutes or hours.

_____ Minutes after waking (Range: 0–60)

_____ Hours after waking (Range: 0–24)

999 Prefer not to answer

PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 60 FOR MINUTES. ALLOW A MINIMUM OF 0 AND A MAXIMUM OF 24 FOR HOURS.

PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX

IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN [0 AND 60/ 0 AND 24].” IN LOWERCASE LETTERS

ALLOW R TO ENTER MINUTES OR HOURS. IF MINUTES AND HOURS ARE ENTERED ERROR MESSAGE SHOULD SAY, “PLEASE ENTER A NUMBER OF MINUTES OR A NUMBER OF HOURS, BUT NOT BOTH. IN LOWERCASE LETTERS

ASK: All respondents

TOBACCO PURCHASING BEHAVIOR

C5. Do you usually buy your own cigarettes?

Yes
No –> GO TO C15

999 Prefer not to answer

ASK: All respondents

C6. [IF C5=1 OR C5=999]

Do you usually buy your cigarettes by the carton, pack, or single cigarettes, or do you roll your own?

Carton
Pack
Single cigarettes
Roll your own

999 Prefer not to answer

ASK: Respondents who usually buy their own cigarettes or did not indicate whether they usually buy their own cigarettes

C7. [IF C5=1 OR C5=999]

Now think about cigarettes you purchased for your own personal use in the past 7 days. How many of the past 7 days did you purchase cigarettes?

_____ Number of days (Range: 0–7)

999 Prefer not to answer

PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 7

PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX

IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 7” IN LOWERCASE LETTERS

ASK: Respondents who usually buy their own cigarettes or did not indicate whether they usually buy their own cigarettes

C8. [IF C7 NE 0 OR C6=4]

In the past 7 days, how many cartons, packs, single cigarettes, and pouches of roll-your-own tobacco did you buy for your own personal use?

C8_1. _____ Cartons (Range: 0–99)

C8_2. _____ Packs (Range: 0–99)

C8_3. _____ Single cigarettes (Range: 0–99)

C8_4. _____ Pouches of roll your own tobacco (Range: 0–99)

999 Prefer not to answer

PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 99 FOR C8_1, C8_2, C8_3, C8_4

PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX

IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 99.” IN LOWERCASE LETTERS

IF A NUMERIC RESPONSE IS NOT CAPTURED FOR EACH ITEM, ERROR MESSAGE SHOULD SAY “PLEASE ENTER NUMBERS FOR ALL TOBACCO PRODUCTS”. IN LOWERCASE LETTERS

IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A PRICE WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.

ASK: Respondents who purchased cigarettes for their own personal use in the past 7 days

C9. [IF C8_1 > 0]

When you last got a carton of cigarettes for your own personal use, what price did you pay?

$_ _ _._ _ per carton (Range: 0–150.00)

999 Prefer not to answer

PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 150.00

PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX

IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 150.00.” IN LOWERCASE LETTERS

ASK: Respondents who purchased at least one carton of cigarettes for their own personal use in the past 7 days

C10. [IF C8_2 > 0]

When you last got a pack of cigarettes for your own personal use, what price did you pay?

$_ _ _._ _ per pack (Range: 0–20.00)

999 Prefer not to answer

PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 20.00

PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX

IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 20.00.” IN LOWERCASE LETTERS

ASK: Respondents who purchased at least one pack of cigarettes for their own personal use in the past 7 days

C11. [IF C8_1>0 OR C8_2>0 OR C8_3>0]

When you last got a single cigarette for your own personal use, what price did you pay?

$_ _ _._ _ per cigarette (Range: 0–15.00)

_____ I have never purchased a single cigarette

999 Prefer not to answer

PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 15.00

PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX

IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 15.00.” IN LOWERCASE LETTERS

ASK: Respondents who purchased at least one pack of cigarettes or one carton of cigarettes or one cigarette for their own personal use in the past 7 days

C12. [IF C8_4>0]

When you last got a pouch of roll-your-own-tobacco for your own personal use, what price did you pay?

$_ _ _._ _ per pouch (Range: 0–30.00)

999 Prefer not to answer

PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 30.00

PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX

IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 30.00.” IN LOWERCASE LETTERS

ASK: Respondents who purchased at least one pouch of roll-your-own tobacco for their own personal use in the past 7 days

C13 INTRO [IF C7 NE 0 OR C8_4 >0]

Next, we would like to ask two questions about where you got cigarettes in the past 7 days. Please think about purchases that you made for your personal use.

C13. [IF C7 NE 0 OR C8_4 >0]

In the past 7 days, have you purchased cigarettes or roll your own tobacco from any of the following locations?

		Yes	No	Prefer not to answer
C13_1.	At a convenience store or gas station	☐₁	☐₂	☐₉₉₉
C13_2.	At a grocery store	☐₁	☐₂	☐₉₉₉
C13_3.	At a drugstore	☐₁	☐₂	☐₉₉₉
C13_4.	Mass merchandisers such as Wal-Mart, Costco, Sam’s Club	☐₁	☐₂	☐₉₉₉
C13_5.	At a tobacco shop	☐₁	☐₂	☐₉₉₉
C13_6.	Other	☐₁	☐₂	☐₉₉₉

ASK: Respondents who purchased cigarettes for their own personal use in the past 7 days

[IF C13_1=1 OR C13_2=1 OR C13_3=1 OR C13_4=1 OR C13_5=1 OR C13_6=1, ASK C14; ELSE, GO TO C15]

C14. [IF C13_1=1 OR C13_2=1 OR C13_3=1 OR C13_4=1 OR C13_5=1 OR C13_6=1]

Please write the name of the specific store where you usually bought cigarettes or roll-your-own-tobacco in the past 7 days for your own use.

_______________________ (ALLOW 25 ALPHA OR NUMERIC CHARACTERS).

999 Prefer not to answer

PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX

ASK: Respondents who purchased cigarettes from a location for their own personal use in the past 7 days

CURRENT ELECTRONIC VAPOR PRODUCT USE

This question focuses on electronic vapor products, which include e-cigarettes, e-cigars, e-hookahs, e-pipes, vape pens, tanks, mods, and hookah pens.

C15. Do you now use an electronic vapor product . . .

Every day
Some days
Rarely
Not at all

999 Prefer not to answer

ASK: All respondents

CURRENT SMOKELESS USE

Next, we ask a question about smokeless tobacco which you put in your mouth. You chew, suck or spit some types of smokeless tobacco but not other types. For example, snus is smokeless tobacco that comes in a small pouch that you put inside your lip.

There are many kinds of smokeless tobacco, such as snus pouches, loose snus, moist snuff, dip, spit, and chewing tobacco. Common brands include Redman, Levi Garrett, Beechnut, Skoal, Grizzly, Nordic Ice and Copenhagen.

C16. Do you now use smokeless tobacco products . . .

Every day
Some days
Rarely
Not at all

999 Prefer not to answer

ASK: All respondents

CURRENT CIGAR/CIGARILLO USE

The next question is about traditional cigars, cigarillos, little cigars, and filtered cigars. These products go by lots of different names, so please use these descriptions and photos to understand what they are.

Traditional cigars contain tightly rolled tobacco that is wrapped in a tobacco leaf. Some common brands of cigars include Macanudo, Romeo y Julieta, and Arturo Fuente, but there are many others.

Cigarillos, little cigars, and filtered cigars are smaller than traditional cigars. They are usually brown. Some are the same size as cigarettes, and some come with filters or with plastic or wooden tips. Some common brands are Black & Mild, Swisher Sweets, Dutch Masters, Phillies Blunts, Prime Time, and Winchester.

C17. Do you now use traditional cigars, cigarillos, little cigars and/or filtered cigars . . .

Every day
Some days
Rarely
Not at all

999 Prefer not to answer

ASK: All respondents

CURRENT HOOKAH USE

We next ask about smoking tobacco in a hookah, which is a type of water pipe. It is sometimes also called shisha or a “narghile” pipe. From now on, we will use “hookah” to refer to a water pipe, shisha, or narghile pipe that is often used to smoke tobacco.

There are many types of hookahs. People often smoke tobacco in hookahs in groups at cafes or in hookah bars.

C18. Do you now smoke tobacco in a hookah, even one or two puffs . . .

Every day
Some days
Rarely
Not at all

999 Prefer not to answer

ASK: All respondents

SECTION D: TOBACCO USE INTENTIONS AND SELF-EFFICACY

INTRODUCTION: In the next section, we ask you some questions about quitting smoking cigarettes.

SMOKING EXPECTATIONS

D1. Three months from now, how much do you expect to be smoking cigarettes, compared to now?

Not smoking cigarettes at all
A lot less than now
A little less than now
The same amount as now
A little more than now
A lot more than now

999 Prefer not to answer

ASK: All respondents

SELF-EFFICACY FOR QUITTING

D2. If you did try to quit smoking cigarettes altogether in the next 3 months, how likely do you think you would be to succeed?

Not at all likely
A little likely
Somewhat likely
Very likely

999 Prefer not to answer

ASK: All respondents

D3. How much do you believe that quitting smoking completely is possible for you?

Not at all possible
Somewhat possible
Very possible

999 Prefer not to answer

ASK: All respondents

D4 INTRO: How much do you disagree or agree with the following statement?

D4. I feel ready to take a small step toward quitting.

Strongly disagree
Disagree
Neither disagree nor agree
Agree

5 Strongly agree

999 Prefer not to answer

ASK: All respondents

SECTION E: CESSATION (INTENTION, BEHAVIOR, MOTIVATION)

QUIT BEHAVIOR

E1. Have you ever tried to quit smoking cigarettes?

Yes
No–> GO TO E10

999 Prefer not to answer

ASK: All respondents

E2. [IF E1=1 OR E1=999]

Of all the times you tried to quit smoking cigarettes, what was the longest period you stayed off cigarettes completely? Enter either hours, days, weeks, months or years below.

______ (NUMERIC ENTRY)

hours (Range: 0-23)
days (Range: 0-6)
weeks (Range: 0-4)
months (Range: 0-11)
years (Range: 0-99)

999 Prefer not to answer

PROGRAMMER: ALLOW R TO ENTER EITHER HOURS, DAYS, WEEKS, MONTHS, OR YEARS. NUMERIC RESPONSE.

IF HOURS SELECTED ALLOW A MINIMUM OF 0 AND MAXIMUM OF 23.

IF DAYS SELECTED ALLOW A MINIMUM OF 0 AND MAXIMUM OF 6.

IF WEEKS SELECTED ALLOW A MINIMUM OF 0 AND MAXIMUM OF 4.

IF MONTHS SELECTED ALLOW A MINIMUM OF 0 AND MAXIMUM OF 11.

IF YEARS SELECTED ALLOW A MINIMUM OF 0 AND MAXIMUM OF 99.

PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX

IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND (HOURS: 23; DAYS: 6; WEEKS: 4; MONTHS: 11; YEARS: 99).” IN LOWERCASE LETTERS

ASK: Respondents who have tried to quit smoking or preferred not to indicate whether they have tried to quit smoking

E3 INTRO: [IF E1=1 OR E1=999]

For most of the questions in this section, we ask you about the past 3 months. For the next question, please note that we are asking you about the past 6 months.

E3. In the past 6 months, did you intentionally quit smoking cigarettes for at least 24 hours?

999 Prefer not to answer

ASK: Respondents who have tried to quit smoking or preferred not to indicate whether they have tried to quit smoking.

E4 INTRO: [IF (E1=1 OR E1=999) AND E3 NE 2]

Now, we are going to ask you about your behavior in the past 3 months again.

E4. In the past 3 months, did you intentionally quit smoking cigarettes for at least 24 hours?

Yes
No–> GO TO E8

999 Prefer not to answer

ASK: Respondents who have tried to quit smoking or preferred not to indicate whether they have tried to quit smoking.

E5. [IF E4=1 OR E4=999]

In the past 3 months, how many times have you intentionally quit smoking cigarettes for at least 24 hours?

_____ times (Range: 0–99)

999 Prefer not to answer

PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 99

PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX

IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 99” IN LOWERCASE LETTERS

ASK: Respondents who intentionally quit smoking cigarettes in the past 3 months for at least 24 hours, or Respondents who preferred not to indicate whether they had intentionally quit smoking cigarettes in the past 3 months for at least 24 hours.

E6. [IF E4=1 OR E4=999]

When you tried to quit smoking cigarettes in the past 3 months, did you avoid going to places where you used to buy cigarettes in case you might be tempted to buy them?

Never
Once
A few times
Lots of times

999 Prefer not to answer

E7. [IF E4=1 OR E4=999]

When you tried to quit smoking cigarettes in the past 3 months, was there a time when seeing the cigarette pack display in the store gave you an urge to buy cigarettes?

Never
Once
A few times
Lots of times

999 Prefer not to answer

MOTIVATION TO QUIT

E8. [IF E1=1 OR E1=999]

How much do you want to quit smoking cigarettes?

Not at all
A little
Somewhat
A lot

999 Prefer not to answer

ASK: Respondents who have tried to quit smoking or preferred not to indicate whether they have tried to quit smoking.

E9. [IF E1=1 OR E1=999]

In the past 3 months, have you tried to quit smoking cigarettes by reducing or cutting back on the number of cigarettes you smoke?

999 Prefer not to answer

ASK: Respondents who have tried to quit smoking or preferred not to indicate whether they have tried to quit smoking.

E10. On a scale of 1-5, where 1 is the lowest and 5 is the highest, how would you rate quitting smoking cigarettes as a priority in your life?

Lowest priority
Highest priority

999 Prefer not to answer

PROGRAMMER: LABEL RESPONSE OPTIONS WITH NUMBERS

ASK: All respondents

INTENTION TO QUIT

E11. Do you plan to quit smoking cigarettes for good . . .

In the next 7 days,
In the next 30 days,
In the next 3 months,
In the next 6 months,
In the next year, or
More than one year from now?
I do not plan to quit smoking cigarettes for good
Not sure/uncertain

999 Prefer not to answer

ASK: All respondents

E12. [IF E11=1 OR 2 OR 3 OR 4 OR 5 OR 6]

Have you set a firm date to quit smoking cigarettes?

999 Prefer not to answer

ASK: Respondents who plan to quit smoking cigarettes for good

CESSATION COGNITION INDEX

E13. INTRO: Please tell us how much you disagree or agree with the following statements.

PROGRAMMER: RANDOMIZE ALL

		Strongly Disagree	Disagree	Neither Agree or Disagree	Agree	Strongly Agree	Prefer Not to Answer
E13_1.	I have been thinking a lot about quitting smoking cigarettes recently.	₁	₂	₃	₄	₅	₉₉₉
E13_2.	I am eager for a life without smoking cigarettes.	₁	₂	₃	₄	₅	₉₉₉
E13_3.	Lately, I have been thinking about which cigarettes during my day would be the hardest to give up.	₁	₂	₃	₄	₅	₉₉₉
E13_4.	I am not prepared to make changes in my life to quit smoking cigarettes.	₁	₂	₃	₄	₅	₉₉₉

ASK: All respondents

E14. During the past 3 months, how often would you say you have thought about the changes you will have to make in your life to quit smoking cigarettes?

Never
Once
A few times
Lots of times

999 Prefer not to answer

ASK: All respondents

MICROINDICATORS OF QUITTING

E15. Compared to three months ago, are you more or less concerned about the price of cigarettes?

Less concerned
Just as concerned
More concerned

999 Prefer not to answer

ASK: All respondents

E16. In the past 3 months, did you practice not smoking in some situations, or for periods of time?

999 Prefer not to answer

ASK: All respondents

E17. In the past 3 months, have you stubbed out a cigarette before you finished it because you wanted to quit smoking?

999 Prefer not to answer

ASK: All respondents

E18. In the past 3 months, how often did you put off purchasing cigarettes because you wanted to quit smoking?

Never
Once
A few times
Lots of times

999 Prefer not to answer

ASK: All respondents

E19. In the past 3 months, how often have you stopped yourself from having a cigarette when you had the urge to smoke?

Never
Once
A few times
Lots of times

999 Prefer not to answer

ASK: All respondents

E20. In the past 3 months, how often did you avoid social situations where people were smoking?

Never
Once
A few times
Lots of times

999 Prefer not to answer

ASK: All respondents

SECTION F: ATTITUDES, BELIEFS & RISK PERCEPTIONS, SOCIAL NORMS

INTRODUCTION: Now we would like to ask you some questions about your attitudes and beliefs.

SMOKING BELIEFS

F1. How harmful do you think smoking cigarettes is to people’s health in general?

Not at all harmful
Slightly harmful
Somewhat harmful
Very harmful
Extremely harmful

999 Prefer not to answer

ASK: All respondents

F2. Please tell us how much do you disagree or agree with the following statements about smoking cigarettes.

PROGRAMMER: RANDOMIZE ORDER OF QUESTIONS

		Strongly Disagree	Disagree	Neither Agree or Disagree	Agree	Strongly Agree	Prefer Not to Answer
F2_1.	I would be more energetic right now if I didn’t smoke cigarettes.	₁	₂	₃	₄	₅	₉₉₉
F2_2.	I’m embarrassed that I smoke cigarettes.	₁	₂	₃	₄	₅	₉₉₉
F2_3.	Smoking cigarettes is hazardous to my health.	₁	₂	₃	₄	₅	₉₉₉
F2_4.	Smoking cigarettes is pleasurable.	₁	₂	₃	₄	₅	₉₉₉
F2_5.	Smoking cigarettes reduces stress.	₁	₂	₃	₄	₅	₉₉₉
F2_6.	Smoking cigarettes helps me concentrate.	₁	₂	₃	₄	₅	₉₉₉
F2_7.	Smoking cigarettes helps keep my weight down.	₁	₂	₃	₄	₅	₉₉₉

ASK: All respondents

F3. In the past 3 months, how often did you think about the harm your cigarette smoking might be doing to you?

Never
Once
A few times
Lots of times

999 Prefer not to answer

ASK: All respondents

F4. How likely do you think you are to develop a smoking-related disease as a result of smoking cigarettes?

Extremely unlikely
Very unlikely
Very likely
Extremely likely

999 Prefer not to answer

ASK: All respondents

F5. Please tell us how much you disagree or agree that smoking cigarettes increases your risk of . . . [randomize presentation]

PROGRAMMER: RANDOMIZE PRESENTATION

		Strongly Disagree	Disagree	Neither Agree or Disagree	Agree	Strongly Agree	Prefer Not to Answer
F5_1.	Lung cancer?	₁	₂	₃	₄	₅	₉₉₉
F5_2.	Heart disease?	₁	₂	₃	₄	₅	₉₉₉
F5_3.	Emphysema?	₁	₂	₃	₄	₅	₉₉₉
F5_4.	Chronic obstructive pulmonary disorder (COPD) or chronic bronchitis?	₁	₂	₃	₄	₅	₉₉₉

ASK: All respondents

CESSATION BELIEFS

F6. How much do you think your health would improve if you were to stop smoking cigarettes for good?

Not at all
A little
Somewhat
A lot

999 Prefer not to answer

ASK: All respondents

SECTION G: MEDIA USE AND AWARENESS

INTRODUCTION: Next, we’d like to ask you about your use of TV and other media.

GENERAL MEDIA EXPOSURE

G1. How often do you…

PROGRAMMER: RANDOMIZE PRESENTATION

		Never	Once a month or less	Every few weeks	1-3 days a week	4-6 days a week	About once a day	Several times a day	Prefer not to answer
G1_1.	Watch television, including streaming TV (Hulu, Netflix, or Amazon Prime)?	₁	₂	₃	₄	₅	₆	₇	₉₉₉
G1_2.	Watch videos on YouTube?	₁	₂	₃	₄	₅	₆	₇	₉₉₉
G1_3.	Listen to streaming radio?	₁	₂	₃	₄	₅	₆	₇	₉₉₉
G1_4.	Listen to radio over the air?	₁	₂	₃	₄	₅	₆	₇	₉₉₉

ASK: All respondents

G2. Thinking about the social networking sites you use, about how often do you visit or use the following…

PROGRAMMER: RANDOMIZE PRESENTATION

		Never	Once a month or less	Every few weeks	1-3 days a week	4-6 days a week	About once a day	Several times a day	Prefer not to answer
G2_1.	Facebook	₁	₂	₃	₄	₅	₆	₇	₉₉₉
G2_2.	Instagram	₁	₂	₃	₄	₅	₆	₇	₉₉₉
G2_3.	Twitter	₁	₂	₃	₄	₅	₆	₇	₉₉₉
G2_4.	Tumblr	₁	₂	₃	₄	₅	₆	₇	₉₉₉
G2_5.	Snapchat	₁	₂	₃	₄	₅	₆	₇	₉₉₉
G2_6.	Pinterest	₁	₂	₃	₄	₅	₆	₇	₉₉₉

ASK: All respondents

ANTI-SMOKING MEDIA EXPOSURE

G3. In the past 3 months, how frequently have you seen or heard the following slogan or theme on the TV, radio, or Internet?

Tips from Former Smokers (Tips)

Never
Once
A few times
Lots of times

999 Prefer not to answer

ASK: All respondents

EVERY TRY COUNTS EXPOSURE

G4. In the past 3 months, how frequently have you seen or heard the following slogan or theme?

Every Try Counts

PROGRAMMER: RANDOMLY INSERT 1 OF THE FOLLOWING FOUR EXAMPLE ADS

Ad 1: “You didn’t fail at quitting”

Ad 2: “If at first you don’t succeed”

Ad 3: “Every time you put out a cigarette”

Ad 4: Keep Your Head Up

Never–> GO TO G6
Once
A few times
Lots of times

999 Prefer not to answer–> GO TO G6

ASK: All respondents

G5. [IF G4>=2 AND G4 NE 999]

You said you have seen or heard “Every Try Counts”. Where have you seen or heard it? Please check “yes” or “no” for each item.

PROGRAMMER: RANDOMIZE PRESENTATION

		Yes	No	Prefer not to answer
G5_1.	Inside of a store	₁	₂	₉₉₉
G5_2.	Outside of a store	₁	₂	₉₉₉
G5_3.	At the gas pump	₁	₂	₉₉₉
G5_4.	On a billboard	₁	₂	₉₉₉
G5_5.	On television	₁	₂	₉₉₉
G5_6.	On the internet and/or on social media	₁	₂	₉₉₉
G5_7.	On the radio	₁	₂	₉₉₉

ASK: Respondents who indicated they saw or hear the ‘Every Try Counts’ slogan or theme once, a few times, or a lot of times in the past 3 months.

IDENTIFICATION WITH CAMPAIGN MESSAGE

G6. Please tell us how much you disagree or agree with the following statements about smoking cigarettes?

PROGRAMMER: RANDOMIZE PRESENTATION

		Strongly Disagree	Disagree	Neither Agree or Disagree	Agree	Strongly Agree	Prefer Not to Answer
G6_1.	I feel like a failure when I start smoking again after quitting.	₁	₂	₃	₄	₅	₉₉₉
G6_2.	Every quit attempt I make is a step towards quitting smoking cigarettes for good.	₁	₂	₃	₄	₅	₉₉₉
G6_3.	The more times I try to quit smoking cigarettes, the more likely I am to quit for good.	₁	₂	₃	₄	₅	₉₉₉
G6_4.	It may take me several quit attempts to quit smoking cigarettes for good.	₁	₂	₃	₄	₅	₉₉₉
G6_5.	I have a chance to learn something new with every quit attempt.	₁	₂	₃	₄	₅	₉₉₉
G6_6.	It’s important for me to learn not to smoke cigarettes in situations where I typically smoke.	₁	₂	₃	₄	₅	₉₉₉
G6_7.	With each quit attempt, I become better at quitting.	₁	₂	₃	₄	₅	₉₉₉

ASK: All respondents

G7 INTRO: Please tell us how much do you disagree or agree with the following statements.

G7. When I think about quitting smoking cigarettes, I feel…

		Strongly Disagree	Disagree	Neither Agree or Disagree	Agree	Strongly Agree	Prefer Not to Answer
G7_1.	Confident	₁	₂	₃	₄	₅	₉₉₉
G7_2.	Hopeful	₁	₂	₃	₄	₅	₉₉₉
G7_3.	Discouraged	₁	₂	₃	₄	₅	₉₉₉
G7_4.	Stressed	₁	₂	₃	₄	₅	₉₉₉

ASK: All respondents

G8 INTRO: How much do you disagree or agree with the following statements?

G8. I continue to smoke cigarettes because…

		Strongly Disagree	Disagree	Neither Agree or Disagree	Agree	Strongly Agree	Prefer Not to Answer
G8_1.	I’m addicted to smoking.	₁	₂	₃	₄	₅	₉₉₉
G8_2.	I enjoy smoking.	₁	₂	₃	₄	₅	₉₉₉
G8_3.	I don’t have enough willpower.	₁	₂	₃	₄	₅	₉₉₉
G8_4.	I’m stressed out.	₁	₂	₃	₄	₅	₉₉₉
G8_5.	I don’t have the support I need from friends and family.	₁	₂	₃	₄	₅	₉₉₉
G8_6.	I haven’t tried to quit enough times.	₁	₂	₃	₄	₅	₉₉₉

ASK: All respondents

G9 INTRO: Now we would like to show you some ads that you may have seen close to places that sell tobacco.

PROGRAMMER: RANDOMIZE PRESENTATION OF G9-G10 LOOP RANDOMIZE PRESENTATION. THE AD SELECTED FOR G4 SHOULD SKIP QG9 AND GO TO QG10 INSTEAD:

G9_1. Apart from this survey, how frequently have you seen this ad in the past 3 months?

Never
Once
A few times
Lots of times

999 Prefer not to answer

PROGRAMMER: DISPLAY CAMPAIGN AD FOR “YOU DIDN’T FAIL AT QUITTING…”

ASK: All respondents

G9_2. Apart from this survey, how frequently have you seen this ad in the past 3 months?

Never
Once
A few times
Lots of times

999 Prefer not to answer

PROGRAMMER: DISPLAY CAMPAIGN AD FOR “IF AT FIRST YOU DON’T SUCCEED…”

ASK: All respondents

G9_3. Apart from this survey, how frequently have you seen this ad in the past 3 months?

Never
Once
A few times
Lots of times

999 Prefer not to answer

PROGRAMMER: DISPLAY CAMPAIGN AD FOR “EVERY TIME YOU PUT OUT A CIGARETTE”

G9_4 Apart from this survey, how frequently have you seen this ad in the past 3 months?

Never
Once
A few times
Lots of times

999 Prefer not to answer

PROGRAMMER: DISPLAY CAMPAIGN AD FOR “KEEP YOUR HEAD UP”

ASK: All respondents

PERCEIVED EFFICACY OF CAMPAIGNS

G10_1. Please tell us how much you disagree or agree with the following statements about this ad.

PROGRAMMER: RANDOMIZE PRESENTATION. DISPLAY CAMPAIGN AD FOR “YOU DIDN’T FAIL AT QUITTING…”

		Strongly Disagree	Disagree	Neither Agree or Disagree	Agree	Strongly Agree	Prefer Not to Answer
G10_1_1.	This ad is worth remembering.	₁	₂	₃	₄	₅	₉₉₉
G10_1_2.	This ad grabbed my attention.	₁	₂	₃	₄	₅	₉₉₉
G10_1_3.	This ad is powerful.	₁	₂	₃	₄	₅	₉₉₉
G10_1_4.	This ad is informative.	₁	₂	₃	₄	₅	₉₉₉
G10_1_5.	This ad is meaningful to me.	₁	₂	₃	₄	₅	₉₉₉
G10_1_6.	This ad is convincing.	₁	₂	₃	₄	₅	₉₉₉
G10_1_7.	This ad made me want to quit smoking cigarettes.	₁	₂	₃	₄	₅	₉₉₉
G10_1_8.	This ad made me feel motivated to try to quit smoking cigarettes.	₁	₂	₃	₄	₅	₉₉₉
G10_1_9.	This ad made me feel hopeful about quitting smoking cigarettes.	₁	₂	₃	₄	₅	₉₉₉
G10_1_10.	This ad made me feel understood.	₁	₂	₃	₄	₅	₉₉₉

ASK: All respondents

G10_2. Please tell us how much you disagree or agree with the following statements about this ad.

PROGRAMMER: RANDOMIZE PRESENTATION. DISPLAY CAMPAIGN AD FOR “IF AT FIRST YOU DON’T SUCCEED…”

		Strongly Disagree	Disagree	Neither Agree or Disagree	Agree	Strongly Agree	Prefer Not to Answer
G10_2_1.	This ad is worth remembering.	₁	₂	₃	₄	₅	₉₉₉
G10_2_2.	This ad grabbed my attention.	₁	₂	₃	₄	₅	₉₉₉
G10_2_3.	This ad is powerful.	₁	₂	₃	₄	₅	₉₉₉
G10_2_4.	This ad is informative.	₁	₂	₃	₄	₅	₉₉₉
G10_2_5.	This ad is meaningful to me.	₁	₂	₃	₄	₅	₉₉₉
G10_2_6.	This ad is convincing.	₁	₂	₃	₄	₅	₉₉₉
G10_2_7.	This ad made me want to quit smoking cigarettes.	₁	₂	₃	₄	₅	₉₉₉
G10_2_8.	This ad made me feel motivated to try to quit smoking cigarettes.	₁	₂	₃	₄	₅	₉₉₉
G10_2_9.	This ad made me feel hopeful about quitting smoking cigarettes.	₁	₂	₃	₄	₅	₉₉₉
G10_2_10.	This ad made me feel understood.	₁	₂	₃	₄	₅	₉₉₉

ASK: All respondents

G10_3. Please tell us how much you disagree or agree with the following statements about this ad.

PROGRAMMER: RANDOMIZE PRESENTATION. DISPLAY CAMPAIGN AD FOR “EVERY TIME YOU PUT OUT A CIGARETTE”

		Strongly Disagree	Disagree	Neither Agree or Disagree	Agree	Strongly Agree	Prefer Not to Answer
G10_3_1.	This ad is worth remembering.	₁	₂	₃	₄	₅	₉₉₉
G10_3_2.	This ad grabbed my attention.	₁	₂	₃	₄	₅	₉₉₉
G10_3_3.	This ad is powerful.	₁	₂	₃	₄	₅	₉₉₉
G10_3_4.	This ad is informative.	₁	₂	₃	₄	₅	₉₉₉
G10_3_5.	This ad is meaningful to me.	₁	₂	₃	₄	₅	₉₉₉
G10_3_6.	This ad is convincing.	₁	₂	₃	₄	₅	₉₉₉
G10_3_7.	This ad made me want to quit smoking cigarettes.	₁	₂	₃	₄	₅	₉₉₉
G10_3_8.	This ad made me feel motivated to try to quit smoking cigarettes.	₁	₂	₃	₄	₅	₉₉₉
G10_3_9.	This ad made me feel hopeful about quitting smoking cigarettes.	₁	₂	₃	₄	₅	₉₉₉
G10_3_10.	This ad made me feel understood.	₁	₂	₃	₄	₅	₉₉₉

ASK: All respondents

G10_4. Please tell us how much you disagree or agree with the following statements about this ad.

PROGRAMMER: RANDOMIZE PRESENTATION. DISPLAY CAMPAIGN AD FOR “KEEP YOUR HEAD UP”

		Strongly Disagree	Disagree	Neither Agree or Disagree	Agree	Strongly Agree	Prefer Not to Answer
G10_4_1.	This ad is worth remembering.	₁	₂	₃	₄	₅	₉₉₉
G10_4_2.	This ad grabbed my attention.	₁	₂	₃	₄	₅	₉₉₉
G10_4_3.	This ad is powerful.	₁	₂	₃	₄	₅	₉₉₉
G10_4_4.	This ad is informative.	₁	₂	₃	₄	₅	₉₉₉
G10_4_5.	This ad is meaningful to me.	₁	₂	₃	₄	₅	₉₉₉
G10_4_6.	This ad is convincing.	₁	₂	₃	₄	₅	₉₉₉
G10_4_7.	This ad made me want to quit smoking cigarettes.	₁	₂	₃	₄	₅	₉₉₉
G10_4_8.	This ad made me feel motivated to try to quit smoking cigarettes.	₁	₂	₃	₄	₅	₉₉₉
G10_4_9.	This ad made me feel hopeful about quitting smoking cigarettes.	₁	₂	₃	₄	₅	₉₉₉
G10_4_10.	This ad made me feel understood.	₁	₂	₃	₄	₅	₉₉₉

ASK: All respondents

COMPREHENSION OF CAMPAIGN MESSAGE

G11. Please pick the answer below that you think best fits the main message of all of the ads we showed you…

Quitting smoking takes practice.
It may take several attempts to quit smoking for good.
You learn something every time you try to quit smoking.
It is important to talk to your doctor before quitting smoking.
Using nicotine patches helps you quit smoking.

999 Prefer not to answer

PROGRAMMER: RANDOMIZE ORDER OR RESPONSE OPTIONS

ASK: All respondents

BRAND IDENTIFICATION

G12. In the past 3 months, did you talk to anyone, either in person or online, about the “Every Try Counts” ads?

999 Prefer not to answer

ASK: All respondents

SECTION H: ENVIRONMENT

INTRODUCTION: This section asks some additional questions about you and your environment.

BLUNT USE

H1. Do you now use a “blunt” (a cigar, cigarillo, little cigar, or filtered cigar with marijuana in it) . . .

Every day
Some days
Rarely
Not at all

999 Prefer not to answer

ASK: All respondents

TOBACCO ENVIRONMENT IN HOME

H2. The next question asks about rules of using tobacco inside your home. Please think about everyone who might be in your home including children, adults, visitors, guests, or workers. For tobacco products that are burned, such as cigarettes, cigars, pipes or hookah, which statement best describes the rules about smoking a tobacco product inside your home?

It is not allowed anywhere or at any time inside my home
It is allowed in some places or at sometimes inside my home
It is allowed anywhere and at any time inside my home

999 Prefer not to answer

ASK: All respondents

H3. Other than you, has anyone who lives with you used any of the following during the past 30 days? Select all that apply.

[PROGRAM SO THAT RESPONDENTS CAN SELECT MORE THAN ONE RESPONSE ON 2–5]

Cigarettes
Traditional cigars, cigarillos, little cigars, or filtered cigars, such as Macanudo, Romeo y Julieta, Arturo Fuente, Black & Mild, Swisher Sweets, Dutch Masters, Phillies Blunts, Prime Time, or Winchester
Tobacco out of a water pipe (also called “hookah”)
Electronic vapor products, also called e-cigarettes, e-cigars, e-hookahs, e-pipes, vape pens, tanks, mods, and hookah pens
Any other form of tobacco
No, no one who lives with me has used any form of tobacco during the past 30 days

999 Prefer not to answer

IF ANY RESPONSE 1- 6 IS SELECTED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “YOU CANNOT SELECT THE OPTION ‘PREFER NOT TO ANSWER’ AND ANY OTHER OPTION ’. IN LOWERCASE LETTERS.

IF RESPONSE 6 IS SELECTED WITH ANY OF THE RESPONSES 1 – 5, ERROR MESSAGE SHOULD SAY “YOU CANNOT SELECT THE OPTION “NO, NO ONE WHO LIVES WITH ME HAS USED ANY FORM OF TOBACCO DURING THE PAST 30 DAYS” AND ANY OTHER OPTION”. IN LOWERCASE LETTERS

ASK: All respondents

POLITICAL PHILOSOPHY

H4. How would you describe your overall political philosophy? Would you describe yourself as . . .

Very conservative
Somewhat conservative
Moderate—neither liberal nor conservative
Somewhat liberal
Very liberal
None of the above

999 Prefer not to answer

ASK: All respondents

PHYSICAL HEALTH

H5. In general, how would you rate your physical health?

Poor
Fair
Good
Very good
Excellent

999 Prefer not to answer

ASK: All respondents

MARITAL STATUS

H6. What is your marital status?

Now married–> GO TO H8
Widowed
Divorced
Separated
Never married

999 Prefer not to answer

ASK: All respondents

H7. [IF H6>1 OR H6=999]

Do you share a household with a boyfriend, girlfriend, or partner?

999 Prefer not to answer

ASK: Respondents who are not married.

MILITARY SERVICE

H8. Have you ever served on active duty in the U.S. Armed Forces, Military Reserves, or National Guard? Note: Active duty for the Reserves or National Guard does not include the regular training for the Reserves or Guard. It does include being activated for deployment, such as for the Iraq War.

Yes, on active duty in the past, but not now
No, training for Reserves or National Guard only
No, never served in the military

999 Prefer not to answer

ASK: All respondents

H9. [IF B5=1 OR 3 OR 999]

We would like to get a better estimate of your total HOUSEHOLD income in the past 12 months before taxes. Was it…

Less than $5,000
$5,000 to $7,499
$7,500 to $9,999
$10,000 to $12,499
$12,500 to $14,999
$15,000 to $19,999
$20,000 to $24,999
$25,000 to $29,999
$30,000 to $34,999

999 Prefer not to answer

ASK: All respondents who indicated their total household income in the past 12 months was below $35,000; all respondents who don’t know their total household income in the past 12 months; all respondents who indicated they preferred not to answer what their total household income was in the past 12 months.

H10. [IF B5=2]

We would like to get a better estimate of your total HOUSEHOLD income in the past 12 months before taxes. Was it…

$35,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $74,999
$75,000 to $84,999
$85,000 to $99,999
$100,000 to $124,999
$125,000 to $149,999
$150,000 to $174,999
$175,000 or more

999 Prefer not to answer

ASK: All respondents who indicated their total household income in the past 12 months was $35,000 or more.

MENTAL HEALTH

H11. Now thinking about your mental health, which includes stress, depression, and emotional problems, for how many days during the past 30 days was your mental health not good?

_____ Number of days (Range: 0–30)

999 Prefer not to answer

PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 30

PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX

IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 30” IN LOWERCASE LETTERS

IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A NUMBER OF DAYS WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.

ASK: All respondents

H12. [IF H11 >0] During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

_____ Number of days (Range: 0–30)

999 Prefer not to answer

PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 30

PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX

IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 30” IN LOWERCASE LETTERS

ASK: All respondents

SEX/GENDER

H13. What is your current gender identity?

Male
Female
Trans male/Trans man
Trans female/Trans woman
Genderqueer/Gender non-conforming/Intersex
Different identity

999 Prefer not to answer

ASK: All respondents

H13OT. [IF H13=6]

Please specify your current gender identity.

________ [ALLOW 20 ALPHA CHARACTERS]

999 Prefer not to answer

PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX

ASK: Respondents who indicate a different gender identity than those listed in H13

H14. What sex were you assigned at birth, on your birth certificate?

Male
Female

999 Prefer not to answer

ASK: All respondents

SEXUAL ATTRACTION

H15. People are different in their sexual attraction to other people. Which statement best describes your feelings?

I am only attracted to males
I am mostly attracted to males
I am equally attracted to males and females
I am mostly attracted to females
I am only attracted to females
I am not sure

999 Prefer not to answer

ASK: All respondents

SEXUAL ORIENTATION

H16. Which of the following best represents how you think of yourself?

Lesbian or gay
Straight, that is, not lesbian or gay
Bisexual
Something else
I don’t know the answer

999 Prefer not to answer

ASK: All respondents

H16OT. [IF H16=4]

Please specify how you think of yourself.

________ [ALLOW 20 ALPHA CHARACTERS]

999 Prefer not to answer

PROVIDE A CHECKBOX FOR THE ‘PREFER NOT TO ANSWER’ OPTION. ADD VALIDATION CHECK TO PROHIBIT HAVING BOTH A NUMBER RESPONSE AND A CHECKED BOX

ASK: Respondents who indicated something else best represents them than the responses listed in H16.

ENDCASI. Thank you for your answering these questions.

When you leave this screen, the responses you entered into the laptop can no longer be seen by you, the interviewer, or anyone else who uses this computer. When you are ready, please press NEXT to complete this part of the interview.

ASK: All respondents

ENDCASI2. Please tell your interviewer that you are finished.

INTERVIEWER: ENTER THE CODE TO MOVE TO THE NEXT SECTION.

ASK: All respondents

SECTION AL: LOCATOR MODULE

INSTRUCTIONS TO INTERVIEWER: READ ALL TEXT AND QUESTIONS IN REGULAR TYPE.

[INITIATE CARI RECORDING IF SECA_CONSENTCARI = 1]

AL_INT1. Thank you for completing the interview. Finally, we would like to offer you the opportunity to participate in future interviews (approximately three over the next two years). To help us reach you in the future, it would be helpful if you provided us with some additional contact information. This information will be held securely and confidentially by RTI, and will only be used to help contact you in the future.

CONTINUE

ASK: All respondents

AL_INT2. Would you be willing to give us some additional personal contact information? IF NECESSARY: Your household might be contacted by RTI to verify that I followed the correct steps in completing this interview, and we would also like to be sure that we have the best contact information for you for future interviews. This information will be stored in a secure location (e.g., locked file cabinet, encrypted computer file) and destroyed after 3 years. We will not share this information with anyone outside of the study.

YES
NO–> GO TO EXIT 1

999 PREFER NOT TO ANSWER–> GO TO EXIT 1

ASK: All respondents

[END CARI RECORDING IF SECA_CONSENTCARI = 1]

AL_FNAME. [IF AL_INT2 = 1] We need to record your full name for future mailings, and we want to make sure we have it spelled correctly. Could you spell your first and last name for me?

INTERVIEWER: CONFIRM SPELLING OF NAME BY READING IT BACK TO RESPONDENT.

FIRST NAME: ________[ALLOW 20 ALPHA CHARACTERS]

999 PREFER NOT TO ANSWER

PROGRAMMER: THIS PART OF THE SCREEN CAPTURES THE RESPONDENT’S FIRST NAME AND SHOULD BE DISPLAYED ON THE SAME SCREEN AS AL_LNAME

ASK: Respondents willing to provide additional personal contact information.

AL_LNAME. What is your last name?

LAST NAME: ________ [ALLOW 20 ALPHA CHARACTERS]

999 PREFER NOT TO ANSWER

PROGRAMMER: THIS PART OF THE SCREEN CAPTURES THE RESPONDENT’S LAST NAME AND SHOULD BE DISPLAYED ON THE SAME SCREEN AS AL_FNAME

IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A NAME WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.

ASK: Respondents willing to provide additional personal contact information.

AL_EADV1. [IF AL_INT2 = 1]

Thank you. Do you have a home telephone number?

999 Prefer not to answer

ASK: Respondents willing to provide additional personal contact information

AL_EHPH2A. [IF AL_EADV1= 1]

What is your home telephone number, including area code?

(__ __ __) __ __ __ - __ __ __ __ PHONE NUMBER [ALLOW 10 NUMERIC CHARACTERS]

999 PREFER NOT TO ANSWER

OPEN END NUM

VALIDATION: MIN 0 MAX 9999999999

PROGRAMMER: VALIDATE FORMAT FOR PHONE NUMBER. IF FORMAT IS INCORRECT, PLEASE DISPLAY: “PLEASE VERIFY THIS AREA CODE WITH RESPONDENT. PRESS “CANCEL” TO CORRECT AREA CODE, OR “OK” TO CONTINUE.

IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A TELEPHONE NUMBER WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.

ASK: Respondents who have and are willing to provide a home telephone number

AL_ECPH1 [IF AL_INT2 = 1]

Do you have a cell phone?

999 PREFER NOT TO ANSWER

ASK: Respondents willing to provide additional personal contact information

AL-ECPH1A [IF AL_ECPH1 = 1]

Is it a smartphone?

IF NECESSARY: A smartphone is a cell phone that has many of the functions a computer has. Usually they have a touch screen and you can do things like access your e-mail and install programs on it.

999 PREFER NOT TO ANSWER

ASK: Respondents willing to provide additional personal contact information and have a cell phone

AL_ECPH1B [IF AL_ECPH1 = 1]

What is your current cell phone number, including area code?

(__ __ __) __ __ __ - __ __ __ __ CELL PHONE NUMBER [ALLOW 10 NUMERIC CHARACTERS]

999 PREFER NOT TO ANSWER

OPEN END NUM

VALIDATION: MIN 0 MAX 9999999999

PROGRAMMER: VALIDATE FORMAT FOR PHONE NUMBER. IF FORMAT IS INCORRECT, PLEASE DISPLAY:

“PLEASE VERIFY THIS AREA CODE WITH RESPONDENT. PRESS “CANCEL” TO CORRECT AREA CODE, OR “OK” TO CONTINUE.

ASK: Respondents willing to provide additional personal contact information and have a cell phone

AL_ECPH2 [IF AL_ECPH1A NE 1]

May we use your personal cell phone to contact you about the study?

999 PREFER NOT TO ANSWER

ASK: Respondents willing to provide additional personal contact information who do not have a smartphone or preferred not to indicate whether they have a smartphone

AL_ECPH3 [IF AL_ECPH1A = 1]

Do you send and receive text messages on your personal cell phone?

999 PREFER NOT TO ANSWER

ASK: Respondents willing to provide additional personal contact information and who have a smartphone

AL_ECPH4 [IF AL_ECPH3 = 1]

May we send text messages to contact you about the study?

999 PREFER NOT TO ANSWER

ASK: Respondents willing to provide additional personal contact information and who have a smartphone and indicated they can send and receive text messages on their person cell phone

AL_EPEM1 [[IF AL_INT2 = 1]

Do you have a personal (non-work) e-mail address that you use at home?

999 PREFER NOT TO ANSWER

ASK: Respondents willing to provide additional personal contact information

AL_EPEM2 [IF AL_EPEM1 = 1] What is this e-mail address?

INTERVIEWER: ENTER THE ADDRESS AS: ___________@______ [ALLOW 40 CHARACTERS]

999 PREFER NOT TO ANSWER

ASK: Respondents willing to provide additional personal contact information and have a personal (non-work) e-mail address that they use at home

AL_EPEM3 [IF AL_EPEM1 = 1 AND IF AL_EPEM2 NE 999]

May we use your personal email address to contact you about the study?

999 Prefer not to answer

ASK: Respondents willing to provide additional personal contact information, have a personal (non-work) e-mail address that they use at home, and provided the e-mail address

[INITIATE CARI RECORDING IF SECA_CONSENTCARI = 1]

AL_INT3 [IF AL_INT2 = 1]

It is often difficult to get in touch with people if their contact information changes. Should this occur, we would still like you to participate in the follow-up interviews. In case we have difficulty getting in touch with you in the future, could you please give me the contact information for another person, who is not currently living with you, who will always know your whereabouts? This information will be kept confidential and not shared with anyone outside the study. We will only use this information if we need to contact you and are unable to do so using the information you have already provided to us.

IF NECESSARY: This might be a family member, a close friend, or someone else who knows where you are. We would only contact this person if we could not reach you.

999 Prefer not to answer

ASK: Respondents willing to provide additional personal contact information

[END CARI RECORDING IF SECA_CONSENTCARI = 1]

AL_A1NAF [IF AL_INT3 = 1]

What is this person's name?

FIRST NAME: ________ [ALLOW 20 ALPHA CHARACTERS]

999 PREFER NOT TO ANSWER

PROGRAMMER: THIS PART OF THE SCREEN CAPTURES THE ALTERNATE PERSON'S FIRST NAME AND SHOULD BE DISPLAYED ON THE SAME SCREEN AS AL_A1NAL

ASK: Respondents willing to provide additional personal contact information and agreed to give contact information for another person who is not currently living with them and who will always know their whereabouts

AL_A1NAL [IF AL_INT3 = 1]

What is this person's name?

LAST NAME: ________ [ALLOW 20 ALPHA CHARACTERS]

999 PREFER NOT TO ANSWER

PROGRAMMER: THIS PART OF THE SCREEN CAPTURES THE ALTERNATE PERSON’S LAST NAME AND SHOULD BE DISPLAYED ON THE SAME SCREEN AS AL_A1NAF

AL_A1REL [IF AL_INT3 = 1]

How is [IF AL_A1NAF NE 999 FILL AL_A1NAF, ELSE FILL: this person] related to you?

MOTHER
FATHER
STEPMOTHER (INCLUDING FOSTER OR ADOPTED MOTHER)
STEPFATHER (INCLUDING FOSTER OR ADOPTED FATHER)
GRANDMOTHER
GRANDFATHER
DAUGHTER
SON
AUNT
UNCLE
SISTER (INCLUDING HALF, STEP, FOSTER OR ADOPTED SISTER)
BROTHER (INCLUDING HALF, STEP, FOSTER OR ADOPTED BROTHER)
OTHER RELATIVE
FRIEND
GIRLFRIEND (NOT LIVING WITH RESPONDENT)
BOYFRIEND (NOT LIVING WITH RESPONDENT)
COWORKER
HUSBAND/WIFE (NOT LIVING WITH RESPONDENT)
EX-HUSBAND OR WIFE
OTHER, SPECIFY

999 PREFER NOT TO ANSWER

PROGRAMMER: IF AL_A1NAF NE 999 FILL AL_A1NAF, ELSE FILL: this person

DISPLAY: AL_A1NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A1NAF.

AL_A1RELs [IF AL_A1REL = 20]

Please specify how [IF AL_A1NAF NE 999 FILL AL_A1NAF, ELSE FILL: this person] is related to you?

SPECIFY:_____________[ALLOW 25 ALPHA CHARACTERS]

999 PREFER NOT TO ANSWER

PROGRAMMER: IF AL_A1NAF NE 999 FILL AL_A1NAF, ELSE FILL: this person

DISPLAY: AL_A1NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A1NAF.

AL_A1HPH [IF AL_INT3 = 1]

What is [IF AL_A1NAF NE 999 FILL AL_A1NAF’s, ELSE FILL: this person’s] home telephone number, including area code?

HOME TELEPHONE NUMBER: __________________________[ALLOW 10 NUMERIC CHARACTERS]

999 PREFER NOT TO ANSWER

OPEN END NUM

VALIDATION: MIN 0 MAX 9999999999

PROGRAMMER: VALIDATE FORMAT FOR PHONE NUMBER. IF FORMAT IS INCORRECT, PLEASE DISPLAY:

“PLEASE VERIFY THIS AREA CODE WITH RESPONDENT. PRESS “CANCEL” TO CORRECT AREA CODE, OR “OK” TO CONTINUE.

IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER A PHONE NUMBER WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.

IF AL_A1NAF NE 999 FILL AL_A1NAF’s, ELSE FILL: this person’s

DISPLAY: AL_A1NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A1NAF.

AL_A1CPH [IF AL_INT3 = 1]

What is [IF AL_A1NAF NE 999 FILL AL_A1NAF’s, ELSE FILL: this person’s] cell phone number, including area code?

CELL PHONE NUMBER:______________ [ALLOW 10 NUMERIC CHARACTERS]

999 PREFER NOT TO ANSWER

OPEN END NUM

VALIDATION: MIN 0 MAX 9999999999

PROGRAMMER: VALIDATE FORMAT FOR PHONE NUMBER. IF FORMAT IS INCORRECT, PLEASE DISPLAY:

“PLEASE VERIFY THIS AREA CODE WITH RESPONDENT. PRESS “CANCEL” TO CORRECT AREA CODE, OR “OK” TO CONTINUE.

IF AL_A1NAF NE 999 FILL AL_A1NAF’s, ELSE FILL: this person’s

DISPLAY: AL_A1NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A1NAF.

AL_A1PEM [IF AL_INT3 = 1]

What is [IF AL_A1NAF NE 999 FILL AL_A1NAF’s, ELSE FILL: this person’s] personal e-mail address?

Interviewer: Enter the address as _______@___[ALLOW 40 CHARACTERS]

999 PREFER NOT TO ANSWER

PROGRAMMER: IF AL_A1NAF NE 999 FILL AL_A1NAF’s, ELSE FILL: this person’s

IF A NUMERIC RESPONSE IS PROVIDED AND THE ‘PREFER NOT TO ANSWER’ BOX IS ALSO CHECKED, ERROR MESSAGE SHOULD SAY “PLEASE DO NOT ENTER AN EMAIL ADDRESS WHILE ALSO SELECTING ‘PREFER NOT TO ANSWER’. IN LOWERCASE LETTERS.

DISPLAY: AL_A1NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A1NAF.

[INITIATE CARI RECORDING IF SECA_CONSENTCARI = 1]

AL_INT4 [AL_INT3 = 1]

To be certain that we are able to contact you for a future interview, we would also like the contact information for one additional person, who is not currently living with you, who would always know your whereabouts. This information will be kept confidential and will only be used by the study to help contact you for a future interview. Could you share this information with us?

If necessary, read: This might be a family member, a close friend, or someone else who knows where you are. We would only contact this person if we could not reach you.

999 PREFER NOT TO ANSWER

[END CARI RECORDING IF SECA_CONSENTCARI = 1]

AL_A2NAF [IF AL_INT4 = 1]

What is this person's name?

FIRST NAME: ________[ALLOW 20 ALPHA CHARACTERS]

999 PREFER NOT TO ANSWER

PROGRAMMER: THIS PART OF THE SCREEN CAPTURES THE ALTERNATE PERSON'S FIRST NAME AND SHOULD BE DISPLAYED ON THE SAME SCREEN AS AL_A2NAL

AL_A2NAL [IF AL_INT4 = 1]

What is this person's name?

LAST NAME: ________[ALLOW 20 ALPHA CHARACTERS]

999 PREFER NOT TO ANSWER

PROGRAMMER: THIS PART OF THE SCREEN CAPTURES THE ALTERNATE PERSON’S LAST NAME AND SHOULD BE DISPLAYED ON THE SAME SCREEN AS AL_A2NAF

AL_A2REL [IF AL_INT4 = 1]

How is [IF AL_A2NAF NE 999 FILL AL_A2NAF, ELSE FILL: this person] related to you?

MOTHER
FATHER
STEPMOTHER (INCLUDING FOSTER OR ADOPTED MOTHER)
STEPFATHER (INCLUDING FOSTER OR ADOPTED FATHER)
GRANDMOTHER
GRANDFATHER
DAUGHTER
SON
AUNT
UNCLE
SISTER (INCLUDING HALF, STEP, FOSTER OR ADOPTED SISTER)
BROTHER (INCLUDING HALF, STEP, FOSTER OR ADOPTED BROTHER)
OTHER RELATIVE
FRIEND
GIRLFRIEND (NOT LIVING WITH RESPONDENT)
BOYFRIEND (NOT LIVING WITH RESPONDENT)
COWORKER
HUSBAND/WIFE (NOT LIVING WITH RESPONDENT)
EX-HUSBAND OR WIFE
OTHER, SPECIFY

999 PREFER NOT TO ANSWER

PROGRAMMER: IF AL_A2NAF NE 999 FILL AL_A2NAF, ELSE FILL: this person

DISPLAY: AL_A1NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A2NAF.

AL_A2RELs [IF AL_A2REL=20]

Please specify how [IF AL_A2NAF NE 999 FILL AL_A2NAF, ELSE FILL: this person] is related to you?

SPECIFY:_____________[ALLOW 25 ALPHA CHARACTERS]

999 PREFER NOT TO ANSWER

PROGRAMMER: IF AL_A2NAF NE 999 FILL AL_A2NAF, ELSE FILL: this person

DISPLAY: AL_A2NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A2NAF.

AL_A2HPH [IF AL_INT4 = 1]

What is [IF AL_A2NAF NE 999 FILL AL_A2NAF’s, ELSE FILL: this person’s] home telephone number, including area code?

HOME TELEPHONE NUMBER: _______________[ALLOW 10 NUMERIC CHARACTERS]

999 PREFER NOT TO ANSWER

OPEN END NUM

VALIDATION: MIN 0 MAX 9999999999

PROGRAMMER: VALIDATE FORMAT FOR PHONE NUMBER. IF FORMAT IS INCORRECT, PLEASE DISPLAY:

“PLEASE VERIFY THIS AREA CODE WITH RESPONDENT. PRESS “CANCEL” TO CORRECT AREA CODE, OR “OK” TO CONTINUE.

IF AL_A2NAF NE 999 FILL AL_A2NAF’s, ELSE FILL: this person’s

DISPLAY: AL_A2NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A2NAF.

AL_A2CPH [IF AL_INT4 = 1]

What is [IF AL_A2NAF NE 999 FILL AL_A2NAF’s, ELSE FILL: this person’s] cell phone number, including area code?

CELL PHONE NUMBER:______________ [ALLOW 10 NUMERIC CHARACTERS]

999 PREFER NOT TO ANSWER

OPEN END NUM

VALIDATION: MIN 0 MAX 9999999999

PROGRAMMER: VALIDATE FORMAT FOR PHONE NUMBER. IF FORMAT IS INCORRECT, PLEASE DISPLAY:

“PLEASE VERIFY THIS AREA CODE WITH RESPONDENT. PRESS “CANCEL” TO CORRECT AREA CODE, OR “OK” TO CONTINUE.

IF AL_A2NAF NE 999 FILL AL_A2NAF’s, ELSE FILL: this person’s

DISPLAY: AL_A2NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A2NAF.

AL_A2PEM [IF AL_INT4 = 1]

What is [IF AL_A2NAF NE 999 FILL AL_A2NAF’s, ELSE FILL: this person’s] personal e-mail address?

Interviewer: Enter the address as _________@____[ALLOW 40 CHARACTERS]

999 PREFER NOT TO ANSWER

PROGRAMMER: IF AL_A2NAF NE 999 FILL AL_A2NAF’s, ELSE FILL: this person’s

DISPLAY: AL_A2NAF is the name who of the person not currently living with the R who will always know their whereabouts, collected at AL_A2NAF.

INTERVIEWER READ: Thank you for providing this information.

SECTION J: APP-BASED PORTION OF STUDY

[INITIATE CARI RECORDING IF SECA_CONSENTCARI = 1]

APP_CONSENT [If AL-ECPH1A= 1]

[INSERT APP CONSENT SCRIPT]

ASK: Respondents willing to provide additional personal contact information and have a smartphone

APP_REFUSAL [IF APP_CONSENT = 2]

INTERVIEWER: WHY DID THE PARTICIPANT REFUSE TO DOWNLOAD THE APP? SELECT ALL THAT APPLY

[PROGRAM SO THAT INTERVIEWERS CAN SELECT MORE THAN ONE RESPONSE]

APP_REFUSAL1 1 DOES NOT HAVE A SMARTPHONE AFTER ALL

APP_REFUSAL2 2 CONCERNED ABOUT PRIVACY

APP_REFUSAL3 3 CONCERNED ABOUT DATA USAGE

APP_REFUSAL4 4 PARTICIPANT REFUSED AFTER DIFFICULTY IN DOWNLOADING AND INSTALLING THE APP

APP_REFUSAL5 5 SAID THE INCENTIVE IS TOO SMALL

APP_REFUSAL6 6 SOME OTHER REASON (SPECIFY)

ASK: Asked of interviewers when participant refuses to participate in the app-based portion of the study

APP_REFOTR [IF APP_REFUSAL = 6]

INTERVIEWER: SPECIFY WHY PARTICIPANT REFUSED TO DOWNLOAD THE APP

SPECIFY:_____________[ALLOW 25 ALPHA CHARACTERS]

ASK: Asked of interviewers that indicate there is another reason the participant refused to participate in the app-based portion of the study

APP_INSTRUCTIONS1 [APP_CONSENT = 1]

[INSERT APP INSTRUCTIONS]

[END CARI RECORDING IF SECA_CONSENTCARI = 1]

APP_EMAIL [IF APP_CONSENT = 1 AND ((AL_EPEM1 = 2 OR 999) OR (AL_EPEM2 = 999))]

We need your e-mail address to contact you about the study, such as providing information about your gift for completing a short questionnaire. What is your personal (non-work) e-mail address that you use at home?

INTERVIEWER:

E NTER THE ADDRESS AS: _______@___ [ALLOW 40 CHARACTERS] GO TO EXIT 3

I do not have an e-mail address GO TO EXIT4

9 99 PREFER NOT TO ANSWER GO TO EXIT4

ASK: Respondents who agreed to app-based data collection but did not provide an e-mail address

[IF (AL-ECPH1A = 2 OR 999) OR (AL_ECPH1 = 2 or 999)]

EXIT 1: Thank you for answering all of our questions. Here is $25 in cash as a token of our appreciation for your participation.

FI PROVIDE RESPONDENT WITH $25 CASH.

I also need to fill out a receipt to certify you received (or declined) the cash incentive. Since maintaining the privacy of your information is important to us, I will not include your name on the receipt.

FI FILL OUT RECEIPT AND PROVIDE RESPONDENT WITH PINK COPY OF RECEIPT.

Here is a copy of the receipt for your records. Thank you again for answering all of our questions

1 RESPONDENT ACCEPTS INCENTIVE

2 RESPONDENT DECLINES INCENTIVE

Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 40 minutes per response (time to read and agree to the assent/consent and respond to the questionnaire). Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to PRAStaff@fda.hhs.gov.

PROGRAMMER: COMPLETED CASE THAT WILL NOT PARTICIPATE IN APP-BASED DATA COLLECTION SHOULD DISPOSITION AS 2690.

ASK: Respondents reaching the end of the survey who either don’t have a smartphone or won’t provide contact information

[IF APP_CONSENT = 2]

EXIT 2: Thank you for considering this part of our study. Here is $25 in cash as a token of our appreciation for your participation.

FI PROVIDE RESPONDENT WITH $25 CASH.

FI FILL OUT RECEIPT AND PROVIDE RESPONDENT WITH PINK COPY OF RECEIPT.

Here is a copy of the receipt for your records. Thank you again for answering all of our questions.

1 RESPONDENT ACCEPTS INCENTIVE

2 RESPONDENT DECLINES INCENTIVE

PROGRAMMER: COMPLETED CASE THAT WILL NOT PARTICIPATE IN APP-BASED DATA COLLECTION SHOULD DISPOSITION AS 2690.

ASK: Respondents reaching the end of the survey who have a smartphone but do not want to participate in the app-based portion of the study

[APP_CONSENT = 1 AND (AL_EPEM2 NE 999 OR (APP_EMAIL NE 999 OR “I do not have an email address”))]

EXIT 3: Thank you for answering our questions. As a reminder, the app will not work if you delete the app, change the app settings, or turn off location services. As a result, we hope that you will not delete the app, change any of the app’s settings, or turn off location services while participating in this study. If you want to stop participating in this portion of the study, please e-mail us at fdastudy@rti.org, and we will send you instructions on how to remove the app from your phone. If you change phones, accidentally delete the app, or lose your phone, or the app stops working, please contact RTI study staff at fdastudy@rti.org.

Here is $25 in cash as a token of our appreciation for your participation.

FI PROVIDE RESPONDENT WITH $25 CASH.

FI FILL OUT RECEIPT AND PROVIDE RESPONDENT WITH PINK COPY OF RECEIPT.

Here is a copy of the receipt for your records. Thank you again for answering all of our questions.

1 RESPONDENT ACCEPTS INCENTIVE

2 RESPONDENT DECLINES INCENTIVE

PROGRAMMER: COMPLETED CASE THAT AGREES TO APP-BASED DATA COLLECTION SHOULD DISPOSITION AS 2691.

ASK: Respondents reaching the end of the survey who want to participate in the app-based portion of the study

EXIT4 [IF APP_EMAIL = 999 OR “I do not have an e-mail address” ] We provide electronic gift cards for participation in the app surveys via email. If you aren’t comfortable providing your e-mail address we can help you uninstall the app. INTERVIEWER: ASK RESPONDENT IF S/HE WOULD LIKE HELP UNINSTALLING THE APP.

Thank you for answering all of our questions. Here is $25 in cash as a token of our appreciation for your participation.

FI PROVIDE RESPONDENT WITH $25 CASH.

FI FILL OUT RECEIPT AND PROVIDE RESPONDENT WITH PINK COPY OF RECEIPT.

Here is a copy of the receipt for your records. Thank you again for answering all of our questions.

1 RESPONDENT ACCEPTS INCENTIVE

2 RESPONDENT DECLINES INCENTIVE

PROGRAMMER: COMPLETED CASE THAT WILL NOT PARTICIPATE IN APP-BASED DATA COLLECTION SHOULD DISPOSITION AS 2690.

ASK: Respondents who agreed to app-based data collection but would not provide an e-mail address

EXIT5_REFUSAL [IF SECA_CONSENT = 2]

FI: ATTEMPT TO CONVERT THE REFUSAL. IF CONVERT GO BACK TO INFORMED CONSENT AND UPDATE RESPONSE TO ‘YES’. IF UNABLE TO CONVERT, WHY DID THE PARTICIPANT REFUSE? SELECT ALL THAT APPLY

[PROGRAM SO THAT INTERVIEWERS CAN SELECT MORE THAN ONE RESPONSE]

CONCERNED ABOUT CONFIDENTIALITY OR PRIVACY
SAID THE INCENTIVE IS TOO SMALL
TOO BUSY/NO TIME/DID TOO MANY ALREADY
SURVEYS/GOVT. INVASIVE
“NOTHING IN IT FOR ME”/UNCOOPERATIVE
SOME OTHER REASON (SPECIFY)

ASK: Respondents who do not consent to the interview

REFOTR [IF EXIT5_REFUSAL = 6]

INTERVIEWER: SPECIFY WHY PARTICIPANT REFUSED

SPECIFY:_____________[ALLOW 25 ALPHA CHARACTERS]

ASK: Asked of interviewers that indicate there is another reason the participant refused to participate

REMAIL: COMBINE EMAIL COLLECTED IN AL_EPEM2 AND APP_EMAIL INTO 1 VARIABLE FOR EXPORT.

CAPI REFUSAL STATUS CODE TRIGGERS

CAPI Question	Final	Input	Medium	Title
EXIT5_REFUSAL = 5	2412	Manual	IFMS	Refusal - Nothing in it for me/Uncooperative
EXIT5_REFUSAL = 3	2413	Manual	IFMS	Refusal - Too Busy/No Time
EXIT5_REFUSAL = 2	2414	Auto	IFMS	Refusal - Incentive too small
EXIT5_REFUSAL = 4	2415	Auto	IFMS	Refusal – Surveys/Govt. invasive
EXIT5_REFUSAL = 1	2416	Auto	IFMS	Refusal – Confidentiality or privacy
EXIT5_REFUSAL = 6		2429	Manual	IFMS

OMB No: 0910-#### Expiration Date: ##/##/20##

RIHSC #17-082CTP

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Gittleson, Daniel
File Modified	0000-00-00
File Created	2021-01-20

Adult smokers ages 25 to 54; Wave 1 Questionnaire

Evaluation of the Food and Drug Administration’s Point-of-Sale Campaign

Attachment_02a_POSITEv_Wave_1_questionnaire Clean