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pdfATTACHMENT 1.
QUESTIONNAIRES: ENGLISH-LANGUAGE VERSIONS
[CLEAN VERSIONS]
Page 1 of 143
Attachment 1-1: Mail Screener
Food and Drug Administration
Center for Tobacco Products
OMB Number:
Expiration Date:
0910-0815
02/28/2023
Thank you for filling out this short survey. Your household’s answers to the questions will be kept
private to the fullest extent allowable by law. They will be used to determine if someone in your
household may be eligible to take part in an important study for the U.S. Food and Drug Administration
(FDA). Your participation is voluntary and the survey will only take 1-2 minutes of your time to
complete.
Start Here. Please use blue or black ink to complete the survey.
1. Please think about everyone who currently lives at this address. How many adults 18 years of age
or older live at this address?
Adults 18 years of age or older
2. Does anyone 18 years of age or older living at this address now smoke cigarettes?
1
2
Yes
No
3. Does anyone 18 years of age or older living at this address now smoke regular cigars, cigarillos, or
little filtered cigars? “Cigarillos” are medium cigars that sometimes are sold with plastic or
wooden tips. Some common brands are Black and Mild, Swisher Sweets, Dutch Masters, and
Phillies Blunts. Cigarillos are usually sold individually or in packs of 5 or fewer. Little filtered cigars
look like cigarettes and are usually brown in color. Like cigarettes, little filtered cigars have a
spongy filter and are sold in packs of 20. Some common brands are Prime Time and Winchester.
1
2
Yes
No
4. Does anyone 18 years of age or older living at this address now use smokeless tobacco products?
Smokeless tobacco products are placed in the mouth or nose and can include chewing tobacco,
snuff, dip, snus (snoose) or dissolvable tobacco. Some common brand names are Skoal,
Copenhagen, Grizzly, Levi Garrett, or Red Man.
1
2
Yes
No
5. Can you connect to the Internet at this address?
1
2
Yes
No
Thank you for completing the survey!
Please place your questionnaire in the provided envelope and return to RTI International. If the envelope has been
misplaced, please mail the questionnaire to:
RTI International (0212926.017.000.006)
5265 Capital Boulevard
Raleigh, NC 27616
Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 2 minutes per response to complete the
survey questions. Send comments regarding this burden estimate or any other aspects of this information collection, including suggestions for
reducing burden, to PRAStaff@fda.hhs.gov.
FORM ID
Page 2 of 143
Attachment 1-2: Field Screening Instrument
National Panel of Tobacco Consumer Studies
Field Screening (SC) Instrument
RTI_Mobile Platform
OMB Number: 0910-0815
Expiration Date: 02/28/2023
A. INTRODUCTION
CONFIRM YOU HAVE OPENED THE CORRECT CASE. IF YOU ARE NOT IN THE
CORRECT CASE, BREAK OFF AND LOCATE THE CORRECT CASE
SCBLANG: INTERVIEWER: WHAT LANGUAGE IS BEING USED TO CONDUCT THIS
INTERVIEW?
1
2
ENGLISH
SPANISH
SCBINTRO: Hello, my name is __________ from Research Triangle Institute in
North Carolina. We are conducting a nationwide study sponsored by the U.S. Food
and Drug Administration (FDA). We mailed a letter to your household prior to my
visit.
HAND R COPY OF LETTER IF NECESSARY. ALLOW TIME TO READ.
B. ADDRESS VERIFICATION
SCB1. For survey purposes, I need to confirm that I have the correct address. Is it
[FILL ADDRESS]?
1
2
3
YES, VERIFIED ADDRESS IS CORRECT
NO, EXIT AND FIND CORRECT ADDRESS
GO TO SCEXIT2
ADDRESS CORRECT, MINOR EDITS NEEDED. GO TO SCEXIT2A
PROGRAM EACH ADDRESS UPDATE ELEMENT AS SINGLE QUESTION AS NEEDED. SCB1B =
STREET NUMBER, SCB1C = STREET NAME, SCB1D = CITY, SCB1E =STATE, SCB1F= ZIP
SCB2. INTERVIEWER: IDENTIFY KNOWLEDGEABLE ADULT RESIDENT TO SCREEN.
First let me verify: do you live here? (Are you a member of this household?)
(IF NOT OBVIOUS): And are you 18 years of age or older?
[IF NO TO EITHER, ASK FOR A KNOWLEDGEABLE ADULT RESIDENT AND BEGIN
INTRO AGAIN.]
1
ADULT SCREENING R AVAILABLE, CONTINUE
GO TO SCBCONSENT
1
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ADULT SCREENING R NOT CURRENTLY AVAILABLE GO TO SCEXIT3
NO HH RESIDENTS 18+
GO TO SCB3
2
3
SCB3. Just to confirm, is there anyone living in this household who is 18 years of
age or older?
YES
NO
1
2
ASK FOR ADULT RESIDENT, GO BACK TO INTRO
GO TO SCEXIT4
SCBCONSENT. SCREENER INFORMED CONSENT: We are working with the FDA to
create a large, national survey panel as part of the National Panel of Tobacco
Consumer Studies, or TCS. This address is one of more than 30,000 addresses
across the U.S. that has been randomly selected. We are contacting this household
to determine if anyone who lives here may be eligible for the panel. My questions
will only take 5-10 minutes of your time. Your answers to the questions will be
kept private to the fullest extent allowable by law, and your participation is
voluntary. If we select someone from your household to take part in the panel,
that person will have the chance to receive cash payments for participating in the
TCS surveys.
CONTINUE
SCB4. Are there any other living quarters within this structure or at this address,
such as a separate apartment with a separate entrance?
YES
NO
1
2
GO TO SCCINTRO
SCB5. Do the occupants of the other living quarters live and eat separately from
the residents of this household? (PROBE IF NEEDED: In other words, do the
occupants live on their own or do they share common space and food?)
YES, OCCUPANTS LIVE SEPARATELY
NO, OCCUPANTS SHARE COMMON FOOD/SPACE
1
2
GO TO SCCINTRO
SCB6. Do the occupants of the additional living quarters have direct access from
the outside or through a common hall?
YES
NO
1
2
GO TO SCCINTRO
SCB7A. FI: DID YOU FIND 5 OR MORE NEW LQs?
1
2
YES
NO GO TO SCB7
SCB7AA. PLEASE COLLECT DETAILED INFO ABOUT ADDITIONAL LQS (5+ LQS) AND
CONTACT YOUR FS UPON LEAVING THE HOME.
CONTINUE GO TO SCCINTRO
2
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SCB7. INTERVIEWER: OCCUPANTS OF ADDITIONAL LQs LIVE ON OWN AND HAVE
DIRECT ACCESS FROM OUTSIDE/COMMON HALL. ENTER ADDRESS OF
SEPARATE LQs. INCLUDE STREET NUMBER, NAME, AND UNIT OR
APARTMENT NUMBER.
[COLLECT UP TO 4]
LQ
LQ
LQ
LQ
1
2
3
4
STREET
STREET
STREET
STREET
NUMBER:_________
NUMBER:_________
NUMBER:_________
NUMBER:_________
STREET
STREET
STREET
STREET
NAME
NAME
NAME
NAME
&
&
&
&
UNIT/APARTMENT
UNIT/APARTMENT
UNIT/APARTMENT
UNIT/APARTMENT
#:_________
#:_________
#:_________
#:_________
[INTERVIEWER: RECORD A DESCRIPTION IF ADDRESS IS NOT KNOWN.]
SCEXIT2. Thank you for answering our questions, but I have the wrong address.
Have a nice day/evening. [EXIT SURVEY. DO NOT ASSIGN EVENT. KEEP AT
MOST CURRENT STATUS/EVENT CODE.]
SCEXIT2A. INTERVIEWER: TAP EXIT. THEN TAP MENU. EDIT ADDRESS AND
MODIFY ADDRESS. TAP MENU AGAIN TO UPDATE. RETURN TO SCREENING
INSTRUMENT. SELECT ‘YES, VERIFIED ADDRESS IS CORRECT’ AND
PROCEED. [DO NOT ASSIGN EVENT. KEEP AT MOST CURRENT
STATUS/EVENT CODE.]
SCEXIT3. [EXIT/BREAKOFF] OBTAIN NAME, DATE, TIME TO RETURN
C. HOUSEHOLD ROSTER
SCCINTRO: Next I would like to ask a few questions about you and your
household.
(TASK 1. BUILD LIST 1: ADULT HOUSEHOLD MEMBERS)
SCC1. First, including yourself, how many adults 18 years of age or older are living
or staying at this address? [IF SCB6 = 1 OR SCB7 = 1, FILL]: Please do not
include persons who live on their own in separate living quarters at this
address or within this structure, such as a separate apartment with a
separate entrance.
[FILL SAMPLE ADDRESS FOR REFERENCE. USE UPDATED ADDRESS FROM
SECTION A IF APPLICABLE.]
INTERVIEWER PROBE IF NEEDED:
•
INCLUDE adults who are away at school or college, lodgers, boarders, or
people you employ who live here.
•
INCLUDE adults who usually stay here but are temporarily away for reasons
such as visiting friends, traveling for their jobs, or in “general” hospitals.
•
[DISPLAY IF SCB5 = 2 OR SCB6 = 2 OR SCB7 = 2]: INCLUDE adults who
share common food or space but that live in other living quarters at the
address.
3
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SCC2. [LOOP 1]: What is your name?
[LOOP 2 (IF SCC1 = 2 OR MORE)]: Please give me the names of all the other
adults age 18 and older who live or stay at this address. [PROBE: What are
the names of the other adults who live or stay here? Let’s start with the
oldest and work down to the youngest adult in this household.]
INTERVIEWER: ASK FOR FULL NAMES, BUT ACCEPT FIRST NAMES, NICKNAMES OR
INITIALS IF NECESSARY. TRY TO DISTINGUISH NAMES (Tom vs. Tom Jr.). ASSURE
R OF PRIVACY.
SCC3. Do any other adults age 18 or older usually live here or stay here?
1
YES
ADD NAME(S) TO ROSTER
2
NO
GO TO CHECK BOX 1
INTERVIEWER: RECORD ALL NAMES. ASK FOR FULL NAMES, BUT ACCEPT FIRST
NAMES, NICKNAMES OR INITIALS IF NECESSARY. TRY TO DISTINGUISH NAMES
(Tom vs. Tom Jr.). ASSURE R OF PRIVACY.
NAMEDUP. [NAME ENTERED] HAS BEEN PREVIOUSLY ENTERED. PROBE FOR
UNIQUE NAME, AND RE-ENTER.
TASK 2. DETERMINE "HOUSEHOLDER" (HHNAME FILL) FOR RELATIONSHIP
MAPPING)
CHECK BOX 1:
IF ROSTER CONTAINS ONLY 1 ADULT GO TO CHECK BOX 2.
IF ROSTER CONTAINS 2 OR MORE ADULTS CONTINUE
SCC4. Please tell me the name of the adult or one of the adults living here who
owns or rents this home. We’ll refer to this person as the “householder.”
INTERVIEWER: PICK “HOUSEHOLDER” FROM DISPLAYED ROSTER. IF SCREENING
RESPONDENT IS ONE OF THE “HOUSEHOLDERS,” SELECT HIM/HER FROM ROSTER.
[PROGRAMMER: IDENTIFY SELECTED “HOUSEHOLDER” AS “HHNAME” FILL.]
SCC5INTRO. Now I have a few questions about the adults who live in this
household. Let’s start with you.
(TASK 3. GATHER KEY CHARACTERISTICS OF EVERYONE ON LIST 1)
CHECK BOX 2:
IF ROSTER CONTAINS ONLY 1 ADULT CODE THE ADULT AS “HOUSEHOLDER (0)” IN SCC5
AND GO TO SCC6.
IF ROSTER CONTAINS 2 OR MORE ADULTS ASK SCC5-SCD4 FOR EACH ADULT ON LIST 1.
4
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SCC5. [IF LOOP 1 (SCREENING R)]: How are you related to the householder, [FILL
HHNAME NAME]?
[IF LOOP 2+]: [IF LOOP 2: Now let's talk about the other adults in the
household.] How is [FILL NAME] related to [IF SCREENING R IS
HOUSEHOLDER IN SCC4, FILL: “you”/ELSE, FILL “[HHNAME]”?]
[DISPLAY OPTION 0 (HOUSEHOLDER) ONLY UNTIL SELECTED.]
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
HOUSEHOLDER (OWNS OR RENTS HOME)
HUSBAND
WIFE
SON (INCLUDES STEP)
DAUGHTER (INCLUDES STEP)
SON-IN-LAW/DAUGHTER-IN-LAW
BROTHER (INCLUDES STEP)
SISTER (INCLUDES STEP)
PARENT/GUARDIAN (INCLUDING STEP)
GRANDPARENT
GRANDCHILD
LIVE-IN PARTNER
FRIEND/ROOMMATE
OTHER RELATIVE
OTHER NON-RELATIVE
RELATIONSHIP UNSPECIFIED
SCC6. [IF LOOP 1]: INTERVIEWER: CODE GENDER OF R.
[IF LOOP 2+]: ASK IF NECESSARY: Is [FILL NAME] male or female?
1
2
-2
MALE
FEMALE
REFUSED
SCC7. [IF LOOP 1]: How old are you? [IF LOOP 2+]: How old is [FILL NAME]?
_____ AGE (RANGE: 18-110)
[If DK, REF THEN ASK SCC7A]
SCC7A. Providing an age is important. This ensures we can accurately determine
whether [you are] or [fill person name] is] eligible to participate in the
panel. Can you confirm which of the following age categories [you
belong/[fill person name] belongs] to?
1
2
3
4
5
-1
18-25
26-34
35-49
50-74
75 +
DON’T KNOW
5
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-2
REFUSED
[IF STILL DK, REF, CONTINUE WITH SCC8] NOTE: THIS PERSON WOULD NOT BE
CONSIDERED IN THE HH.
SCC8. [IF LOOP 1, FILL]: Are you/ELSE: Is [FILL NAME]] currently serving on
active duty in the U.S. Armed Forces, Military Reserves or National Guard?
[FILL FOR LOOP 1 ONLY]: 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 war in Afghanistan.
1
2
-1
-2
YES
NO
DON’T KNOW
REFUSED
INTERVIEWER: IF ASKED, THE US ARMED FORCES ARE ARMY, NAVY, AIR FORCE,
AND MARINE CORPS.
CHECK BOX 3:
IF SCC5 = 1 OR 2 FOR ADULT BEING DISCUSSED SET SCC9 TO 1 (MARRIED) GO TO SCC10.
SCC9. [IF LOOP 1, FILL: Are you/ELSE FILL: Is [NAME]…[READ LIST]?
1
2
3
4
5
-1
-2
Married or living with a partner
Widowed
Divorced
Separated
Never married
DON’T KNOW
REFUSED
SCC10. What is the highest grade or year of school (IF LOOP 1, FILL "you have",
ELSE FILL "[NAME] has") completed?
INTERVIEWER: FOR THOSE CURRENTLY IN SCHOOL, THIS DOES NOT INCLUDE THE
CURRENT YEAR OF SCHOOL, UNLESS IT IS ALREADY COMPLETED.
1
2
3
4
5
-1
-2
LESS THAN HIGH SCHOOL
HIGH SCHOOL GRADUATE OR GED
SOME COLLEGE/VOCATIONAL SCHOOL (NO DEGREE)
2-YEAR COLLEGE/VOCATIONAL/ASSOCIATE’S DEGREE
4-YEAR COLLEGE DEGREE OR HIGHER(E.G., BA, BS, MA, MS, Ph.D)
DON’T KNOW
REFUSED
SCC11. In the past 30 days, did (IF LOOP 1, FILL "you", ELSE FILL "[NAME]") do
any work for pay, including both full-time and part-time work?
1
2
-1
YES
NO
DON’T KNOW
6
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-2
REFUSED
SCC12. (IF LOOP 1, FILL "Are you", ELSE FILL "Is [NAME]") Hispanic, [IF SCC6 =1
OR -2, FILL: Latino / IF SCC6 = 2, FILL: Latina], or of Spanish origin?
1
2
-2
YES
NO
REFUSED
SCC13. What is (IF LOOP 1, FILL "your", ELSE IF SCC6 = 1, FILL: his/IF SCC6 = 2,
FILL her)/IF SCC6 = -2, FILL [NAME’s] race? I'm going to read a list. Please
select one or more.
1
2
3
4
5
-2
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
REFUSED
SCC14. (IF LOOP 1, FILL "Do you", ELSE FILL "Does [NAME]") live here full time or
part time? PROBE: (IF LOOP 1, FILL "Do you", ELSE FILL "Does [FILL
NAME] spend half or more of (IF LOOP 1, FILL "your", ELSE IF SCC6=1, FILL
"his", ELSE IF SCC6 = 2, FILL "her". ELSE IF SCC6 = -2, FILL: “his/her”)
time in this household?)
1
2
-1
-2
FULL TIME (SPENDS HALF TIME OR MORE IN THIS HH)
PART TIME (SPENDS LESS THAN HALF TIME IN THIS HH)
DON’T KNOW
REFUSED
D. TOBACCO USE SCREENER
CHECK BOX 4:
PROGRAMMER: CONTINUE WITH SCD1 – SCD4 FOR THE SCREENING RESPONDENT; THEN
LOOP BACK TO QUESTION SCC5 AND COMPLETE SCC5 THROUGH SCD4 FOR ALL OTHER
ADULTS LISTED IN HH ROSTER.
CIGARETTES
SCDINTRO: The next questions are about tobacco products (IF LOOP 1, FILL "you
use"/ELSE FILL "[NAME] uses") and how often (IF LOOP 1, FILL "you use" if SR;
ELSE FILL "he uses” if Male “she uses” if Female and “he/she uses” if REF) them.
The first question is about cigarettes.
SCD1. [ASK ONLY OF SCREENING R (LOOP 1)]: Have you smoked at least 100
cigarettes in your entire life?
1
2
YES
NO GO TO CHECK BOX 5
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PROGRAMMER NOTE: IF SCD1 = 2, SET SCD2 TO 3 (NOT AT ALL) FOR PURPOSES
OF CIGARETTE USE CLASSIFICATION IN CHECK BOX 5. SCD2 VALUE CAN BE
RECODED TO “LEGITIMATE SKIP” FOR DATA DELIVERY.
SCD2. (IF LOOP 1, FILL: Do you/ELSE FILL: Does [NAME]) now smoke cigarettes
every day, some days, or not at all?
1
2
3
-1
-2
EVERY DAY
SOME DAYS
NOT AT ALL
DON’T KNOW
REFUSED
CHECK BOX 5:
IF SCREENING R: CLASSIFY AS TOBACCO USER (SMOKER) IF SCD2 = 1 OR 2). ELSE,
CLASSIFY AS NON-SMOKER.
IF OTHER ADULT IN HH: CLASSIFY AS TOBACCO USER (SMOKER) IF SCD2 = 1 OR 2. ELSE,
CLASSIFY AS NON-SMOKER.
REGULAR CIGARS/CIGARILLOS/LITTLE FILTERED CIGARS
SCD3INTRO: The next question is about tobacco products that (IF LOOP 1, FILL:
you smoke/ELSE FILL: [NAME] smokes) other than cigarettes, specifically regular
cigars, cigarillos and little filtered cigars. [IF LOOP 2+, FILL: READ IF
NECESSARY:] “Cigarillos” are medium cigars that sometimes are sold with plastic
or wooden tips. Some common brands are Black and Mild, Swisher Sweets, Dutch
Masters, and Phillies Blunts. Cigarillos are usually sold individually or in packs of 5
or fewer. Little filtered cigars look like cigarettes and are usually brown in color.
Like cigarettes, little filtered cigars have a spongy filter and are sold in packs of
20. Some common brands are Prime Time and Winchester.
SCD3. (IF LOOP 1, FILL: Do you/ELSE FILL: Does [NAME]) now smoke regular
cigars, cigarillos, or little filtered cigars every day, some days, or not at all?
1
2
3
-1
-2
EVERY DAY
SOME DAYS
NOT AT ALL
DON’T KNOW
REFUSED
CHECK BOX 6:
IF SMOKING BEHAVIOR OF NAMED HH MEMBER (SCD3) = 1 OR 2, CLASSIFY AS TOBACCO
USER (CIGAR SMOKER). ELSE, CLASSIFY AS NON-CIGAR SMOKER.
NONCOMBUSTIBLE (SMOKELESS) TOBACCO PRODUCTS
SCD4INTRO: Now we’d like to ask you about smokeless tobacco products,
specifically chewing tobacco, snuff, dip, snus (snoose), or dissolvable tobacco. [IF
LOOP 2+, FILL: READ IF NECESSARY:] Some examples of these product brands are
Skoal, Copenhagen, Grizzly, Levi Garrett, or Red Man.
SCD4. (IF LOOP 1, FILL: Do you/ELSE FILL: Does [NAME]) now use smokeless
tobacco every day, some days, or not at all?
8
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1
2
3
-1
-2
EVERY DAY
SOME DAYS
NOT AT ALL
DON’T KNOW
REFUSED
CHECK BOX 7:
IF SMOKING BEHAVIOR OF NAMED HH MEMBER (SCD4) = 1 OR 2, CLASSIFY AS TOBACCO
USER (SMOKELESS USER). ELSE, CLASSIFY AS NON-SMOKELESS USER.
CHECK BOX 8: LIST 1 LOOP END
REPEAT QUESTIONS SCC6 THROUGH SCD4 FOR ALL OTHER ADULTS LISTED IN HH
ROSTER. THEN CONTINUE WITH SECTION E.
(TASK 4. HOUSEHOLD MEMBERS AGE 17 AND YOUNGER)
E. CHILDREN/YOUTH AGE 17 AND YOUNGER
SCE1. Now I’d like to ask you a few questions about the children living or staying
at this address. Are there any children between the ages of 13 and 17 who
spend more than half of their time living in this household?
1
2
-1
-2
YES
NO
DON’T KNOW
REFUSED
GO TO SCE6
GO TO SCE6
GO TO SCE6
SCE2. How many children age 13-17 spend more than half of their time living in
this household?
____ CHILDREN 13-17 (RANGE 1-10)
NODK
SCE6. Are there any children 12 or younger who spend more than half of their time
living in this household?
1
2
-1
-2
YES
NO
DON’T KNOW
REFUSED
GO TO SCE8
GO TO SCE8
GO TO SCE8
SCE7. How many children 12 or younger spend more than half of their time living
in this household?
_______ CHILDREN 12 OR YOUNGER
NODK
(TASK 6. DETERMINE WHETHER HOUSEHOLD INCOME IS < $30,000)
9
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SCE8. What was the total combined income of all members of your family during
the past 12 months? This includes money from jobs, net income from
business, farm or rent, pensions, dividends, interest, social security
payments and any other money income received by members of your family
who are 18 years of age or older. Would you say it was…
1
2
-1
-2
Less than $30,000 a year
$30,000 a year or more
DON’T KNOW
REFUSED
(TASK 8. PANEL MEMBER SELECTION)
F. PANEL MEMBER SELECTION
CHECK BOX 10: SELECT SAMPLED ADULT, APPLYING OVERSAMPLING OF 18-25 YEAR
OLDS AND HIGHER PROBABILITY FOR SMOKELESS USERS. SELECT 1 ALTERNATE
ELIGIBLE IN HH (IF ANY) IN CASE FIRST SAMPLED ADULT IS INELIGIBLE PER FI
ENROLLMENT SURVEY MODULE. ONCE SELECTED, GO TO SCF1. ELSE, IF NO ELIGIBLES IN
HH, GO TO SCEXIT4.
ANY PERSON
� 18 OR OLDER or DK/REF on age
AND
� NOT ON ACTIVE DUTY (SCC8 = 2) or DK/REF
AND
� LIVES IN HH FULL TIME (SCC14=1) or DK/REF
AND
� CURRENT TOBACCO USER (CLASSIFIED AS SMOKER, CIGAR SMOKER, OR
SMOKELESS USER IN CHECK BOX 5, 6, OR 7. ADULT MAY BE CLASSIFIED AS MORE
THAN ONE TYPE OF USER.)
END OF SELECTION.
SCF1. The computer has selected [READ DISPLAYED NAME] for the study. I want
to make sure I have (your/his/her) full name before we continue.
[DISPLAY NAME, AGE, GENDER OF SAMPLED ADULT SO FI ASKS FOR CORRECT
PERSON]
INTERVIEWER: UPDATE NAME AS NEEDED.
INTERVIEWER: ASK TO SPEAK WITH SAMPLED ADULT IF DIFFERENT FROM
SCREENING RESPONDENT. PROCEED TO FI ENROLLMENT SURVEY.
1
NAME CORRECT AS IS
2
UPDATE NAME
3
UPDATE GENDER
GO TO CHECK BOX 11
SCF2. INTERVIEWER: PLEASE OBTAIN/VERIFY [primary sampled adult]’s FULL
NAME.
10
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NAME: __________________________________
SCF3. INTERVIEWER: PLEASE VERIFY [primary sampled adult]’s GENDER.
GENDER:_______
SCF4. INTERVIEWER: OBTAIN A GOOD PHONE NUMBER FOR THE SAMPLED ADULT.
GO TO CHECK BOX 11
SCEXIT4. Thank you for answering our survey. [IF NO ONE ELIGIBLE, FILL: Based
on the information you provided, there are no eligible household members
at this address.]
Someone may contact you to check on the quality of my work. May I please
confirm your name and obtain your telephone number? (This is solely to
monitor that I’ve done my job correctly. It is the only way my supervisor
can check on the quality of my work – your name and number would not be
used for any other purpose.)
1
2
YES GO TO SCEXIT4A
NO/REFUSED
SCEXIT4END Have a nice day/evening. [EXIT SURVEY. ASSIGN FINAL SCREENING
INELIGIBLE CODE 2601 IF INELIGIBLE – NO ONE 18+; ASSIGN FINAL
SCREENING CODE 2605 IF INELIGIBLE – NO ELIGIBLE TOBACCO USERS
SAMPLED]
SCEXIT4A. May I please [IF NO ONE 18+, FILL “have”, IF NO ONE SELECTED, FILL
“confirm”] your first and last name?
FIRST and LAST NAME: ____________________________
SCEXIT4B. May I please [IF NO ONE 18+ or only 1 person in household and SCC8 =
2 (active military ) or SCC14 = 2 ( part-time HH, FILL “have”, IF NO ONE
SELECTED, FILL “confirm”] your phone number?
PHONE NUMBER: ______________________________
Have a nice day/evening.
[EXIT SURVEY. ASSIGN FINAL SCREENING INELIGIBLE CODE 2601 IF
INELIGIBLE – NO ONE 18+; ASSIGN FINAL SCREENING CODE 2605 IF
INELIGIBLE – NO ELIGIBLE HOUSEHOLD MEMBERS SAMPLED]
CHECK BOX 11:
CONTINUE WITH ENROLLMENT SURVEY MODULE ON FI TABLET TO EXTEND PANEL
INVITATION, OBTAIN CONSENT, AND COLLECT BASELINE DATA FOR SELECTED PANELIST.
ASSIGN COMPLETED SCREENING CODE 2610 (Screening Complete - One Selected),
2620 (SCREENING COMPLETE - One Plus One Alternate Selected), or 2607 (Screening
Complete - unknown eligibility – DK/REF on age for all HH)
11
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OUTPUT VARIABLES TO PASS TO FI ENROLLMENT SURVEY MODULE:
-
-
SAMPLED HH MEMBER’S NAME (FROM ROSTER OR F1 UPDATE)
SAMPLED HH MEMBER’S DEMOGRAPHICS FROM ROSTER (ALL - AGE, RACE,
GENDER, MARITAL STATUS, EDUCATION)
TOBACCO USE CLASSIFICATION(S) FOR SAMPLED HH MEMBER: E.G., SMOKER,
CIGAR SMOKER, SMOKELESS USER.
WHETHER SAMPLED HH MEMBER WAS THE SCREENING RESPONDENT (SET FLAG)
IF APPLICABLE: ALTERNATE ELIGIBLE HH MEMBER’S NAME (FROM ROSTER)
IF APPLICABLE: ALTERNATE ELIGIBLE HH MEMBER’S DEMOGRAPHICS FROM
ROSTER (ALL – AGE, RACE, GENDER, MARITAL STATUS, EDUCATION)
IF APPLICABLE: TOBACCO USE CLASSIFICATION(S) FOR ALTERNATE ELIGIBLE HH
MEMBER: E.G., SMOKER, CIGAR SMOKER, SMOKELESS USER.
Paperwork Reduction Act Statement: The public reporting burden for this information collection has
been estimated to average 10 minutes per response to complete the survey questions. Send comments
regarding this burden estimate or any other aspects of this information collection, including suggestions
for reducing burden, to PRAStaff@fda.hhs.gov.
12
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Attachment 1-3: Enrollment Survey
National Panel of Tobacco Consumer Studies
Enrollment Survey (ES)
RTI_Mobile Platform
OMB Number: 0910-0815
Expiration Date: 02/28/2023
PROGRAMMER: DISPLAY CASE ID, SAMPLED ADULT, AND SAMPLED ADDRESS TO
CONFIRM THE CORRECT CASE IS BEING OPENED BY THE INTERVIEWER.
FI: CONFIRM YOU HAVE OPENED THE CORRECT CASE. IF YOU ARE NOT IN THE
CORRECT CASE, BREAK OFF AND LOCATE THE CORRECT CASE.
GPS CAPTURE: IMPLEMENT PASSIVE GPS & BEARING CAPTURE FOR SAMPLED ADDRESS.
ASK ALL
ESLANG: INTERVIEWER: WHAT LANGUAGE IS BEING USED TO CONDUCT THIS
INTERVIEW?
1
2
ENGLISH
SPANISH
CHECK BOX 1:
IF SAMPLED ADULT = SCREENING RESPONDENT GO TO ESBINTRO.
IF SAMPLED ADULT IS NOT THE SCREENING RESPONDENT GO TO ESINTRO.
ESINTRO: (Hello, my name is…). I’m part of a team working with the FDA to
create a large, national survey panel as part of the National Panel of Tobacco
Consumer Studies, or TCS. This address is one of more than 30,000 addresses
across the U.S. that has been randomly selected for participation. We are speaking
with you because the household summary information provided by [NAME/your
household] indicates you may be eligible to take part in the panel. My questions
will only take 5-10 minutes of your time. Your answers to the questions will be
kept private to the fullest extent allowable by law, and your participation is
voluntary. If we verify you are eligible, you will have the chance to receive cash
payments as a token of appreciation for participating in the TCS surveys.
ESINTROA. First, I want to make sure I have (your) full name before we continue.
1
Page 15 of 143
INTERVIEWER: PLEASE OBTAIN/VERIFY [Alternate sampled adult]’s FULL NAME.
[DISPLAY SAMPLED ADULT’S NAME:______________________________]
FI: DOES NAME NEED TO BE UPDATED?
1
2
A.
YES, UPDATE
NO, NAME IS CORRECT
ELIGIBILITY VERIFICATION (if Sampled Adult not Screening Respondent)
ESA1. Next, I need to verify you are eligible to participate in the survey panel.
Do you live here fulltime? (Half or more than half time in this household)
[DISPLAY SAMPLED ADDRESS]
1
2
-1
-2
YES
NO
DON’T KNOW
REFUSED
GO TO CHECK BOX 3
GO TO CHECK BOX 3
GO TO CHECK BOX 3
ESA2. (IF NOT OBVIOUS): And are you 18 years of age or older?
1
2
-1
-2
YES
NO
DON’T KNOW
REFUSED
GO TO CHECK BOX 3
GO TO CHECK BOX 3
GO TO CHECK BOX 3
ESA2a. Are you currently serving on active duty in the U.S. Armed Forces, Military
Reserves or National Guard? (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 war in Afghanistan.)
1
2
-1
-2
YES
NO
DON’T KNOW
REFUSED
GO TO CHECK BOX 3
GO TO CHECK BOX 3
GO TO CHECK BOX 3
INTERVIEWER: IF ASKED, THE US ARMED FORCES ARE ARMY, NAVY, AIR FORCE, AND
MARINE CORPS.
ESA3. Have you smoked at least 100 cigarettes in your entire life?
1
2
YES
NO GO TO ESA5INTRO
2
Page 16 of 143
PROGRAMMER NOTE: IF ESA3 = 2 (NO), SET ESA4 TO 3 (NOT AT ALL) FOR PURPOSES OF
CIGARETTE USE CLASSIFICATION IN CHECK BOX 2. ESA4 CAN BE RECODED TO
“LEGITIMATE SKIP” FOR DATA DELIVERY PURPOSES.
ESA4. Do you now smoke cigarettes every day, some days, or not at all?
1
2
3
-2
EVERY DAY
SOME DAYS
NOT AT ALL
REFUSED
ESA5INTRO. The next questions are about tobacco products that you smoke other
than cigarettes, specifically regular cigars, cigarillos and little filtered cigars.
“Cigarillos” are medium cigars that sometimes are sold with plastic or wooden
tips. Some common brands are Black and Mild, Swisher Sweets, Dutch Masters,
and Phillies Blunts. Cigarillos are usually sold individually or in packs of 5 or
fewer. Little filtered cigars look like cigarettes and are usually brown in color. Like
cigarettes, little filtered cigars have a spongy filter and are sold in packs of 20.
Some common brands are Prime Time and Winchester.
ESA5. Do you now smoke regular cigars, cigarillos, or little filtered cigars every
day, some days, or not at all?
1
2
3
-2
EVERY DAY
SOME DAYS
NOT AT ALL
REFUSED
ESA6INTRO: Now we’d like to ask you about smokeless tobacco products.
Smokeless tobacco products are placed in the mouth or nose and can include
chewing tobacco, snuff, dip, snus (snoose), or dissolvable tobacco. Some examples
of these product brands are Skoal, Copenhagen, Grizzly, Levi Garrett, or Red Man.
ESA6. Do you now use smokeless tobacco every day, some days, or not at all?
1
2
3
-2
EVERY DAY
SOME DAYS
NOT AT ALL
REFUSED
CHECK BOX 2: UPDATE SMOKING CLASSIFICATION OF SAMPLED ADULT WHO IS NOT
SCREENING R (IF NEEDED):
CLASSIFY AS TOBACCO USER (SMOKER) IF ESA4 = 1 OR 2). ELSE, CLASSIFY AS
NON-SMOKER.
CLASSIFY AS TOBACCO USER (CIGAR SMOKER) IF ESA5 = 1 OR 2. ELSE, CLASSIFY
AS NON-CIGAR SMOKER.
3
Page 17 of 143
CLASSIFY AS TOBACCO USER (SMOKELESS USER) IF ESA6 = 1 OR 2. ELSE,
CLASSIFY AS NON-SMOKELESS USER.
GO TO CHECK BOX 3.
CHECK BOX 3: DETERMINE ELIGIBILITY OF NON-SCREENING R.
-> IF R REFUSED ALL (? ) ESA4, ESA5, ESA6, GO TO ESAEXT4 (UNKNOWN INELIGIBLE)
IF (ESA1 = 1) AND (ESA2 = 1) AND (ESA2a = 2) AND (R IS CLASSIFIED AS SMOKER,
CIGAR SMOKER, OR SMOKELESS USER PER CHECK BOX 2), SAMPLE MEMBER IS
CONFIRMED ELIGIBLE:
GO TO ESBINTRO B FOR PANEL CONSENT
ELSE, SAMPLE MEMBER IS NOT ELIGIBLE. CHECK FOR ALTERNATE ELIGIBLE IN HH.
IF ALTERNATE
IF ESA1 = 2 OR -1 OR -2 (DOES NOT LIVE AT ADDRESS FULLTIME), GO TO ESAALT1
IF ESA2 = 2 OR -1 OR -2 (NOT AGE 18+) OR ESA2a = 1 OR -1 OR -2 (IS ACTIVE DUTY
MILITARY), GO TO ESAALT2
IF R NOT A TOBACCO USER PER CHECK BOX 2, GO TO ESAALT3
CREATE variable to track whether ineligible.
(both) ineligible.
1 = 1 person ineligible, 2 = 2 persons
IF NO (REMAINING) ALTERNATE:
IF ESA1 = 2 OR -1 OR -2 (DOES NOT LIVE AT ADDRESS FULLTIME), GO TO ESAEXT1
IF ESA2 = 2 OR -1 OR -2 (NOT AGE 18+) OR ESA2a = 1 OR -1 OR -2 (IS ACTIVE DUTY
MILITARY), GO TO ESAEXT2
IF R NOT A TOBACCO USER PER CHECK BOX 2, If there is an alternate go to ESAALT3
ELSE GO TO ESAEXT3
ESAEXT1: These are all the questions I have. Because we are only interviewing
persons who usually live at this address fulltime, you are not eligible to participate
in the survey panel. Thank you for your time, and have a nice day/evening.
[EXIT SURVEY – ASSIGN PENDING CODE 1323 – INELIGIBLE, DOES NOT RESIDE AT
SAMPLED ADDRESS]
ESAEXT2: These are all the questions I have. According to the information you
provided, you are not eligible to participate in the survey panel. Thank you for
your time and have a nice day/evening.
[EXIT SURVEY – ASSIGN PENDING CODE 1321 – INELIGIBLE, 17 YEARS OF AGE OR
YOUNGER]
[EXIT SURVEY – ASSIGN PENDING CODE 1327 – INELIGIBLE, ACTIVE DUTY]
ESAEXT3: These are all the questions I have. Because we are only interviewing
adults who regularly use these tobacco products, you are not eligible to participate
in the survey panel. Thank you for your time, and have a nice day/evening.
4
Page 18 of 143
[EXIT SURVEY – ASSIGN PENDING CODE 1322 – INELIGIBLE, DO NOT REGULARLY
USE]
ESAEXT4: These are all the questions I have. We are unable to confirm your
eligibility for the panel at this time. Thank you for your time, and have a nice
day/evening.
[EXIT SURVEY – ASSIGN FINAL CODE 1324 – UNKNOWN REFUSED TO ANSWER
TOBACCO Qs]
ESAALT1: These are all the questions I have. Because we are only interviewing
persons who usually live at this address fulltime, you are not eligible to participate
in the survey panel. However, our records indicate another adult in your
household may be eligible to take part. May I please speak to [FILL ALTERNATE
NAME]?
1
2
YES FLAG PRIMARY SAMPLED ADULT AS 1323 INELIGIBLE – DOES NOT
RESIDE AT SAMPLE. RETURN TO ESINTRO AND LOOP THROUGH SECTION A
FOR ALTERNATE ADULT.
NO BREAKOFF AND SCHEDULE RETURN VISIT [ASSIGN PENDING CODE
1323 INELIGIBLE – DOES NOT RESIDE AT SAMPLE]
ESAALT2: These are all the questions I have. According to the information you
provided, you are not eligible to participate in the survey panel. However, our
records indicate another adult in your household may be eligible to take part. May
I please speak to [FILL ALTERNATE NAME]?
1
2
YES FLAG PRIMARY SAMPLED ADULT AS 1321 INELIGIBLE – 17 YEARS OF
AGE OR YOUNGER or 1327 – INELIGIBLE, ACTIVE DUTY. RETURN TO
ESINTRO AND LOOP THROUGH SECTION A FOR ALTERNATE ADULT.
NO BREAKOFF AND SCHEDULE RETURN VISIT [ASSIGN PENDING CODE
1321 INELIGIBLE – 17 YEARS OF AGE OR YOUNGER or 1327 – INELIGIBLE,
ACTIVE DUTY]
ESAALT3: These are all the questions I have. Because we are only interviewing
adults who regularly use these tobacco products, you are not eligible to participate
in the survey panel. However, our records indicate another adult in your
household may be eligible to take part. May I please speak to [FILL ALTERNATE
NAME]?
1
2
YES FLAG PRIMARY SAMPLED ADULT AS 1322 INELIGIBLE – DOES NOT
REGULARLY USE TOBACCO PRODUCTS. RETURN TO ESINTRO
AND LOOP THROUGH SECTION A FOR ALTERNATE ADULT.
NO BREAKOFF AND SCHEDULE RETURN VISIT [ASSIGN PENDING CODE
1322, INELIGIBLE – DOES NOT REGULARLY USE TOBACCO PRODUCTS]
5
Page 19 of 143
B.
PANEL MODE DETERMINATION/INFORMED CONSENT
ESBINTRO: [IF SAMPLED ADULT IS NOT SCREENING R, FILL: Thank you. Based on
the information you’ve provided, you are eligible to participate in the survey
panel for the National Panel of Tobacco Consumer Studies]
[ALL]: I’d like to tell you more about the TCS survey panel and determine
the most convenient way for you to take part. If you agree to enroll in the
panel, you will have the opportunity to receive cash payments as a token of
our appreciation for participating in the surveys.
So that my supervisor can review my work, some parts of this interview
may be recorded for quality control purposes. Is this okay with you?
1
2
YES
NO
ENABLE CARI
DISABLE CARI
ACTIVATE CARI RECORDING THROUGH ESB9.
ESB1. First, I have some questions that will help me determine the best way for
you to participate in the survey panel.
Do you have an Internet connection in your home?
YES
NO GO TO ESB3
1
2
ESB2. Which of the following do you use to connect to the internet from home?
Please select all that apply.
1
2
3
4
5
6
7
Dial Up
DSL
Cable (through TV or phone company)
Fiber optic (FIOS)
Satellite
Data plan (for cell phone, smart phone, tablet or computer)
WiFi (including wireless hotspot, wireless router)
ESB3. Do you regularly access the Internet outside of your home?
YES
NO GO TO ESB5
1
2
ESB4. Where do you regularly access the Internet outside of your home? Please
select all that apply.
1
2
3
4
5
At
At
At
At
At
work
school
the library
a coffee shop/restaurant/or other WiFi enabled public location
a friend’s/neighbor’s/family member’s house
6
Page 20 of 143
6
7
Can access anywhere via phone/tablet/computer
Other location (Please specify) _______________
ESB5. Overall, would you say you can successfully connect to the Internet
whenever you need? (PROMPT IF NEEDED: That is, you can connect to the
Internet at home or outside the home whenever you need to.)
YES
NO GO TO ESB7
1
2
ESB6. Which of the following devices do you usually use to access the Internet?
Please select all that apply.
1
2
3
Desktop or laptop computer
Tablet computer
Cell phone/smart phone
ESB7. Do you have a personal e-mail address? This may include a home email
address that you share with others in your household.
1
2
YES
NO
ES8INTRO. Next, I’d like to tell you more about what your participation in the
National Panel of Tobacco Consumer Studies would involve. By joining the panel
you will have the opportunity to participate in several short surveys for the Food
and Drug Administration (FDA) over a 3-year period. You will be asked to
complete about 2-3 short surveys a year and your participation in each survey is
voluntary. The surveys will only take about 15 to 20 minutes to complete. If you
complete the panel enrollment process with me, you will receive a $35 cash
payment as a token of our appreciation for joining the panel. As a panel member,
you will also receive a $15 cash payment for each of the short surveys you
complete.
CONTINUE
ESB8. [IF ESB1 = 1 OR ESB3 = 1 OR ESB5 = 1 OR ESB7 = 1, FILL: We expect most
panel members will be able to participate in the short surveys online, that is
via the web. Based on the information you’ve provided, it appears you have
convenient access to the Internet. This means you can complete the short
surveys online through the secure TCS panel website.]
[ELSE, FILL: Based on the information you’ve provided, it appears the best
way for you to participate in the panel is by mail. This means we can mail
you a paper questionnaire for each of the short surveys. Once you answer
the questions, you can simply return the questionnaire to us in the postagepaid envelope we provide.]
[ALL]: Is this a convenient way for you to participate in the panel?
1
YES GO TO ESB10
7
Page 21 of 143
NO IF ESB1 =1 OR ESB3 = 1 OR ESB5 = 1 OR ESB7 =1, GO TO ESB9CHK.
ELSE, GO TO ESB9CHK2.
2
ESB9CHK: FI: ENCOURAGE WEB PARTICIPATION (E.G., 2-3 SHORT
SURVEYS/YEAR, SECURE TCS WEBSITE, DATA ENCRYPTED WHEN SENT TO RTI,
EASY TO LOGIN/COMPLETE SURVEYS ONLINE). ENTER “1” IF R SAYS WEB
PARTICIPATION IS CONVENIENT. ELSE, ENTER “2”.
WEB MODE IS CONVENIENT FOR R GO TO ESB10
WEB MODE IS NOT CONVENIENT FOR R GO TO ESB9CHK2
1
2
ESB9CHK2: Because our goal is to enroll as many people as possible to complete
the panel surveys online, there may be another way you can take part. A small
number of panel members may be eligible for the loan of a tablet computer while
they are in the panel. The tablet loan may make it more convenient to complete
the short panel surveys on the study website. Is this something you might be
interested in?
YES, TABLET LOAN WOULD ENABLE R’S WEB PARTICIPATION GO TO
ESBEXT2
NO, TABLET LOAN IS NOT A VIABLE OPTION FOR R GO TO CHECK BOX 4
1
2
CHECK BOX 4: CONSIDER ALTERNATE MODE OFFER.
IF ESB9CHK2 = 2
IF WEB OFFERED AT ESB8: IF ESB1 = 1 OR ESB3 = 1 OR ESB5 = 1 OR ESB7 = 1, GO
TO ESB9.
IF MAIL OFFERED AT ESB8: IF ESB1 NE 1 AND ESB3 NE 1 AND ESB5 NE 1 AND ESB7
NE 1 GO TO ESBEXT2.
ESB9: You can also participate in the panel by mail. This means each of the short
surveys you are asked to complete can be mailed to you. Once you answer
the questions, you would simply return the questionnaire to us in the
postage-paid envelope we provide.
Is mail a more convenient way for you to participate?
1
2
YES
NO / R REFUSED MAIL GO TO ESBEXT2
FI: ENCOURAGE R’S PARTICIPATION BY MAIL.
DISCONTINUE CARI RECORDING.
ESB10. FI: CONFIRM R’S CONVENIENT MODE OF PARTICIPATION:
1
2
WEB GO TO ESB11
MAIL GO TO ESB11
8
Page 22 of 143
ESBEXT2: We would really like you to join the TCS panel. [IF ESB9CHK2 = 1, FILL:
I will talk to my supervisor to see if you may be eligible for the loan of a
tablet computer while you are in the panel or if there is another way for you
to participate. ELSE, FILL: I will talk to my supervisor to see if there is
another way for you to participate.] I will contact you again once I speak
with him/her.
What would be the best telephone number for me to contact you at?
FI: ENTER 9 FOR DK/REF
Phone Number: ___________________
Thank you for your time today.
FI: ANSWER CLOSING QUESTIONS AFTER LEAVING THE HOUSEHOLD.
ESBEXT2A: WHAT IS THE MAIN REASON THE SAMPLED ADULT CANNOT/WILL NOT
PARTICIPATE BY WEB OR MAIL? (CHECK ALL THAT APPLY)
1
2
3
4
NO PERSONAL DEVICE/INTERNET, NO ACCESS TO OTHER INTERNETENABLED DEVICE
WEB NOT CONVENIENT (E.G., NOT COMFORTABLE USING ELECTRONIC
DEVICES/ACCESSING THE INTERNET)
COMPLETING AND MAILING A HARDCOPY FORM IS TOO MUCH WORK OR IS
NOT CONVENIENT (E.G., DIFFICULT TO SEND/RECEIVE USPS MAIL)
OTHER (SPECIFY): _______
ESBEXT2B: IF KNOWN, DOES THE SAMPLED ADULT HAVE ANY EXPERIENCE WITH
USING ANY OF THE FOLLOWING DEVICES? (CHECK ALL THE APPLY)
1
2
3
4
5
DESKTOP OR LAPTOP COMPUTER
TABLET COMPUTER
CELL PHONE/SMART PHONE
ELECTRONIC READER (E.G., KINDLE, NOOK)
UNKNOWN
ESBEXT2C: WHAT IS YOUR OPINION OF THE PM’S COMFORT LEVEL WITH
COMPUTERS?
1
2
3
4
5
6
7
VERY COMFORTABLE
COMFORTABLE
SOMEWHAT COMFORTABLE
SOMEWHAT UNCOMFORTABLE
UNCOMFORTABLE
VERY UNCOMFORTABLE
UNKNOWN
9
Page 23 of 143
ESBEXT2D: WHAT IS YOUR OPINION OF THE PM’S COMFORT LEVEL WITH THE
INTERNET?
VERY COMFORTABLE
COMFORTABLE
SOMEWHAT COMFORTABLE
SOMEWHAT UNCOMFORTABLE
UNCOMFORTABLE
VERY UNCOMFORTABLE
UNKNOWN
1
2
3
4
5
6
7
ESBEXT2E: IN YOUR OPINION, HOW LIKELY IS IT THAT THE PM WILL JOIN THE
PANEL IF OFFERED A LOANER TABLET?
VERY LIKELY
LIKELY
SOMEWHAT LIKELY
SOMEWHAT UNLIKELY
UNLIKELY
VERY UNLIKELY
1
2
3
4
5
6
ASSIGN PENDING CODE 1693, PENDING TABLET LOANER DECISION FROM RTI]
ACTIVATE CARI RECORDING THROUGH ESB11B.
ESB11: Now that we’ve determined the most convenient way for you to
participate, I’d like to review the panel consent form with you and have you
sign and date it.
READ CORRECT VERSION OF CONSENT FORM TO R: STANDARD WEB/MAIL
OR TABLET. OBTAIN PM’S SIGNATURE/DATE.
a. FI: DID PM CONSENT TO JOIN THE PANEL?
1
2
YES
NO GO TO ESBEXT3
b. FI: CONFIRM MODE OF PARTICIPATION FROM CONSENT:
1
2
3
WEB, WITH PERSONAL DEVICE
MAIL SURVEY
WEB, WITH STUDY TABLET
GO TO ESB14
GO TO ESB14
GO TO ESB12
ESB12: FI: RECORD ID OF LOANED STUDY TABLET BELOW.
a. TABLET ID NUMBER:
b. VERIFY ID NUMBER:
_____________
_____________
[CHECK ESB11a & b MATCH; ELSE, REQUIRE REENTRY.]
10
Page 24 of 143
ESB13 FI: READ EQUIPMENT AGREEMENT FORM TO PM. THEN ALLOW TIME FOR
THEM TO REVIEW IT ON THEIR OWN AND SIGN.
DID THE PM SIGN THE EQUIPMENT AGREEMENT FORM?
1
2
YES
NO GO TO ESBEXT4
ESB14. FI: (ASK IF NECESSARY): WHAT IS PM’S PREFERRED LANGUAGE OF
PARTICIPATION?
1
2
ENGLISH
SPANISH
DISCONTINUE CARI RECORDING.
ESBEXT3: Thank you for your time. Have a nice day/evening.
[ASSIGN PENDING CODE 1440, REFUSAL BY SM, BREAKOFF]
ESBEXT4: Thank you for your time. Have a nice day/evening.
[ASSIGN PENDING CODE 1446, TABLET OFFER REFUSED]
C.
PANEL MEMBER DEMOGRAPHICS
ESCINTRO: Thank you for consenting to join the TCS panel. Now I have a few
background questions about you.
ESC1. In general, would you say your health is excellent, very good, good, fair, or
poor?
1
2
3
4
5
-1
-2
EXCELLENT
VERY GOOD
GOOD
FAIR
POOR
DON’T KNOW
REFUSED
CHECK BOX 5: IF SCREENING R = PANEL MEMBER GO TO ESC2 AND CONFIRM
SCREENER DEMOGRAPHICS. ELSE, FOR ALL OTHER PANEL MEMBERS GO TO ESC3.
ESC2. Let me confirm the information collected earlier.
GENDER: [FILL FROM SCREENER SCC6]
AGE: [FILL FROM SCREENER SCC7/SCC7A]
MARITAL STATUS: [FILL FROM SCREENER SCC9]
HIGHEST SCHOOL GRADE/YEAR: [FILL FROM SCREENER SCC10]
11
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WORK FOR PAY IN PAST 30 DAYS: [FILL FROM SCREENER SCC11]
HISPANIC ORIGIN: [FILL FROM SCREENER SCC12]
RACE: [FILL FROM SCREENER SCC13]
SELECT ITEMS TO UPDATE:
1
2
4
5
6
7
8
10
GENDER
---------MARITAL STATUS
HIGHEST SCHOOL GRADE/YEAR
WORK FOR PAY IN PAST 30 DAYS
HISPANIC ORIGIN
RACE
NONE GO TO ESC12INTRO
FI: ENTER 999 WHEN ALL UPDATES ARE COMPLETED.
[WHEN 999 IS ENTERED, GO TO ESC3]
ROUTE EACH UPDATE ELEMENT AS TO APPROPRIATE VARIABLE ESC3 – ESC11 UNTIL ALL
SELECTED ELEMENTS ARE COMPLETE.
ESC3. INTERVIEWER: CONFIRM GENDER OF PANEL MEMBER.
1
2
MALE
FEMALE
ESC4. How old are you?
FI: ENTER 9 for DK/REF
_____ AGE (RANGE 18-110)
[If DK, REF (9) THEN ASK ESC4A]
ESC4A. Providing your age is important. This ensures we can accurately
determine whether you are eligible to participate in the panel. Can you
confirm which of the following age categories you belong to?
1
2
3
4
5
-1
-2
18-25
26-34
35-49
50-74
75 +
DON’T KNOW
REFUSED
12
Page 26 of 143
ESC6. Are you currently…[READ LIST]?
1
2
3
4
5
-1
-2
Married or living with a partner,
Widowed,
Divorced,
Separated, or
Never married?
DON’T KNOW
REFUSED
ESC7. What is the highest grade or year of school you have completed?
INTERVIEWER NOTE: FOR THOSE CURRENTLY IN SCHOOL, THIS DOES NOT
INCLUDE THE CURRENT YEAR OF SCHOOL, UNLESS IT IS ALREADY COMPLETED.
1
2
3
4
5
-1
-2
LESS THAN HIGH SCHOOL
HIGH SCHOOL GRADUATE OR GED
SOME COLLEGE/VOCATIONAL SCHOOL (NO DEGREE)
2-YEAR COLLEGE/VOCATIONAL/ASSOCIATE’S DEGREE
4-YEAR COLLEGE DEGREE OR HIGHER(E.G., BA, BS, MA, MS, Ph.D)
DON’T KNOW
REFUSED
ESC8. In the past 30 days, did you do any work for pay, including both full-time
and part-time work?
1
2
-1
-2
YES
NO
DON’T KNOW
REFUSED
ESC9. Are you Hispanic, [IF ESC3 not blank, then IF ESC3 =1, FILL: Latino / IF
ESC3 = 2, FILL: Latina else if primary then GENDER
(Male=Latino/Female=Latina) from FIELD SCREENER (SCC6), if alternate
then GENDER (Male=Latino/Female=Latina) from FIELD SCREENER (SCC6),
or of Spanish origin?
1
2
-2
YES
NO
REFUSED
ESC10. What is your race? I’m going to read a list. Please select one or more.
(READ LIST. SELECT ALL THAT APPLY.)
1
2
3
4
5
-2
White
Black or African American
American Indian or Alaska Native
Asian, or
Native Hawaiian or Other Pacific Islander?
REFUSED
13
Page 27 of 143
ESC12INTRO: Thank you. I have one additional follow-up question for you
regarding your household income.
ACTIVATE CARI RECORDING THROUGH ESC13.
ESC12. What was the total combined income of all members of your family during
the past 12 months? This includes money from jobs, net income from
business, farm or rent, pensions, dividends, interest, social security
payments and any other money income received by members of your family
who are 18 years of age or older. Would you say it was…
1
2
3
4
5
6
7
8
9
Under $30,000
$30,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $124,999
$125,000 to $149,999
$150,000 or more
DON’T KNOW
REFUSED
GO
GO
GO
GO
GO
GO
GO
TO
TO
TO
TO
TO
TO
TO
ESC14
ESC14
ESC14
ESC14
ESC14
ESC14
ESC14
ESC13. It is very important that we have some measure of your household’s
income. Would you say the total combined income of all members of your
household during the past 12 months was less than $30,000 or $30,000 or
more?
1
2
-1
-2
LESS THAN $30,000
$30,000 OR MORE
DON’T KNOW
REFUSED
ESC14. In what month and year were you born?
A. MONTH
-1
-2
B. YEAR
DON’T KNOW
REFUSED
DISCONTINUE CARI RECORDING.
D.
CONTACT AND TRACKING QUESTIONS
ESDINTRO: It is important that we have accurate contact information for you so
that we can stay in touch regularly throughout your time in the TCS panel.
ESD1. First, let me confirm your full name and street address: [CONFIRM OR
COLLECT IF MISSING.]
NAME
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ADDRESS
CITY
STATE
ZIP
INTERVIEWER: VERIFY SPELLING OF NAME, STREET, & CITY. OBTAIN STREET
ADDRESS, NOT P.O. BOX NUMBER.
SELECT ITEMS TO UPDATE:
1
2
3
4
5
6
7
8
NAME
STREET NUMBER
STREET NAME
APT NUMBER
CITY
STATE
ZIP
NONE GO TO ESD2
PROGRAM EACH ADDRESS UPDATE ELEMENT AS SINGLE QUESTION AS NEEDED.
ESD1A = NAME, ESD1B – STREET NUMBER, ESD1C = STREET NAME, ESD1D =
APT NUM, ESD1E = CITY, ESD1F = STATE, ESD1G = ZIP.
ESD1AA. Is this also your mailing address?
1
2
YES GO TO ESD2
NO COLLECT MAILING ADDRESS
Programmer Note: For Street Number/PO BOX NUMBER screen include FI
message in ALL CAPS: “IF PO BOX NUMBER, PLEASE INCLUDE ‘PO BOX’ BEFORE
THE NUMBER”
STREET NUMBER/ PO BOX NUMBER
Programmer Note: For Street Name create a warning screen with the following in
ALL CAPS screen include FI message in CAPS: “STREET NAME NOT PROVIDED.
CONFIRMED YOU HAVE CORRECTLY ENTERED THE ADDRESS BEFORE
PROCEEDING.”
STREET NAME
APT NUMBER
CITY
STATE
ZIP
ESD2. What is the best telephone number to use to reach you?
FI: ENTER 9 for REFUSED.
ESD2A. Providing your telephone number is important. This ensures we can reach
you in the future to let you know about upcoming surveys. Your telephone
information will be securely stored and only used for TCS panel related purposes.
It will not be shared with anyone outside of the research team.
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BEST#:
FI: ENTER 9 for REFUSED.
ESD3. Is this a home, work or cell phone number?
1
2
3
4
HOME NUMBER
WORK NUMBER
CELL NUMBER
OTHER NUMBER (E.G., FAMILY, NEIGHBOR)
IF ESD3 = 3 and ((ESD2 ne Blank and ne ‘9’) or (ESD2A ne Blank and ne ‘9’)),
ASK ESD3A.
ESD3A. Can we send text messages to your cell phone, [fill cell phone number
from ESD2/ESD2A]?
1
2
YES
NO
ESD4. Please provide other telephone numbers where you can be reached (PROBE
FOR HOME, WORK, AND CELL NUMBERS).
a.
b.
c.
d.
e.
HOME#:
WORK#:
CELL#:
ALTERNATE CELL #:
NONE
FOR ESD4, PROGRAM EACH PHONE ELEMENT AS SINGLE QUESTION:
ESD4a = Home #, ESD4b = Work #, etc.
CHECK BOX 7: IF ESD4c NE BLANK and ESD4 ne ‘9’, ASK ESD5. ELSE, GO TO CHECK BOX 6.
ESD5. Can we send text messages to your cell phone number, [fill cell phone (ESD4C)]?
1
2
YES
NO
CHECK BOX 8: IF ESD4d NE BLANK and ESD4D ne ‘9’, ASK ESD6. ELSE, GO TO ESD7.
ESD6. You gave us a second cell phone number [fill second cell phone (ESD4D)].
Can we send text messages to this cell number?
1
2
YES
NO
ESD7. One of the primary ways we plan to contact panel members is through
email. Do you have a personal, home, or other email address where you can
receive panel information regularly?
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1
2
3
YES ESD8
NO GO TO ESD11A
PM REFUSED USE OF HIS/HER EMAIL FOR PANEL GO TO ESD7A.
ESD7A. Providing your email address is important. This ensures we can reach you
in the future to let you know about upcoming surveys. Your email information will
be securely stored and only used for TCS panel related purposes. It will not be
shared with anyone outside of the research team.
Do you have a personal, home, or other email address where you can receive panel
information?
1
2
3
YES ESD8
NO GO TO ESD11A
PM REFUSED USE OF HIS/HER EMAIL FOR PANEL GO TO ESD11A.
ESD8. What is the best email address to use to reach you?
BEST EMAIL:
RE-ENTER EMAIL:
FI: CONFIRM SPELLING/ACCURACY OF EMAIL ADDRESS.
ESD8a. Is this your personal or work email address?
1
2
3
PERSONAL/HOME EMAIL
WORK EMAIL
OTHER EMAIL
ESD8b. How often do you check this email address? Would you say…
1
2
3
4
5
Every day
A few times per week
About once a week
About once a month
Less often than once a month
ESD9. Is there another email address where you can receive messages?
1
2
YES
NO GO TO ESD12
ESD10. Please provide the other email where you can receive messages.
OTHER EMAIL:
FI: CONFIRM SPELLING/ACCURACY OF EMAIL ADDRESS.
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ESD10a. Is this a personal or work email address?
1
2
3
PERSONAL/HOME EMAIL
WORK EMAIL
OTHER EMAIL
ESD10b. How frequently do you check this other email address? Would you say…
1
2
3
4
5
Every day
A few times per week
About once a week
About once a month
Less often than once a month
GO TO ESD12
ESD11A. I’d like to work with you to set up a simple Google email address that we
can use to contact you while you are in the panel. This would let us notify
you when a new survey is ready to be completed.
[IMPLEMENT GMAIL PROTOCOL]
a. WAS GMAIL ADDRESS CREATED?
1
2
YES
NO
ESD11b. ENTER GMAIL ADDRESS:
ESD11c. CONFIRM GMAIL ADDRESS:
[CHECK ESD11b & c MATCH; ELSE, REQUIRE REENTRY.]
ESD12. If you happen to move while you are in the panel, would you please give
me the names of two close relatives or friends living outside this household
who would likely know where you can be reached?
1
2
YES GO TO ESD14
NO
FI: ASSURE PM WE WILL CONTACT THESE INDIVIDUALS ONLY IN THE EVENT
HE/SHE MOVES AND WE NEED HELP CONTACTING HIM/HER. ALLOW PM TO LOOK UP
ADDRESSES AND PHONE NUMBERS.
ESD13. It is very important that we be able to reach you if your contact
information changes while you are in the TCS panel. Would you reconsider
and give me the name of a friend or relative outside this household who
would know how to reach you?
1
2
YES, WILL GIVE NAME
NO, WILL NOT GIVE NAME GO TO CHECK BOX 8
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FOR ESD14 PROGRAM EACH ADDRESS ELEMENT AS SINGLE QUESTION. ESD14A =
NAME, ESD14B = RELATIONSHIP TO R, ESD14C = STREET ADDRESS, ESD14D = CITY,
ESD14E = STATE, ESD14F = ZIP, ESD14G = HOME#, ESD14H = CELL#
ESD14. FIRST CONTACT PERSON (COLLECT ALL INFO, INCLUDING PHONE. CANNOT
LIVE AT SAME ADDRESS AS R):
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
NAME: _____________________
RELATIONSHIP TO R: _____________________
STREET NUMBER: _______________________
STREET NAME: _______________________
APT # _______________________
CITY: ___________
STATE: ______
ZIP: ______
HOME #: ___________________________
CELL#: _________________________________
FI: ENTER 99999 for REFUSED.
FOR ESD15 PROGRAM EACH ADDRESS ELEMENT AS SINGLE QUESTION. ESD15A =
NAME, ESD15B = RELATIONSHIP TO R, ESD15C = STREET ADDRESS, ESD15D = CITY,
ESD15E = STATE, ESD15F = ZIP, ESD15G = HOME#, ESD15H = CELL#
ESD15. SECOND CONTACT PERSON (COLLECT ALL INFO, INCLUDING PHONE.
CANNOT LIVE AT SAME ADDRESS AS R): IS THERE A SECOND CONTACT
PERSON?
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
NAME: _________________________________
RELATIONSHIP TO R: _____________________
STREET NUMBER: _______________________
STREET NAME _______________________________
APT # ______________________________
CITY: ___________
STATE: ______
ZIP: ______
HOME #: ___________________________
CELL#: _________________________________
FI: ENTER 99999 for REFUSED.
CHECK BOX 8:
If ESD2a = 9 OR (ESD7A = 3 AND ESD11A = 2) GOT TO ESD15AA
ELSE PROCEED TO CHECK BOX 9
ESD 15AA. FI: PLEASE REVIEW AND CONFIRM THE PM’S PHONE AND EMAIL
INFORMATION. UPDATE AS NEEDED
[DISPLAY BEST PHONE NUMBER]
[DISPLAY BEST EMAIL ADDRESS]
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1
2
3
4
Update Best Phone Number Go to ESD2
Update Email Address ESD8
Refused to provide new information GO TO CHECK BOX 9
No updates needed GO TO CHECK BOX 9
ESD 15AA1. ENTER PHONE NUMBER: ________________________
Enter 9 for REFUSED
ESD 15AA2. ENTER BEST EMAIL ADDRESS: ________________________
CHECK BOX 9: CREATE 3-DIGIT SURVEY INITIATION CODE FROM BEST INFORMATION
(SCREENER OR UPDATED STATUS FROM CHECK BOX 2). EACH DIGIT REPRESENTS STATUS
OF A SPECIFIC TOBACCO PRODUCT USE.
Digit 1 Smoker:
Digit 2 Cigar smoker
Digit 3 Smokeless user
[0,1,2,9]
[0,1,2,9]
[0,1,2,9]
0 = DOES NOT USE PRODUCT
1 = USES PRODUCT EVERY DAY
2 = USES PRODUCT SOME DAYS 9 = DON’T KNOW/REFUSED
CHECK BOX 10:
IF ESB11b = 1 (PERSONAL DEVICE USE) GO TO ESD16
IF ESB11b = 2 (MAIL MODE) GO TO ESDEV2
IF ESB11b = 3 (STUDY TABLET) GO TO ESDEV1
ESD16. FI: WHAT TYPE OF PERSONAL DEVICE IS PM PLANNING TO USE FOR
PANEL?
1
2
3
4
SMART PHONE OR CELL PHONE (e.g., iPhone, Android)
TABLET COMPUTER (e.g., iPad, iPad Mini, Galaxy, Nexus)
LAPTOP OR DESKTOP COMPUTER
OTHER DEVICE (SPECIFY:_____________________)
ESDEV1: Thank you for answering my questions. Now I’d like to show you how to
access the TCS web site. We want to make sure you can log in successfully
at home. We’ll then have you answer a few final tobacco use questions on
your own to complete the enrollment process.
GO TO ESINIT1
ESDEV2: Thank you for answering my questions. To complete your enrollment
process for the TCS panel, I have a few final questions about the tobacco
products you currently use.
GO TO ESINIT2
ESINIT1: WEB BASELINE SURVEY INITIATION STEPS:
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GIVE PM THE PANEL MEMBER INFORMATION SHEET WITH ACCESS CODE
(CASE ID). RECORD SURVEY INITIATION CODE ON CASE FOLDER LABEL.
SURVEY INITIATION CODE:
GO TO CHECK BOX 11
ESINIT2: MAIL BASELINE SURVEY INITIATION STEPS:
GIVE PM THE PANEL MEMBER INFORMATION SHEET WITH ACCESS CODE
(CASE ID). RECORD SURVEY INITIATION CODE ON CASE FOLDER LABEL.
SURVEY INITIATION CODE:
ESEND: EXIT AND TRANSMIT IMMEDIATELY
CHECK BOX 11: OUTPUT VARIABLES TO PASS TO HATTERAS BASELINE MODULE
TCS ID
BASELINE INITIATION CODE (SURVINIT)
SURVINIT
MODE: WEB, MAIL
MODE
EXPERIMENTAL GROUP (FOR INCENTIVE LISTING AT THE END OF THE HATTERAS
INSTRUMENTS)
WAS PM SCREENING RESPONDENT?
SCREENRESP
PANEL MEMBER FIRST NAME
ENRNAME
PANEL MEMBER LAST NAME *** NAME IS NOT BROKEN INTO FIRST & LAST DATA
FIELDS
PHYSICAL ADDRESS – STREET NUMBER
STNUM
PHYSICAL ADDRESS – STREET NAME
STNAME
PHYSICAL ADDRESS – UNIT/APT
UNIT
PHYSICAL ADDRESS – CITY
CITY
PHYSICAL ADDRESS – STATE
STATE
PHYSICAL ADDRESS - ZIP/ STATE/ ZIP
ZIPCODE
MAILING ADDRESS – STREET NUMBER
MSTNUM
MAILING ADDRESS – STREET NAME
MSTNAME
MAILING ADDRESS – UNIT/APT
MUNIT
MAILING ADDRESS – CITY
MCITY
MAILING ADDRESS – STATE
MSTATE
MAILING ADDRESS - ZIP/ STATE/ ZIP
MZIPCODE
HOME PHONE NUMBER
HOMEPHONE
WORK PHONE NUMBER
WORKPHONE
CELL PHONE NUMBER
CELLPHONE
ALTERNATE CELL PHONE NUMBER
ALTCELLPHONE
OTHER PHONE
OTHERPHONE
EMAIL ADDRESS
EMAIL
ALTERNATE EMAIL ADDRESS
ALTEMAIL
Paperwork Reduction Act Statement: The public reporting burden for this information
collection has been estimated to average 10 minutes per response to complete the survey
questions. Send comments regarding this burden estimate or any other aspects of this
information collection, including suggestions for reducing burden, to PRAStaff@fda.hhs.gov.
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Attachment 1-4: Baseline Survey
National Panel of Tobacco Consumer Studies
Panelist Baseline (PB) Survey
Hatteras Web Platform
OMB Number: 0910-0815
Expiration Date: 02/28/2023
[HATTERAS SURVEY BANNER SHOULD DISPLAY PANEL MEMBER’S UNIQUE CASE ID
AND NAME TO VERIFY THE CORRECT SURVEY HAS BEEN ACCESSED.]
PBINTRO: Thank you for joining the survey panel for the National Panel of Tobacco
Consumer Studies, or TCS. The information you provide will be very important to
FDA’s research. This first survey will introduce you to some of the features of our
web surveys. It will also collect more detailed information about the tobacco
products you are currently using. If you have any questions about how to answer
a question or need help moving through the survey, please let the interviewer
know.
PROGRAMMER: If SURVEY INITIATION CODE IS AVAILABLE (PASSED TO THE HATTERAS
INSTRUMENT), THEN GO TO PBINIT1A, ELSE PBINIT1B
PBINTIT1A: Your survey initiation code is:
[DISPLAY SURVEY INITIATION CODE] display in bold:
If this code differs from the code given to you by your interviewer, please let him
or her know before proceeding.
1) CODE IS CORRECT, CONTINUE (GOTO PBINIT2 – GOING TO NAME
VERIFICATION ... SKIPPING THE NEXT ONE)
2) CODE IS INCORRECT, (GOTO PBINIT1B – AND THEN GOING TO THE NAME
VERIFICATION)
PBINIT1B: To begin, please enter the 3-digit survey initiation code provided by the
interviewer.
SURVEY INITIATION CODE:
If no code is entered, display “Please enter your survey initiation code provided
by your interviewer.”
PBINIT2.
Please verify first and last name.
[PROVIDE TEXTBOXES FOR PANEL MEMBER TO ENTER FIRST AND LAST NAMES.]
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[FIRST NAME]
____________________________
[LAST NAME]
__________________________
A. WEB SURVEY TUTORIAL
PROGRAMMER: SKIP TUTORIAL IF BASELINE SURVEY IS BEING FI-ADMINISTERED THROUGH HIS/HER STUDY
LOGIN. GO TO SECTION B.
PBA1. Now, let’s review how to move from one question to another in the web
survey. The navigation buttons in the bottom tool bar will help you move
through the survey.
The [NEXT] button at the bottom right side of your screen will allow you
to move forward from one question to the next.
The [PREVIOUS] button at the bottom left side of your screen will let you
back up and change an answer to a previous question. You can then click
the [NEXT] button to go to the next question you need to answer.
The LOG OUT button at the top of your screen can be used if you need to
exit the survey and finish it at a later time. Any information you have
already entered will be saved.
Click the [NEXT] button to continue.
PBA2. While you are in the panel, you will be asked different types of survey
questions. We have a short 6-question tutorial that will let you practice
entering answers to several types of items. Would you like to use the
tutorial to practice answering questions, or skip the tutorial?
1
2
Use the tutorial to answer practice questions
Skip the tutorial GO TO PBBROWSER
Click [NEXT] to continue.
PBA3. In a survey, some questions will ask you to pick one answer from a list of
answer choices. To pick your answer, simply click the radio button beside
your answer choice. The circle will be filled beside the answer you have
selected. Once your answer is selected, click [NEXT] to move to the next
question. Practice picking an answer for the following question.
Do you like ice cream?
1
2
Yes
No
PBA4. You may also see “Yes” and “No” questions presented in a grid format. This
format lets you pick “Yes” or “No” for a list of related items on the same
survey screen. In the example question below, practice answering “Yes” or
“No” to each answer choice. Click on the correct radio button for each
answer choice; then click [NEXT] when done.
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In the past 30 days, have you purchased any of the following items? Answer
“Yes” or “No” for each.
YES
NO
1
2
a.
Ice cream
1
2
b.
Frozen yogurt or sorbet
1
2
c.
Other frozen desserts (e.g., pies, cakes)
PBA5. Some questions may ask you to select all the answers that apply to you
from a list. These questions will have this instruction: “Select all that
apply.” You can pick one or more than one answer choice. Simply click the
box beside each answer you want to select. If you pick an answer by
mistake, just click the box beside that answer again to remove the check
mark. Once you have selected all your answers, click [NEXT] to continue.
Practice selecting more than one answer to this example question:
Which of the following ice cream flavors do you like? Select all that apply.
1
2
3
4
5
6
Vanilla
Chocolate
Strawberry
Peach
Cookies & Cream
None of the above/Do not eat ice cream
PBA6. You may also be asked to type your answer rather than pick it from a list.
For example, you may be asked to enter a numeric answer—that is, a
number or dollar amount—using the number keys on the keypad or
keyboard. Use the number keys to answer the following example question.
Then click [NEXT] to continue.
On average, about how many hours of TV do you watch each day?
_________ Hours watch TV (RANGE 0-24)
PBA7. Occasionally, you may be asked to pick your answer using drop down lists.
For example, you may be asked to pick the month and year something
happened using drop down lists. Click the arrow beside the “month” item,
and then click on the month you want to select as your answer. Repeat
these steps to select the year.
Practice using drop down boxes to enter today’s date. Then click [NEXT] to
continue.
What is today’s date? Please select the month, day, and year.
Month (1-12)
Day (1-31) Year (1909-2020)
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PBA8. Finally, some questions may ask you to type a text answer using the
alphabetical (letter) keys on the keypad or keyboard. Use the letter keys to
answer the practice question below. Then click [NEXT] to continue.
What is your favorite color? Please enter your answer in the space below.
_________________________________
PBTUTOREND: You have reached the end of the practice questions. Please click
[NEXT] to continue.
PBBROWSER: Please don’t click your browser’s back button during the
survey. Use the navigation buttons at the bottom of the survey instead.
Click [NEXT] to continue.
B. TOBACCO USE QUESTIONS
PBBINTRO: Now we’d like to collect more information about the tobacco products
you currently use.
Please click [NEXT] to continue.
CHECK BOX 1: BASED ON SURVEY INITIATION CODE
R CLASSIFIED AS “EVERY DAY” SMOKER, GO TO PBB1
R CLASSIFIED AS “SOME DAY” SMOKER”, GO TO PBB2
R NOT CLASSIFIED AS “SMOKER” (EVERY DAY, SOME DAYS), GO TO CHECK BOX 2
(CIGARS)
CIGARETTES
PROGRAMMER NOTE: INSERT BANNER—“CIGARETTES”— AT THE TOP OF SCREENS FOR PBB1
THROUGH PBB8.
PBB1. Let’s begin with cigarettes.
On the average, about how many cigarettes do you now smoke a day?
Please enter the number of cigarettes below. You can use the chart below,
which tells you how many cigarettes are in a pack.
¼ PACK = 5
1¼ PACKS = 25
2¼ PACKS = 45
½ PACK = 10
1½ PACKS = 30
2½ PACKS = 50
¾ PACK = 15
1¾ PACKS = 35
2¾ PACKS = 55
1 PACK = 20
2 PACKS = 40
3 PACKS = 60
______ Number of cigarettes (RANGE 1-99)
RANGE CHECK: Please enter a number between 1 and 99.
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PROGRAMMER NOTE: ALL RESPONDENTS WHO ANSWERED PBB1 SHOULD SKIP TO PBB4. (PBB2
AND PBB3 ARE FOR NON-DAILY SMOKERS.)
ELSE, IF R LEAVES PBB1 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB1
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB4
PBB2. On how many of the past 30 days did you smoke a cigarette?
_____ Number of days (RANGE 0-30)
RANGE CHECK: Please enter a number between 0 and 30.
PROGRAMMER NOTE: IF PBB2 = 0, GO TO PBB4.
IF R LEAVES PBB2 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB2
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB3
PBB3. On the average, on days when you smoked cigarettes during the past 30
days, about how many did you smoke a day?
Please enter the number of cigarettes below. You can use the chart below,
which tells you how many cigarettes are in a pack.
¼ PACK = 5
1¼ PACKS = 25
2¼ PACKS = 45
½ PACK = 10
1½ PACKS = 30
2½ PACKS = 50
¾ PACK = 15
1¾ PACKS = 35
2¾ PACKS = 55
1 PACK = 20
2 PACKS = 40
3 PACKS = 60
______ Number of cigarettes (RANGE 1-99)
RANGE CHECK: Please enter a number between 1 and 99.
PROGRAMMER NOTE: IF R LEAVES PBB3 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB3
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB4
PBB4. Do you usually smoke menthol or non-menthol cigarettes?
1
2
3
Menthol
Non-Menthol
No usual type
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PROGRAMMER NOTE: IF R LEAVES PBB4 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB4
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB5
PBB5. How soon after you wake up do you usually have your first cigarette?
1
2
3
4
Within 5 minutes
From 6 to 30 minutes
From more than 30 minutes to 1 hour
After more than 1 hour
PROGRAMMER NOTE: IF R LEAVES PBB5 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB5
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB6
PBB6. Are you planning to stop smoking cigarettes within the next 30 days?
1
2
Yes
No
PROGRAMMER NOTE: IF R LEAVES PBB6 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB6
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO CHECK BOX 2
CHECK BOX 2: BASED ON SURVEY INITIATION CODE:
R CLASSIFIED AS “CIGAR SMOKER” (EVERY DAY OR SOME DAYS), GO TO PBB7INTRO
R NOT CLASSIFIED AS “CIGAR SMOKER”, GO TO CHECK BOX 4 (SMOKELESS)
REGULAR CIGARS/CIGARILLOS/LITTLE FILTERED CIGARS
PBB7INTRO: [IF PBB6 NE BLANK, FILL: The next/ELSE, FILL: These] questions are
about regular cigars, cigarillos and little filtered cigars. “Cigarillos” are medium
cigars that sometimes are sold with plastic or wooden tips. Some common brands
are Black and Mild, Swisher Sweets, Dutch Masters, and Phillies Blunts. Cigarillos
are usually sold individually or in packs of 5 or fewer. Little filtered cigars look like
cigarettes and are usually brown in color. Like cigarettes, little filtered cigars have
a spongy filter and are sold in packs of 20. Some common brands are Prime Time
and Winchester.
PROGRAMMER NOTE: INSERT BANNER—“REGULAR CIGARS/CIGARILLOS/LITTLE FILTERED
CIGARS”— AT THE TOP OF SCREENS SHOWING PBB7INTRO THROUGH PBB11.
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PBB7. Have you smoked at least 50 regular cigars, cigarillos, or little filtered cigars
in your entire life?
1
2
Yes
No
CHECK BOX 3: BASED ON SURVEY INITIATION CODE:
R CLASSIFIED AS “EVERY DAY” CIGAR SMOKER, GO TO PBB8
R CLASSIFIED AS “SOME DAY” CIGAR SMOKER”, GO TO PBB9
PBB8. On the average, about how many regular cigars, cigarillos, or little filtered
cigars do you now smoke a day?
____ Number of regular cigars, cigarillos, or little filtered cigars (RANGE = 1-99)
RANGE CHECK: Please enter a number between 1 and 99.
PROGRAMMER NOTE: ALL RESPONDENTS WHO ANSWERED PBB8 SHOULD SKIP TO PBB10a. (PBB9
AND PBB10 ARE FOR NON-DAILY CIGAR SMOKERS.)
IF R LEAVES PBB8 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB8
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB10a
PBB9. On how many of the past 30 days did you smoke regular cigars, cigarillos,
or little filtered cigars?
____ Number of days (RANGE 0-30)
RANGE CHECK: Please enter a number between 0 and 30.
PROGRAMMER NOTE: IF PBB9 = 0, GO TO PBB10A.
IF R LEAVES PBB9 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB9
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB10
PBB10. On the average, on days when you smoked regular cigars, cigarillos, or
little filtered cigars during the past 30 days, about how many did you smoke
a day?
____ Number of regular cigars, cigarillos, or little filtered cigars (RANGE = 1-99)
RANGE CHECK: Please enter a number between 1 and 99.
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PROGRAMMER NOTE: IF R LEAVES PBB10 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB10
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB10a
PBB10a. How soon after you wake up do you usually have your first regular cigar,
cigarillo, or little filtered cigar?
1
2
3
4
Within 5 minutes
From 6 to 30 minutes
From more than 30 minutes to 1 hour
After more than 1 hour
PROGRAMMER NOTE: IF R LEAVES PBB10a BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB10a
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB11
PBB11. Are you planning to stop smoking regular cigars, cigarillos, or little filtered
cigars within the next 30 days?
1
2
Yes
No
PROGRAMMER NOTE: IF R LEAVES PBB11 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB11
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO CHECK BOX 4
CHECK BOX 4: BASED ON SURVEY INITIATION CODE:
R CLASSIFIED AS “SMOKELESS USER” (EVERY DAY OR SOME DAYS), GO TO PB12INTRO
R NOT CLASSIFIED AS “SMOKELESS USER”, GO TO PBB20INTRO
SMOKELESS TOBACCO
PBB12INTRO: [IF PBB6 OR PBB11 NE BLANK, FILL: Now/ELSE, FILL: First] we’d
like to ask you about smokeless tobacco products. Smokeless tobacco products are
placed in the mouth or nose and can include chewing tobacco, snuff, dip, snus
(snoose), or dissolvable tobacco. Some examples of these product brands are
Skoal, Copenhagen, Grizzly, Levi Garrett, and Red Man.
PROGRAMMER NOTE: INSERT BANNER—“SMOKELESS TOBACCO”— AT THE TOP OF SCREENS
SHOWING QUESTIONS PBB12INTRO THROUGH PBB19
PBB12. Have you used smokeless tobacco at least 20 times in your entire life?
1
2
YES
NO
8
Page 43 of 143
CHECK BOX
R
ARE
R
5: BASED ON SURVEY INITIATION CODE:
CLASSIFIED AS “EVERY DAY” SMOKELESS USER, GO TO PBB12a. PBB13 AND PBB14
FOR NON-DAILY SMOKELESS USERS.
CLASSIFIED AS “SOME DAY” SMOKELESS USER”, GO TO PBB13
PBB12a. On the average, about how many times do you now use smokeless
tobacco a day?
____ Number of times (RANGE 0-99) GO TO PBB15
PBB13. On how many of the past 30 days did you use smokeless tobacco?
____ Number of days (RANGE 0-30)
RANGE CHECK: Please enter a number between 0 and 30.
PROGRAMMER NOTE: IF PBB13 = 0, GO TO PBB15.
IF R LEAVES PBB13 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB13
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB14
PBB14. On the average, on days when you used smokeless tobacco during the past
30 days, about how many times did you use a day?
____ Number of times (RANGE 0-99)
PROGRAMMER NOTE: IF R LEAVES PBB14 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response. Select
“continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB14
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB15
PBB15. What brand of smokeless tobacco do you usually use? Please select one.
1
2
3
4
5
6
Copenhagen
Skoal
Red Man
Grizzly
Kodiak
Some other brand (Please specify: ________________)
PROGRAMMER NOTE: IF R LEAVES PBB15 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB15
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB16
9
Page 44 of 143
PBB16. Do you usually use smokeless tobacco that is in a pouch?
1
2
Yes
No
PROGRAMMER NOTE: IF R LEAVES PBB16 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB16
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB18
PBB18. How soon after you wake up do you usually use smokeless tobacco?
1
2
3
4
Within 5 minutes
From 6 to 30 minutes
From more than 30 minutes to 1 hour
After more than 1 hour
PROGRAMMER NOTE: IF R LEAVES PBB18 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB18
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB19
PBB19. Are you planning to stop using smokeless tobacco within the next 30 days?
1
2
Yes
No
PROGRAMMER NOTE: IF R LEAVES PBB19 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB19
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBB20INTRO
OTHER TOBACCO PRODUCTS
PBB20INTRO: The next questions are about electronic cigarettes or e-cigarettes.
You may also know them as vape-pens, hookah-pens, e-hookahs, or evaporizers. Some look like cigarettes, and others look like pens or small
pipes. These are battery-powered, usually contain liquid nicotine, and
produce vapor instead of smoke.
PROGRAMMER NOTE: INSERT BANNER—“OTHER TOBACCO PRODUCTS”— AT THE TOP OF SCREEN
FOR QUESTION PBB20.
PBB20I1. Have you EVER used an e-cigarette EVEN ONE TIME?
1
2
Yes
No GO TO PBB20
10
Page 45 of 143
PBB20I2. Do you now use e-cigarettes every day, some days, or not at all?
1
2
3
Every day
Some days
Not at all
PBB20I3. On how many of the past 30 days did you use e-cigarettes?
____ Number of days (RANGE 0-30)
RANGE CHECK: Please enter a number between 0 and 30.
PBB20. Do you now use any of the following tobacco products? Answer “Yes” or
“No” for each.
YES
NO
1
2
a. Pipe
1
2
b. Water pipe (or Hookah)
1
2
c. Other tobacco products not already mentioned (SPECIFY IF YES)
PROGRAMMER NOTE: IF R LEAVES ANY ITEM IN PBB20 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB20
-2
CONTINUE CODE BLANK ITEM AS -2 (REFUSED) AND CONTINUE TO CHECK BOX 6
CHECK BOX 6: BASED ON SURVEY INITIATION CODE:
- IF PARTICIPANT IS CLASSIFIED AS ONLY ONE OF THE FOLLOWING--SMOKER OR CIGAR
SMOKER OR SMOKELESS USER CONTINUE TO PBB21
- IF PARTICIPANT IS CLASSIFIED AS A DUAL OR POLY TOBACCO USER (CLASSIFIED AS AT
LEAST 2 OF THE 3 TYPES OF TOBACCO USERS) GO TO PBB22.
PBB21. Do you consider yourself a [CHOOSE THE TOBACCO PRODUCT PARTICIPANT IS
CLASSIFIED AS USING: smoker/regular cigar, cigarillo, or little filtered cigar
smoker/smokeless tobacco user]?
1
2
Yes
No GO TO PBC1
PROGRAMMER NOTE: IF R LEAVES PBB21 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB21
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBC1
PBB22. You said you [CHOOSE WHICH OF THE FOLLOWING 3 PRODUCTS PARTICIPANT
IS CLASSIFIED AS USING: smoke cigarettes/”and” smoke regular cigars,
cigarillos, or little filtered cigars/”and” use smokeless tobacco products].
Do you consider yourself primarily a [CHOOSE WHICH OF THE FOLLOWING 3
PRODUCTS PARTICIPANT IS CLASSIFIED AS USING: cigarette smoker, regular
cigar, cigarillo, or little filtered cigar smoker, or smokeless tobacco user]?
Please select one.
11
Page 46 of 143
[PROGRAMMER: DISPLAY ONLY OPTIONS THAT APPLY TO R, PLUS “NONE OF
THESE”]
1
2
3
4
Cigarette smoker
Regular cigar, cigarillo, or little filtered cigar smoker
Smokeless tobacco user
None of these
PROGRAMMER NOTE: IF R LEAVES PBB22 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBB22
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBC1
C. COMPUTER METHODOLOGY QUESTIONS
PBC1. The last questions are about your use of computers. In the past 30 days,
have you used any of the following computing devices? Please include
devices you may have used at home, work, school, or a library. Answer
“Yes” or “No” for each.
a.
b.
c.
d.
Smart Phone or Cell Phone (Examples: iPhone or
Android)
Tablet (Examples: iPad, iPad Mini, Galaxy, Nexus)
E-Reader (Examples: Kindle or Nook)
Laptop or Desktop Computer
YES
NO
1
2
1
2
1
2
1
2
PROGRAMMER NOTE: IF R LEAVES ANY ITEM IN PBC1 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBC1
-2
CONTINUE CODE BLANK ITEM AS -2 (REFUSED) AND CONTINUE TO CHECK
BOX 7
CHECK BOX 7: IF “NO” TO ALL IN PBC1 (items a-d) GO TO PBC6. ELSE, CONTINUE.
PBC2. In the past 30 days, how often did you use a computing device, such as a
computer, tablet, e-reader or a smart phone? Would you say…
1
2
3
4
5
Every day
A few times per week
Once a week GO TO PBC4
Once a month GO TO PBC4
Never GO TO PBC4
12
Page 47 of 143
PBC3. On an average day, how many hours do you use a computing device, such as
a computer, tablet, e-reader, or smart phone? Would you say…
1
2
3
4
Less than 1 hour per day
Between 1-5 hours per day
Between 5-8 hours per day
More than 8 hours per day
PROGRAMMER NOTE: IF R LEAVES PBC3 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBC3
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PBC4
PBC4. The next question is about your use of Apps. An App is a small specialized
program downloaded onto a mobile device. Apps may be used to do things
like play games or music, go to social media sites like Twitter or Facebook,
or get directions.
In the past 30 days, how often have you used Apps? Would you say…
1
2
3
4
5
Every day
A few times per week
Once a week
Once a month
Never
PBC6. How comfortable do you feel using a computer? Would you say…
1
2
3
4
Very comfortable
Comfortable
Uncomfortable
Very uncomfortable
PROGRAMMER NOTE: IF R LEAVES PBC6 BLANK, ASK:
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBC6
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PB_END
PBEND: So that we can confirm we have an active email address on file for you,
please enter your best email address in the blank below. Once you enter your
address and complete this survey, you will receive a confirmation email from
tcs@rti.org to verify your email address and provide the link to the panel website
for future surveys. We recommend that you keep this email for future reference.
[Collect 1 email address – with checks for acceptable email address]
1
No email address
PROGRAMMER NOTE: IF R LEAVES PBEND BLANK, ASK:
13
Page 48 of 143
Could you please enter a response? Select “return to question” to enter a response.
Select “continue” to skip this question.
1
RETURN TO QUESTION RETURN TO PBEND
-2
CONTINUE CODE AS -2 (REFUSED) AND CONTINUE TO PB_END2
PBEND2: Thank you for completing this first survey. Again, we look forward to
your participation in the TCS survey panel.
As a reminder, RTI International may send you one or more messages in
approximately one week, thanking you for your participation in the panel. This
could take the form of a brief email, text message, and/or automated phone call.
This message will also serve as a confirmation that all information collected during
your enrollment was entered correctly. If you have any questions, please feel free
to visit the TCS panel website (https://tcs.rti.org), call our project helpline (1800-613-0326), or send an email to tcs@rti.org.
Paperwork Reduction Act Statement: The public reporting burden for this information collection has
been estimated to average 10 minutes per response to complete the survey questions. Send
comments regarding this burden estimate or any other aspects of this information collection, including
suggestions for reducing burden, to PRAStaff@fda.hhs.gov.
14
Page 49 of 143
Attachment 1-5: Interviewer Observation Questionnaire
NATIONAL PANEL OF TOBACCO CONSUMER STUDIES
INTERVIEWER OBSERVATION (IO) SURVEY
RTI_Mobile Platform
OMB Number: 0910-0815
Expiration Date: 02/28/2023
MODULE 1: POST-ENROLLMENT ITEMS
INTERVIEWER: COMPLETE FOR EACH PM AFTER HIS/HER ENROLLMENT AND
BASELINE SURVEYS COMPLETED. ANSWER QUESTIONS AFTER LEAVING PM’S HOME.
IOA.
DID PM CONSENT TO PARTICIPATE VIA WEB OR MAIL?
1
2
IOB.
WEB GO TO IOC
MAIL
WHAT IS THE MAIN REASON MAIL MODE WAS OFFERED TO THE PM?
1
2
3
4
REFUSED WEB MODE, REQUESTED MAIL MODE
INSTRUMENT SUGGESTED MAIL MODE (E.G., NO PERSONAL DEVICE/INTERNET)
--STUDY-PROVIDED TABLET NOT OFFERED
STUDY-PROVIDED TABLET REFUSED, REQUESTED MAIL MODE
OTHER REASON
ALL GO TO IO4
IOC.
IS PM USING A PERSONAL DEVICE OR A STUDY-PROVIDED TABLET FOR THE
PANEL?
1
2
IOD.
DID YOU CONFIRM WITH THE PM THAT THEY RECEIVED THE AUTOMATED
EMAIL FROM THE BASELINE SURVEY?
1
2
3
4
IOE.
PERSONAL DEVICE (INCLUDES HH DEVICE)
STUDY-PROVIDED TABLET
YES
NO GO TO CHECK BOX 1
NOT SURE/UNABLE TO VERIFY RECEIPT OF MESSAGE GO TO CHECK BOX 1
NOT APPLICABLE--DID PAPI BASELINE GO TO CHECK BOX 1
WAS THE PM ABLE TO ACCESS THE PANEL WEBSITE VIA THE LINK IN THE
EMAIL?
1
2
3
4
YES
NO
NOT SURE/UNABLE TO VERIFY USE OF EMAIL LINK
NOT APPLICABLE--DID PAPI BASELINE
Page 50 of 143
CHECK BOX 1: IF IOC = 2 (STUDY-PROVIDED TABLET), ASK IOF; ELSE GO TO IOG.
IOF.
WHAT PROBLEMS, IF ANY, DID YOU HAVE SETTING UP THE STUDY-PROVIDED
TABLET FOR THE PM? (DO NOT INCLUDE TCS WEBSITE OR BASELINE SURVEY
ACCESS ISSUES.) SELECT ALL THAT APPLY.
1
2
3
4
5
6
IOG.
DID PM HAVE PROBLEMS ACCESSING THE SURVEY WEBSITE OR BASELINE
SURVEY?
1
2
IOH.
YES
NO GO TO IO1
WHAT KIND OF PROBLEMS DID THE PM HAVE ACCESSING THE SURVEY
WEBSITE OR BASELINE SURVEY? SELECT ALL THAT APPLY.
1
2
3
4
5
6
IOI.
PROBLEMS ACCESSING THE INTERNET
UNRESOLVABLE TABLET MALFUNCTION – NEEDED REPLACEMENT
DIFFICULTY SETTING UP GMAIL ACCOUNT FOR PM
NON-PANEL RELATED TECHNICAL ISSUES (I.E. SCREEN RESOLUTION ISSUES,
BATTERY ISSUES, PROBLEMS WITH GENERAL TABLET FUNCTIONALITY)
OTHER (SPECIFY): _________________________________ (500 chars)
NO PROBLEMS
POOR/NO INTERNET CONNECTION/COULD NOT CONNECT TO WEBSITE
INCOMPATIBLE BROWSER (E.G., OLD VERSION OF INTERNET EXPLORER,
CHROME, FIREFOX)
PROBLEMS WITH USERNAME OR PASSWORD
PROBLEMS CREATING NEW PASSWORD
PROBLEMS ANSWERING SECURITY QUESTIONS AND/OR ENTERING EMAIL
OTHER
WHAT STEPS DID YOU TAKE TO HELP ADDRESS THESE ACCESS ISSUES?
SELECT ALL THAT APPLY.
1
2
3
4
5
6
7
8
CALLED FS/RS FOR ASSISTANCE
CALLED RTI TECH SUPPORT FOR ASSISTANCE
REFERRED TO PROJECT JOB AID/MANUAL
PM UPDATED/INSTALLED NEW BROWSER
PM CONSULTED THEIR INTERNET SERVICE PROVIDER FOR ASSISTANCE
OTHER TECHNICAL/SUPPORT STEPS
DID PAPI BASELINE
USED FI TABLET
Page 51 of 143
IO1.
WHAT LEVEL OF ASSISTANCE DID YOU PROVIDE THE PM DURING HIS/HER
BASELINE SURVEY?
PM COMPLETED SURVEY WITH NO ASSISTANCE FROM ME GO TO IO3
PM COMPLETED SURVEY, BUT NEEDED ASSISTANCE ON A FEW SCREENS
GO TO IO2
PM COMPLETED SURVEY, BUT NEEDED ASSISTANCE ON MANY SCREENS
GO TO IO2
I ADMINISTERED THE SURVEY TO PM USING FI TABLET OR DID PAPI GO TO
1
2
3
4
IO1A
5
IO1a.
I WAS UNABLE TO OBSERVE PM’S WEB SURVEY COMPLETION GO TO IO3
DID YOU ADMINISTER THE BASELINE INTERVIEW ON YOUR PROJECT
TABLET OR ON A PAPER VERSION OF THE QUESTIONNAIRE?
1
2
IO1b.
ON MY PROJECT TABLET GO TO IO1C
ON A PAPER VERSION OF THE QUESTIONNAIRE
WHY DID YOU ADMINISTER THE BASELINE INTERVIEW ON A PAPER
VERSION OF THE QUESTIONNAIRE?
1
2
3
THE INTERNET IN THE HOME WAS TEMPORARILY NOT WORKING, I COULD NOT
ACCESS THE INTERNET ON MY TABLET
THERE WAS NO INTERNET IN THE HOME, AND I COULD NOT ACCESS THE
INTERNET
OTHER (SPECIFY): _________________________________ (500 chars)
GO TO IO3
101c.
WHY DID YOU ADMINISTER THE BASELINE SURVEY TO THE PM?
1
2
3
4
5
IO2.
PM VISION/PHYSICAL ISSUES, UNABLE TO SEE WEB SCREENS
TEMPORARY INTERNET OUTAGE OR TECHNICAL PROBLEM – PM UNABLE TO USE
PERSONAL DEVICE
PM DID NOT HAVE ACCESS TO PERSONAL DEVICE (I.E., BEING REPAIRED OR
USED BY OTHER HH MEMBER)
PM’S DEVICE WAS IN REMOTE AREA OF HOME, FI COULD NOT ACCOMPANY PM
OR STAY UNATTENDED IN HOME
OTHER (SPECIFY:___________________________) (500 chars)
WHAT TYPE OF ASSISTANCE DID YOU PROVIDE THE PM DURING THE
BASELINE SURVEY? (SELECT ALL THAT APPLY.)
1
2
3
4
5
6
7
HELPED PM ENTER ONE OR MORE ANSWERS
HELPED PM MOVE TO NEXT SCREEN/QUESTION
HELPED PM BACK UP TO PREVIOUS SCREEN/QUESTION
HELPED PM RESUME SURVEY AFTER BREAKOFF/TIME-OUT
HELPED PM WITH TECH ISSUES (E.G., SCREEN BRIGHTNESS, CONTRAST, FONT)
ANSWERED QUESTIONS ABOUT A PARTICULAR SURVEY ITEM
OTHER
Page 52 of 143
IO3.
OVERALL, WHAT IS YOUR OPINION OF THE PM’S COMFORT LEVEL WITH
COMPUTERS/THE INTERNET?
1
2
3
4
5
6
VERY COMFORTABLE
COMFORTABLE
SOMEWHAT COMFORTABLE
SOMEWHAT UNCOMFORTABLE
UNCOMFORTABLE
VERY UNCOMFORTABLE
IO3A. DO YOU THINK THE PM WILL NEED TECHNICAL OR OTHER SUPPORT TO
SUCCESSFULLY COMPLETE FUTURE TCS SURVEYS?
1
2
3
YES
NO
NOT SURE
GO TO IO4
GO TO IO4
IO3B. WHAT TYPE OF SUPPORT MIGHT THE PM NEED? SELECT ALL THAT APPLY.
1
2
3
4
5
6
IO4.
HOW EASY OR DIFFICULT WAS IT TO RECRUIT THE PM TO PARTICIPATE IN
THE PANEL?
1
2
3
4
5
IO5.
INSTRUCTION ON ACCESSING PANEL WEBSITE
PASSWORD ISSUES/ASSISTANCE IN LOGGING INTO PANEL SURVEYS
GENERAL PANEL-RELATED TECH SUPPORT (I.E., TIMING OUT, NAVIGATING
WITHIN SURVEYS, PANEL EMAIL RECEIPT ISSUES)
GENERAL NON-PANEL RELATED TECH SUPPORT (I.E., PROBLEMS WITH
PERSONAL DEVICE OR STUDY-PROVIDED TABLET, WEB BROWSERS)
NON-TECHNICAL SUPPORT (GENERAL QUESTIONS ABOUT PANEL, SURVEYS,
INCENTIVES)
OTHER (SPECIFY:__________________) (500 chars)
EXTREMELY EASY GO TO IO6
MODERATELY EASY GO TO IO6
NEITHER EASY NOR DIFFICULT GO TO IO6
MODERATELY DIFFICULT
EXTREMELY DIFFICULT
WHAT WAS THE MAIN REASON FOR THE PM’S RESISTANCE?
1
2
3
4
5
6
7
8
LACK OF INTEREST
LACK OF TIME
FEAR OF A SCAM
PRIVACY / CONFIDENTIALITY CONCERNS
CONCERN ABOUT PANEL BURDEN/COMMITMENT
DISLIKE OF THE SURVEY SPONSOR
DISLIKE OF THE SURVEY TOPICS/PANEL FOCUS
OTHER (SPECIFY:_________________________) (500 chars)
Page 53 of 143
IO6.
WHY DO YOU THINK THE PM AGREED TO PARTICIPATE IN THE PANEL? SELECT
ALL THAT APPLY.
1
2
3
4
5
IO7.
HOW LIKELY IS IT THAT THE PM WILL STAY IN THE PANEL?
1
2
3
4
5
6
IO8.
GENERAL INTEREST/BELIEF IN IMPORTANCE OF PANEL TOPICS
MONETARY INCENTIVE
TO GAIN USE OF STUDY-PROVIDED TABLET
UNSURE/UNKNOWN REASON
OTHER (SPECIFY:__________________) (500 chars)
VERY LIKELY EXIT SURVEY
LIKELY EXIT SURVEY
SOMEWHAT LIKELY EXIT SURVEY
SOMEWHAT UNLIKELY
UNLIKELY
VERY UNLIKELY
WHAT IS THE MAIN REASON YOU FEEL THIS WAY? SELECT ONLY ONE
RESPONSE.
1
2
3
4
5
6
7
PM HESITANT ABOUT PARTICIPATING FOR FULL PANEL PERIOD
PM NOT MOTIVATED BY INCENTIVE/INCENTIVE NOT SUFFICIENT
PM DISINTERESTED IN PANEL OBJECTIVE/STUDY TOPICS
GENERAL PANEL BURDEN (NUMBER OF SURVEYS)
WEB MODE MAY BE BURDENSOME FOR PM
MAIL MODE MAY BE BURDENSOME FOR PM
OTHER (SPECIFY:__________________) (500 chars)
INTERVIEWER: THIS IS THE END OF MODULE 1. EXIT SURVEY. MODULE 2 IS TO BE
COMPLETED WITH TABLET-LOANED PMs 1 WEEK AFTER ENROLLMENT.
CHECKBOX 2: IF PANEL MEMBER ENROLLED FOR WEB OR MAIL MODE (IOA = 2 OR
IOC = 1), EXIT SURVEY AND ASSIGN FINAL CODE 2690. ELSE, IF TABLET PANELIST
(IOC = 2), EXIT SURVEY AND ASSIGN PENDING CODE 1692 FOR MODULE 1
COMPLETION.
MODULE 2: FOLLOW-UP CONTACT WITH TABLET-LOANED PANELIST
INTRO: (ONCE PM ON THE PHONE, SAY): Hello, this is [NAME]. I’m calling to thank
you for your recent enrollment in the survey panel for the National Panel of Tobacco
Consumer Studies (TCS). I also want to answer any questions you may have about
the tablet computer that was loaned to you or about the survey panel itself.
Page 54 of 143
IOFU1. In the past week, that is, since you received the tablet, have you used it?
(PROBE TO SEE IF PM TURNED IT ON, TRIED TO ACCESS INTERNET, ETC.)
YES
NO GO TO IOFU3
1
2
IOFU2. Have you used it to log in to the panel website or check for panel email?
YES
NO
1
2
IOFU3. Do you have any questions about the tablet computer or the survey panel?
YES
NO GO TO EXIT SCRIPT
1
2
IOFU4. What questions do you have? (RESPOND TO QUESTIONS; DOCUMENT THEM
BELOW.)
1
2
3
4
5
6
PM ASKED FOR INSTRUCTION ON ACCESSING PANEL WEBSITE
PM HAD PASSWORD ISSUES/NEEDED ASSISTANCE LOGGING INTO WEBSITE
PM NEEDED GENERAL PANEL-RELATED TECH SUPPORT (I.E., TIMING OUT,
NAVIGATING, PANEL EMAIL RECEIPT ISSUES)
PM NEEDED GENERAL TABLET TECH SUPPORT (I.E., TURNING ON/CHARGING
TABLET, SETTING VOLUME/BRIGHTNESS, GETTING TO WEB BROWSERS)
PM NEEDED NON-TECHNICAL SUPPORT (GENERAL QUESTIONS ABOUT PANEL,
SURVEYS, INCENTIVES)
OTHER (SPECIFY: _____________) (500 chars)
EXIT SCRIPT: Thank you for answering my questions. As a reminder, you can contact
our project Helpdesk if you need help with the tablet or have (additional) questions
about the panel. The Helpdesk can be reached at:
Phone: 1-800-XXX-XXXX
Email: tcs@rti.org
Have a great day/evening.
IOFU5. INTERVIEWER: DOES PM NEED A FOLLOW-UP CONTACT FROM RTI TECH
SUPPORT TO ASSIST WITH TABLET ISSUES?
1
2
YES (EXPLAIN WHY:___________________________________)(500 chars)
NO
EXIT SURVEY. ASSIGN FINAL CODE 2695.
Paperwork Reduction Act Statement: The public reporting burden for this information collection has been
estimated to average 10 minutes per response to complete the survey questions. Send comments
regarding this burden estimate or any other aspects of this information collection, including suggestions for
reducing burden, to PRAStaff@fda.hhs.gov.
Page 55 of 143
Attachment 1-7: Contact Information Update
National Panel of Tobacco Consumer Studies
Contact Information (CI) Update
OMB Number: 0910-0815
Expiration Date: 02/28/2023
[CONTACT INFO WOULD COME FROM THE LATEST IN THE CONTROL SYSTEM.]
CI1.
It is important that we maintain accurate contact information for you while
you are in the survey panel. Please review the following information and
make any needed changes or corrections.
All information is correct, no changes needed
[DISPLAY PRELOADED INFORMATION]:
FIRST NAME:
LAST NAME:
STREET NUMBER AND NAME:
APT/UNIT:
CITY:
STATE:
ZIP:
SUFFIX:
HOME PHONE NUMBER:
WORK PHONE NUMBER
CELL PHONE NUMBER:
Can we send text messages to this cell number?
ALTERNATE CELL PHONE NUMBER: Can we send text messages to your cell phone
number?
PRIMARY EMAIL ADDRESS:
ALTERNATE EMAIL ADDRESS:
Contact Person Update
CI2.
When you joined the panel, you gave us the name and contact information
for one or more persons who live outside your household who would always
know how to reach you if you move. These persons are listed below. Please
confirm or update their contact information. You can also provide contact
information for a different person if needed.
All information is correct, no changes needed
[DISPLAY CONTACT PERSON 1 INFO]:
FIRST NAME: LAST NAME:
STREET NUMBER AND NAME:
APT/UNIT:
CITY:
1
Page 56 of 143
STATE:
ZIP:
HOME PHONE NUMBER:
CELL PHONE NUMBER:
[DISPLAY CONTACT PERSON 2 INFO]:
FIRST NAME: LAST NAME:
STREET NUMBER AND NAME:
APT/UNIT:
CITY:
STATE:
ZIP:
HOME PHONE NUMBER:
CELL PHONE NUMBER:
Thank you for updating your TCS contact information.
Programmer Note: For first and subsequent iterations of the survey, the PM’s info will be
pulled from Nirvana Control System. Reasoning: the PM may have updated the contact
table on the web portal between rounds and the control system will have this and any
information from the Mobile FS Responses table.
For the first time, Contact 1 & 2 will preload from the Nirvana Control System (confirmation
source = MobileFS, contact1 = 57, contact2 = 58). Subsequent iterations will grab from the
previous Hatteras contact info survey.
Paperwork Reduction Act Statement: The public reporting burden for this information collection has
been estimated to average 5 minutes per response to complete the survey questions. Send comments
regarding this burden estimate or any other aspects of this information collection, including suggestions
for reducing burden, to PRAStaff@fda.hhs.gov.
2
Page 57 of 143
TCS ID
Attachment 1-13: Contact Information Update: Mail
OMB Number:
Expiration Date:
0910-0815
02/28/2023
Start Here
1.
Please review the following information and make any needed changes or corrections.
[DISPLAY INFORMATION LABEL HERE]:
Is all of the above information correct, or do you need to change or add something?
1
All information is correct, no changes needed
2
I need to change or add information:
First Name
Last Name
Street Address
City/State/Zip
Home Phone Number
Work Phone Number
Cell Phone Number
Can we send text messages to this cell number?
Alternate Cell Phone Number
Can we send text messages to this cell number?
Email Address
Alternate Email Address
1
FORM ID
Page 58 of 143
TCS ID
2.
Contact Person Update: You gave us the name and contact information of the persons listed below who live
outside your household who would always know how to reach you if you move. Please confirm or update their
contact information. You can also provide contact information for a different person if needed.
[DISPLAY CONTACT PERSON 1 LABEL]:
[DISPLAY CONTACT PERSON 2 LABEL]:
Is all of the above information correct, or do you need to change or add something?
1
All information is correct, no changes needed
2
I need to change or add information:
PERSON 1:
Name
Street Address
City/State/Zip
Telephone Number
PERSON 2:
Name
Street Address
City/State/Zip
Telephone Number
Thank you for completing the survey!
Please mail to: RTI International – [project number]
3040 E Cornwallis Rd.,
Research Triangle Park, NC 27709
Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 5 minutes per
response to complete and return the survey form. Send comments regarding this burden estimate or any other aspects of this information
collection, including suggestions for reducing burden, to PRAStaff@fda.hhs.gov.
2
FORM ID
Page 59 of 143
Attachment 1-16: Tracing/Nonresponse Follow-up Questionnaire
National Panel of Tobacco Consumer Studies
Tracing / Nonresponse Follow-up Questionnaire
OMB Number: 0910-0815
Expiration Date: 02/28/2023
PROGRAMMER: INCLUDE THE FOLLOWING PRE-LOADS: (1) PANEL MEMBER NAME,
(2) SAMPLED ADDRESS, OR LAST UPDATED ADDRESS (MOST RECENT), (3) ALL
KNOWN TELEPHONE NUMBERS, (4) CONTACT #1 INFORMATION, (5) CONTACT #2
INFORMATION, AND (6) MODE OF PARTICIPATION. IF ANY FIELDS WERE REF/DK
(ITEMS 1-5) LEAVE BLANK.
CONTACT1: ARE YOU SPEAKING TO [NAME] OR KNOWLEDGEABLE
INFORMANT?
1
2
3
YES, SPEAKING TO [NAME] GO TO CONTACT2
NO, BUT SPEAKING TO KNOWLEDGEABLE INFORMANT GO TO CONTACT3
NO EXIT; ASSIGN PENDING CODE 1180 UNABLE TO LOCATE
CONTACT 2: We are trying to reach you regarding your continued
participation in the National Panel of Tobacco Consumer Studies (TCS).
We have attempted to reach you earlier but have been unsuccessful.
I’m here today to make sure that we have the correct contact
information for you, and to answer any questions you may have about
your continued participation in the panel.
GO TO CONTACT4
CONTACT3: We are trying to reach [NAME] about an important research
study. We have attempted to reach him/her earlier but were unsuccessful.
Would you know where I could reach him/her?
YES GO TO CONTACT4
NO GO TO CONTACT16 AND EXIT/BREAKOFF
1
2
CONTACT4: [Are you/Is [NAME] currently living at [LAST KNOWN
ADDRESS]?
1
2
3
YES, CURRENT ADDRESS IS ACCURATE GO TO CONTACT7
NO, CURRENT ADDRESS IS INACCURATE GO TO CONTACT5
DON’T KNOW GO TO CONTACT7
1
Page 60 of 143
CONTACT5: Can you please provide me with your/[NAME’s] new address
information?
YES GO TO NEWADD1
NO GO TO CONTACT7
1
2
NEWADD1: ENTER ANY NEW ADDRESS INFORMATION. (IF YOU DID NOT
OBTAIN A FULL ADDRESS ENTER WHAT YOU WERE ABLE TO OBTAIN.)
a.
b.
c.
d.
e.
f.
STREET NUMBER
STREET NAME
APT NUMBER
CITY
STATE
ZIP
NEWADD2: Is this your/[NAME’s] mailing address as well?
YES GO TO CONTACT7
NO GO TO CONTACT6
1
2
CONTACT6: What is your/[NAME’s] full mailing address?
YES GO TO CONTACT6A
REFUSED GOTO CONTACT7
1
2
a.
b.
c.
d.
e.
f.
(CONTACT6A) STREET NUMBER/PO BOX Number
(CONTACT6B) STREET NAME
(CONTACT6C) APT NUMBER
(CONTACT6D) CITY
(CONTACT6E) STATE
(CONTACT6F) ZIP
CONTACT7. What is the best telephone number to use to reach you/[NAME]?
PROGRAMMER: LOOP TO COLLECT UP TO 4 NUMBERS.
TELEPHONE [1,2,3,4]
1
2
3
4
5
6
LANDLINE
CELL
WORK
OTHER
NO PHONE
REFUSED
FI: ENTER 9 FOR REFUSED.
2
Page 61 of 143
IF CONTACT7 = 9 (REFUSED);
IF CONTACT1 = 1, GO TO CONTACT7A;
ELSE (CONTACT1 = 2,) GO TO CONTACT10. (will not be getting a phone number)
ELSE (CONTACT7 NE 9), GO TO CONTACT7B
CONTACT7A. Providing your telephone number is important. This ensures we can
reach you in the future to let you know about upcoming surveys. Your telephone
information will be securely stored and only used for TCS panel related purposes.
It will not be shared with anyone outside of the research team.
BEST#:
FI: ENTER 9 for REFUSED. IF ‘9’ GO TO CONTACT7B
CONTACT7B. Is this a home, work or cell phone number?
1
2
3
4
HOME NUMBER
WORK NUMBER
CELL NUMBER -> Note: (if contact1=2, will not be asking about texting)
OTHER NUMBER (E.G., FAMILY, NEIGHBOR)
IF (CONTACT7 or CONTACT7A) ne blank and ne ‘9’ and CONTACT7B = 3 and
contact1 = 1 (we should ask only of PM), ASK CONTACT7AA.
CONTACT7AA. Can we send text messages to your cell phone number, [fill cell
CONTACT7A/CONTACT7B]?
1
2
YES
NO
CONTACT7C. Please provide other telephone numbers where you/[NAME] can be
reached (PROBE FOR HOME, WORK, AND CELL NUMBERS).
a.
b.
c.
d.
HOME#:
WORK#:
CELL#:
ALTERNATE CELL #:
FOR CONTACT7C, PROGRAM EACH PHONE ELEMENT AS SINGLE QUESTION:
CONTACT7CA = Home #, CONTACT7CB = Work #, CONTACT7CC =cell,
CONTACT7CD=other. For each phone number, add text ‘FI: ENTER ‘9’ FOR
DK/REF’.
CHECK BOX 1: IF ((CONTACT7CC NE BLANK and NE -9 ) AND CONTACT1 eq 1 ), ASK
CONTACT7D. ELSE, GO TO CHECK BOX 2.
CONTACT7D. Can we send text messages to your cell phone number, [fill cell
CONTACT7CC]?
3
Page 62 of 143
1
2
YES
NO
CHECK BOX 2: IF ((CONTACT7CD NE BLANK and NE -9) and contact1 eq 1 [pm]), ASK
CONTACT7E ELSE, IF CONTACT1 = 1 [pm] GO TO CONTACT 8, ELSE (contact1 =2
[informant] ) GO TO CONTACT9.
CONTACT7E. You gave us a second cell phone number. Can we send text messages
to this cell number, [fill cell CONTACT7CD]?
1
2
YES
NO
CONTACT8. Do you/[NAME] have an email address? IF YES: What is it? (COLLECT
UP TO 2 EMAIL ADDRESSES.)
1
2
3
4
YES, GO TO CONTACT8A
NO, GO TO CONTACT9
DON’T KNOW GO TO CONTACT9
REFUSED GO TO CONTACT9
CONTACT8A ENTER EMAIL ADDRESS.
CONTACT8B. Do you/[NAME] have another email address?
1
2
3
4
YES, GO TO CONTACT8C
NO, GO TO CONTACT9
DON’T KNOW GO TO CONTACT9
REFUSED GO TO CONTACT9
CONTACT8C. ENTER NEXT EMAIL ADDRESS
EMAIL ADDRESS. _______________________________
CONTACT9. Would you provide me with the name and contact information
for up to two persons who might be able to locate you/[NAME] in case
we can’t contact you/him/her? (RECORD ALL INFORMATION
POSSIBLE)
a. NAME
b. RELATIONSHIP TO RESPONDENT
c. STREET NUMBER
d. STREEET NAME
e. APT NUMBER
f. CITY
4
Page 63 of 143
g. STATE
h. ZIP
TELEPHONE:________ 1 LANDLINE 2 MOBILE
EMAIL:__________ 1 NO EMAIL 2 REFUSED
1 REFUSED
1
2
YES GO TO CONTACT9A
REFUSED GO TO CONTACT10
CONTACT9A. FIRST CONTACT PERSON (COLLECT ALL INFO): [Note for
phone numbers add text ‘FI: ENTER ‘9’ FOR DK/REF’.]
a.
b.
c.
d.
e.
f.
g.
h.
NAME: _________________________________
RELATIONSHIP TO R: _____________________
STREET ADDRESS: _______________________
CITY: ___________
STATE: ______
ZIP: ______
HOME #: ___________________________
CELL#: _________________________________
CONTACT9B. SECOND CONTACT PERSON (COLLECT ALL INFO): [Note for
phone numbers add text ‘FI: ENTER ‘9’ FOR DK/REF’.]
a.
b.
c.
d.
e.
f.
g.
h.
NAME: _________________________________
RELATIONSHIP TO R: _____________________
STREET ADDRESS: _______________________
CITY: ___________
STATE: ______
ZIP: ______
HOME #: ___________________________
CELL#: _________________________________
CONTACT10: Thank you, these are all of the questions I have for today.
PROGRAMMER: IF SPEAKING TO KNOWLEDGEABLE INFORMANT [CONTACT1 = 2],
PENDING CODE AS 1150 – TRACING COMPLETED WITH KNOWLEDGEABLE
INFORMANT. ELSE, CONTINUE.
INTERVIEWER: ANSWER THE FOLLOWING QUESTIONS ABOUT YOUR
INTERACTION WITH THE PANEL MEMBER:
CONTACT11: DID HE/SHE HAVE ANY QUESTIONS ABOUT THEIR
CONTINUED PARTICIPATION IN THE PANEL?
5
Page 64 of 143
1
2
YES GO TO CONTACT12
NO GO TO CONTACT 13
CONTACT12: IF YES, WHAT WERE THE QUESTIONS ABOUT (CODE ALL THAT
APPLY)?
1
2
1
2
1
2
PURPOSE OF PANEL
PANEL PARTICIPATION REQUIREMENTS
INCENTIVES
MODE (IE: WANTS TO CHANGE FROM WEB TO MAIL MODE)
PROJECT-PROVIDED TABLET
OTHER, SPECIFY: __________________________(500 chars)
CONTACT13: DID HE/SHE EXPRESS RELUCTANCE ABOUT CONTINUED
PARTICIPATION?
1
2
YES GO TO CONTACT14
NO GO TO CONTACT15
CONTACT14: WHAT WAS THE REASON FOR RELUCTANCE?
1
2
3
4
5
6
7
8
9
10
NOT INTERESTED/TOO BUSY/TIME COMMITMENT
TOO PERSONAL
COMPENSATION TOO LOW
ANTI-GOVERNMENT
REFUSAL BREAKOFF
STIGMA OF TOBACCO USE
TECHNOLOGICAL - SELF REPORTED NOT COMPUTER SAVVY
TECHNOLOGICAL - NO INTERNET
REFUSAL BY OTHER
REFUSAL BY HH - OTHER (SPECIFY): _________________ (500 CHARS)
CONTACT15: IN YOUR OPINION, WHAT IS THE LIKELIHOOD OF HIM/HER
REMAINING IN THE PANEL?
1
2
3
4
5
6
VERY LIKELY
LIKELY
SOMEWHAT LIKELY
SOMEWHAT UNLIKELY
UNLIKELY
VERY UNLIKELY
EXIT SURVEY: FINAL CODE TRACING INSTRUMENT AS 2190 – CONTACT
INFORMATION CONFIRMED WITH SUBJECT.
6
Page 65 of 143
CONTACT16: Thank you. Have a nice day/evening. [EXIT SURVEY. SYSTEM
ASSIGN Pending 1223: Knowledgeable Informant contacted.]
Paperwork Reduction Act Statement: The public reporting burden for this information collection has
been estimated to average 10 minutes per response to complete the survey questions. Send comments
regarding this burden estimate or any other aspects of this information collection, including suggestions
for reducing burden, to PRAStaff@fda.hhs.gov.
7
Page 66 of 143
Attachment 1-17: Verification Interview Scripts (Screener, Enrollment, Ineligible)
OMB Number: 0910-0815
Expiration Date: 02/28/2023
Information needed for completed Screener Verification
Relevant Codes:
2601 (No One Selected - No HH Members 18 years of age or older)
2605 (No Tobacco Users in Household)
Roster Information:
(numberrostered1): total number of people in roster (SCC1 from Screener)
(numberrostered2): total number of people in roster ages 13-17 (SCE2 from Screener)
(numberrostered3): total number of people in roster 12 and under (SCE7 from Screener)
Program fill for (HH Count Noun1)
If number rostered is 0, then fill ‘no’
If number rostered is 1 = person
If number rostered is >1 = people
Program fill for (HH Count Noun2)
If number SCE2 is 1 = person
If number SCE2 is >1 = people
Program fill for (HH Count Noun3)
If number SCE7 is 1 = child
If number SCE7 is >1 = children
Screening Information:
(Screening Date) fill: Date of final Screening Code (MMDDYYYY)
Case Information:
(Street Num, Street Name, Apt/Unit, city, state and zip code): Street number, Street address,
Apt/Unit, city, state and zip code for address
Fills: (first name/a resident of this household) If first name available from data, use this in fill –
otherwise, use “a resident of this household”.
Screening Information Provided:
CaseID
Phone number provided in SCEXIT4B
Address
First Name provided in SCEXIT4A
Screening Date (date of final Screening code)
Roster Data
Information needed for Enrollment Verification Interview Scripts [2690s]
Page 67 of 143
General Information:
Gender = Male/Female
All fills are designated by italics text in parentheses (address)
(Street Num, Street Name, Apt/Unit, city, state and zip code): Street number, Street address,
Apt/Unit, city, state and zip code for address
IF CALL-IN: Thank you for calling this study sponsored by the U.S. Food and Drug Administration
at RTI. This is _____________. In case we get cut off, let me get the telephone number you are
calling from.] (On behalf of the U.S. Food and Drug Administration, I am trying to reach
.)
INTERVIEWER: THE ROSTER WILL BE DISPLAYED NEXT. IF THE PHONE NUMBER EXISTS ON
THE ROSTER FOR THE SUBJECT AND HAS NOT BEEN CODED OUT, SELECT THAT NUMBER.
OTHERWISE, ADD A NEW ROSTER LINE.
CELL_RESP. Are you driving a vehicle at this moment? IF YES, ASK FOR A BETTER TIME TO
CALL AND SET A CALLBACK. IF YES, AND SM INDICATES S/HE IS WILLING TO TALK NOW, SAY
"I'm sorry but for your safety I'm not able to conduct the survey while you're driving. When would
be a better time to call you?" Got to INTRO1
INTRO1. Hello, my name is ________________. I am calling from RTI International regarding a
study sponsored by the U.S. Food and Drug Administration. May I please speak to (Panel Member
Name/Screening Respondent Name)?
1
2
3
3
4
5
6
YES, SPEAKING TO PANEL MEMBER OR SCREENING RESPONDENT [INTRO3]
PANEL MEMBER AVAILABLE [INTRO1A]
PANEL MEMBER UNAVAILABLE [If Enrollment: CALLBACK, If Screener: INTRO2]
PANEL MEMBER UNAVAILABLE - OUT OF THE COUNTRY [OTC_WHY]
PANEL MEMBER/SCREENING RESPONDENT UNKNOWN [INTRO2]
RESPONDENT/PANEL MEMBER KNOWN, BUT WILL NEVER BE AVAILABLE [If
Enrollment: INTRO1B, If Screener: INTRO2]
OTHER [INTRO1B]
SUBJ_UNAVAIL. Can be contacted before March 31, 2016? INTERVIEWER: IF
YES, DETERMINE WHEN THE RESPONDENT WILL RETURN AND SET A CALLBACK.
OTC_WHY. SUBJECT'S NAME: Is
out of the country due to:
INTERVIEWER: TRY TO DETERMINE REASON SUBJECT IS OUT OF THE COUNTRY AND ENTER
BELOW.
GO TO OTC_INFO
OTC_INFO. Can you give me any address or telephone information or an email address for
contacting ?
GO TO END
INTRO1A. May I speak with [him, her, if Screener and INTRO2 = 3: with this person]?
Page 68 of 143
1
2
YES [INTRO3]
NO [CALLBACK]
INTRO1B. ENTER RESPONDENT’S ANSWER VERBATIM. [If Enrollment: CALLBACK, If Screener:
INTRO2]
INTRO2. (If Screener AND INTRO1 = 3, 4, 5 include: Perhaps you can help me.) My name is
____________. I am calling from RTI International regarding a study sponsored by the U.S. Food
and Drug Administration.
Our records indicate that (Screener: you/someone at this number; Enrollment: Panel Member)
(were/was) (SCREENING: contacted concerning address; ENROLLMENT: contacted about an
important research study sponsored by the U.S. Food and Drug Administration).
This call is to verify the quality of our interviewer’s performance. It will take just a few minutes of
your time. For training and quality assurance purposes, this call may be monitored.
[If Screener: Are you (or anyone else at this number) familiar with (address)?]
[If Enrollment: Is this the correct phone number for (first name)?]
PROBE: This is a scientific research study and the quality of data is essential. We monitor our
interviewer’s work in several ways. One very important check is to call some of the residences
that were contacted to ensure the interviewer followed proper procedures and behaved
professionally.
1
2
3
4
5
-1
YES, RESPONDENT IS [INTRO3]
PANEL MEMBER LOCATED [INTRO3]
SOMEONE ELSE IS [INTRO1A]
PANEL MEMBER UNKNOWN [END]
NO [SV1]
DON’T KNOW [SV1]
INTRO3. [SKIP if INTRO1 = 1: Hello, my name is _______________. I am calling from RTI
International regarding a study sponsored by the U.S. Food and Drug Administration.]
[IF Screener: “Our records indicate that someone at this number was contacted concerning
(address)” IF Enrollment: “Our records indicate that you were interviewed for the National Panel
of Tobacco Consumer Studies (TCS)”.]
This call is to verify the quality of our interviewer’s performance. It will take just a few minutes of
your time. For training and quality assurance purposes, this call may be monitored.
[IF Enrollment: Did you complete an interview for this study?
1
2
YES [EV3]
NO [EV2A]
[IF Screener: Are you or anyone else at this number familiar with (address)?]
3
4
5
6
7
YES, ADDRESS OK [SNVCODE]
YES, SOMETHING INCORRECT ABOUT ADDRESS [SV7]
NO [END]
SCHEDULE A CALLBACK [CALLBACK]
OTHER CODES [END]
Page 69 of 143
PROBE: This is a scientific research study and the quality of data is essential. We monitor our
interviewer’s work in several ways. One very important check is to call some of the residences
that were contacted to ensure the interviewer followed proper procedures and behaved
professionally.
SV1. Just to confirm, I was given this telephone number to verify that our interviewer made
contact with someone that either lives at or is knowledgeable about (address). Is there anyone at
this number who might be familiar with (address)?
1
2
3
-1
YES, RESPONDENT IS [SV4]
YES, SOMEONE ELSE IS [SV3]
NO [SV2]
DON’T KNOW [SV2]
SV2. Is there anyone at this number who might be familiar with our interviewer?
1
2
3
-1
YES, RESPONDENT IS [SV4]
YES, SOMEONE ELSE IS [INTRO1A]
NO [END]
DON’T KNOW [END]
EV2A. You may have answered questions concerning your use of tobacco products, and provided
some basic demographic information. The interviewer would have used a tablet computer to
record your responses. Does this sound familiar?
1
2
YES [EV3]
NO [EV2B]
EV2B. Were you ever contacted by one of our interviewers?
1
2
3
YES, BUT RESPONDENT DOES NOT REMEMBER COMPLETING INTERVIEW [EV2C]
YES, AND RESPONDENT DOES REMEMBER COMPLETING INTERVIEW [EV3]
NO [EV2C]
EV2C. Our interviewer would have been wearing a white badge with a picture I.D. (He or she may
have been carrying a tablet computer. Did this person ever contact you?
1
2
3
YES, BUT RESPONDENT DOES NOT REMEMBER COMPLETING INTERVIEW [EVEND]
YES, AND RESPONDENT DOES REMEMBER COMPLETING INTERVIEW [EV3]
NO [EVEND]
EV3. It is important that the interviewer visited the correct address. Please provide the full
address where you lived when the interviewer contacted you. Please tell me the full address
including any apartment number, city, state, and zip code.
TI NOTE: DO NOT READ ADDRESS TO RESPONDENT. IF THE ADDRESS PROVIDED MATCHES
THE BELOW INFORMATION, SELECT CORRECT. IF IT DOES NOT MATCH SELECT INCORRECT.
(address)
TI NOTE: IF RESPONDENT PROVIDES ONLY PARTIAL INFORMATION, YOU SHOULD PROVIDE
THE MISSING INFORMATION TO THE RESPONDENT TO CONFIRM IT IS ACCURATE.
1
2
CORRECT [EV4]
INCORRECT [EV3A]
Page 70 of 143
-1
-2
DON’T KNOW [EVEND]
REFUSE [EVEND]
EV3A. Can you please repeat that?
ENTER ADDITIONAL COMMENTS UP TO 150 CHARACTERS.
ENTER RESPONDENT’S ADDRESS VERBATIM.
EV4. Did the interviewer ask you questions about topics such as your use of tobacco products
and your ability to access the internet or use internet-enabled devices?
1
2
YES [EV6]
NO [EV5]
EV5. Just to be sure, were you asked questions about the type of tobacco products you use (such
as cigarettes, cigars, or smokeless tobacco products) as well as questions about your access to
the internet (either in or outside of your home)?
1
2
YES [EV6]
NO [EV8]
EV6. Did you agree to join the survey panel for the National Panel of Tobacco Consumer Studies,
or TCS? This would involve you participating in several surveys over the next 3 years on tobaccorelated topics.
1
2
YES [EV7]
NO [EV8]
EV7. Did you receive $35 in cash for your participation?
1
2
-1
YES [EVEND]
NO [EVEND]
DON’T KNOW/DON’T REMEMBER [EVEND]
EV8. Did you receive $35 in cash when the interviewer visited you?
1
2
-1
YES [EVEND]
NO [EVEND]
DON’T KNOW/DON’T REMEMBER [EVEND]
SNVCODE.
IF SCREENING CODE 2601 OR 2605 OR 2606 OR 2610 OR 2620, GO TO SV4
SV3. May I speak with this person?
1
2
YES [SV4]
NO [SV4A]
SV4. I’d like to verify what the interviewer reported. First, according to our interviewer, there are
(numberrostered1) (HH Count Noun1) age 18 or older living in your household. Is this
correct?
1
YES [IF numberrostered1 > 0, THEN SV5, ELSE SKIP TO SV8]
Page 71 of 143
2
-1
-2
NO [SV4A]
DON’T KNOW [SV5]
REFUSED [SV5]
SV4A. Would you please describe what is incorrect about the information?
ENTER ADDITIONAL COMMENTS UP TO 150 CHARACTERS. IF IT BECOMES CLEAR THE
RESPONDENT WAS CONFUSED BY THE QUESTION, GO BACK TO THE QUESTION AND
REREAD/PROBE FOR CLARITY. ENTER RESPONDENT’S ANSWER VERBATIM [500 CHAR]
SV5. Next, according to our interviewer, (numberrostered2) (HH Count Noun2) between the age of
13 and 17 live in your household. Is this correct?
1
2
-1
-2
YES [SV6]
NO [SV5A]
DON’T KNOW [SV6]
REFUSED [SV6]
SV5A. Would you please describe what is incorrect about the information?
ENTER ADDITIONAL COMMENTS UP TO 150 CHARACTERS. IF IT BECOMES CLEAR THE
RESPONDENT WAS CONFUSED BY THE QUESTION, GO BACK TO THE QUESTION AND
REREAD/PROBE FOR CLARITY. ENTER RESPONDENT’S ANSWER VERBATIM [500 CHAR]
SV6. And finally, according to our interviewer, (numberrostered3) (HH Count Noun3) age 12 and
under live in your household. Is this correct?
1
2
-1
-2
YES [SV8]
NO [SV6A]
DON’T KNOW [SV8]
REFUSED [SV8]
SV6A. Would you please describe what is incorrect about the information?
ENTER ADDITIONAL COMMENTS UP TO 150 CHARACTERS. IF IT BECOMES CLEAR THE
RESPONDENT WAS CONFUSED BY THE QUESTION, GO BACK TO THE QUESTION AND
REREAD/PROBE FOR CLARITY. ENTER RESPONDENT’S ANSWER VERBATIM [500 CHAR]
GO TO SV8
SV7. It is important that the interviewer visited the correct address. Please provide the full
address where you lived when the interviewer contacted you. Please tell me the full address
including any apartment number, city, state, and zip code.
TI NOTE: DO NOT READ ADDRESS TO RESPONDENT. IF THE ADDRESS PROVIDED MATCHES
THE BELOW INFORMATION, SELECT CORRECT. IF IT DOES NOT MATCH SELECT INCORRECT.
(address)
TI NOTE: IF RESPONDENT PROVIDES ONLY PARTIAL INFORMATION, YOU SHOULD PROVIDE
THE MISSING INFORMATION TO THE RESPONDENT TO CONFIRM IT IS ACCURATE.
1
2
-1
-2
CORRECT [SV8]
INCORRECT [SV7A]
DON’T KNOW [END]
REFUSED [END]
Page 72 of 143
SV7A. Can you please repeat that?
ENTER ADDITIONAL COMMENTS UP TO 150 CHARACTERS.
ENTER RESPONDENT’S ADDRESS VERBATIM.
SV8. Was the interviewer polite and did the interviewer treat you professionally?
1
2
YES [END]
NO [SV8A]
SV8A. Would you please tell me more about that?
ENTER ADDITIONAL COMMENTS UP TO 150 CHARACTERS.
ENTER RESPONDENT’S ANSWER VERBATIM.
IF NO COMMENTS, ENTER NONE [DONEB]
SNV6A. Has (address) been vacant any time within recent weeks?
1
2
-1
YES [SNV9A]
NO [SNV6B]
DON’T KNOW [SNV6B]
SNV6B. Let me verify, was (address) vacant on or around (Screening Date)?
1
2
-1
-2
YES [SNV9A]
NO [SNV9A]
DON’T KNOW [SNV9A]
REFUSED [SNV9A]
SNV7A. (Do/Did) the people who own or occupy (address) have a usual place of residence
elsewhere? PROBE: That is, is (address) used as a second home, seasonal or weekend residence
only?
1
2
-1
YES [SNV9A]
NO [SNV7B]
DON’T KNOW [SNV7B]
SNV7B. Let me verify, (will/did) the people who own or occupy (address) have a usual place of
residence elsewhere? PROBE: That is, they live elsewhere and only use (address) as a second
home, seasonal or weekend residence.
1
2
-1
-2
YES [SNV9A]
NO [SNV7C]
DON’T KNOW [SNV7C]
REFUSED [SNV7C]
SNV7C. To the best of your knowledge, (will/did) the people who own or occupy (address) have a
usual place of residence elsewhere? PROBE: That is, they live elsewhere and only use (address)
as a second home, seasonal or weekend residence.
1
2
-1
YES [SNV9A]
NO [SNV9A]
DON’T KNOW [SNV9A]
Page 73 of 143
-2
REFUSED [SNV9A]
SNV8A. Is (address) a business, military barracks, hotel or motel, a place that was demolished or
does not exist, or another type of place that is not a residence?
1
2
-1
YES [SNV9A]
NO [SNV8B]
DON’T KNOW [SNV8B]
SNV8B. We are trying to distinguish places that are residences such as houses, town houses,
apartments, and college dormitories from the types of places I just mentioned.
To the best of your knowledge, is (address) a business, military barracks, hotel or motel, a place
that was demolished or does not exist, or another type of place that is not a residence?
1
2
-1
-2
YES [SNV9A]
NO [SNV9A]
DON’T KNOW [SNV9A]
REFUSED [SNV9A]
SNV9A. Did you personally speak with our interviewer?
1
2
YES [SNV9B]
NO [END]
SNV9B. Was the interviewer polite and did the interviewer treat you professionally?
1
2
YES [END]
NO [SNV9B1]
SNV9B1. Would you please tell me more about that?
ENTER ADDITIONAL COMMENTS UP TO 150 CHARACTERS.
ENTER RESPONDENT’S ANSWER VERBATIM.
IF NO COMMENTS, ENTER “NONE”. [END]
CALLBACK. Thank you very much for your time, I will call back at a later time. Have a good
(evening/day). [SET FOR CALLBACK]
CALLBACK. Thank you for your time, we will call back. Have a nice evening/day.
END. Those are all of the questions I have. Thank you very much for your time. Have a good
(evening/day).
END SURVEY
VOICEMAILSCRIPTS:
•
SCREENER /INELIGIBLE VERSION: My name is ____________. I am calling from RTI
International regarding an important research study sponsored by the U.S. Food and
Drug Administration. This call is to verify the quality of our interviewer’s performance.
Please call me back at your convenience at 1-xxx-xxx-xxxx.
Page 74 of 143
•
ENROLLMENT VERSION: My name is ____________. I am calling for [fill panel
member] from RTI International regarding an important research study sponsored by the
U.S. Food and Drug Administration. This call is to verify the quality of our interviewer’s
performance. Please call me back at your convenience at 1-xxx-xxx-xxxx.
•
MESSAGE LEFT WITH LIVE PERSON: My name is___________. I am calling from
RTI International regarding an important research study sponsored by the U.S. Food and
Drug Administration. Please ask him/her to call me at his/her earliest convenience at 1xxx-xxx-xxxx.
Page 75 of 143
Attachment 1-18: Study B Questionnaire
National Panel of Tobacco Consumer Studies
Study B Questionnaire
Study B: Coupons and Free Samples Receipt and Use
OMB Number: 0910-0815
Expiration Date: 02/28/2023
PROGRAMMER: INSERT PROMPTS IF AN ITEM IS LEFT BLANK SO R CAN
CHOSE DK OR RE RESPONSE: “Please enter a response. Select “Change
answer” to enter a response. Select “Keep answer and continue” to skip this
question.” ASSIGN -99 TO INDICATE RESPONDENT LEFT THE ITEM BLANK.
FOR NUMERIC ITEMS, THE RANGE CHECK PROMPT IS: Please enter a
number between [FILL LOWER RANGE] and [FILL UPPER RANGE].
SB_INTRO. We are excited that you are part of the TCS survey panel. This study will collect
information about free samples and coupons for tobacco products you may have received,
how you received them, and where you redeemed them for tobacco products. The questions
will take about 20 minutes to complete and you will receive $15 as a token of our
appreciation. Your participation is voluntary and you can skip any question you do not want to
answer. Your answers to the questions will be kept private to the fullest extent required by
law.
[FILL BASED ON ENROLLMENT/RE-CONSENT STATUS: There may be opportunities for TCS
researchers to use, share, or release deidentified panel data for similar research in the future.
”Deidentified” means that we will remove your personal identifying information before the
data are used, shared, or released to others. Although we cannot guarantee that no one can
reidentify these data, it is highly unlikely that this will occur. We will not ask for your
additional informed consent if we use, share, or release deidentified panel data for future
research.]
IF WEB SURVEY: Do you agree to participate in the survey?
1
Yes CONTINUE TO SB_INCENTIVE
2
No EXIT SURVEY: Thank you for your time. Have a nice day/evening. (ASSIGN
CODE 1410 REFUSAL BY SUBJECT)
[IF WEB]: SB_INCENTIVE. Due to the coronavirus (COVID-19) pandemic, we are offering two
ways for you to receive $15 for completing the survey. You can choose to receive a $15 digital
VISA gift card or $15 cash for completing the survey. If you choose the $15 digital VISA gift
card, it will be emailed to you within 3-4 business days after you complete the survey. If you
choose $15 cash, it will be mailed to you in about 1-2 weeks, although delivery may take
longer.
How would you like to receive the $15 token of appreciation for completing the survey?
1
$15 digital VISA gift card via email – GO TO SB_EMAIL1
1
Page 76 of 143
2
$15 cash in the mail CONTINUE WITH SURVEY
[PROGRAMMER: IMPLEMENT HARD CHECK FOR SB_INCENTIVE. IF RESPONDENT DOES NOT
ANSWER, DISPLAY: Please enter a response.]
SB_EMAIL1. Please enter your email address.
EMAIL ADDRESS: __________________________
[PROGRAMMER: RESTRICT TO EMAIL FORMAT. IF RESPONDENT DOES NOT ENTER EMAIL
ADDRESS OR EMAIL ADDRESS IS INVALID, DISPLAY HARD CHECK: We must have a valid email
address to send a digital VISA gift card. Please enter your email address. Else, select the
[PREVIOUS] button to return to the previous question and change your answer to “$15 cash in
the mail” to have the $15 mailed to you after you complete the survey.
SB_EMAIL2. Please confirm your email address.
CONFIRM EMAIL ADDRESS: _______________________
[PROGRAMMER: RESTRICT TO EMAIL FORMAT. IF EMAIL2 DOES NOT MATCH EMAIL1, DISPLAY
HARD CHECK: The second email address does not match the first email address. Please reenter email to confirm your email address. Else, select the [PREVIOUS] button to change your
answer to “$15 cash in the mail” to have the $15 mailed to you after you complete the survey.
[IF MAIL MODE: Please use blue or black ink to complete the survey. Once you complete the
survey, please place it in the enclosed business reply envelope and return it to us at no charge.
Your completion and return of the survey indicates your consent to participate.]
If you have any questions about the study, please call the TCS toll-free project line at 1-800613-0326. If you have questions about your rights as a study participant, please call RTI’s
Office of Research Protection at 1-866-214-2043 (a toll-free number).
Thank you for your participation.
Please complete the survey in a private setting.
A. CIGARETTE MODULE [Ask to all Respondents]
SBA_INTRO. The first questions are about free samples of cigarettes. A free sample is a full
size, trial size, or puff of a cigarette given to you for no cost. This does not include promotions
where you have to buy something in order to receive free cigarettes, such as “buy one get one
free” coupons, membership programs with “punch cards”, or when a friend or family member
gives you cigarettes. You can receive free samples that are given to you in person or a voucher
or coupon that you can redeem at no cost at another time.
[Ask to all Respondents]
SBA1. In the past 12 months, have you seen free samples of cigarettes being handed out?
2
Page 77 of 143
1
2
Yes
No
[Ask to all Respondents]
SBA2. In the past 12 months, have you received free samples of cigarettes? Remember: a free
sample does not include a promotion such as “buy one get one free”, but can be a voucher or
coupon you were given to redeem for a free sample at no cost.
1
Yes GO TO SBA3
2
No GO TO SBA9
[Ask if SBA2=1]
SBA3. In the past 12 months, how many times have you received a free sample of cigarettes?
1
1 time
2
2-4 times
3
5 or more times
[Ask if SBA2=1]
SBA4. What brands of cigarettes were the free samples? Please select all that apply from the
list below.
[DISPLAY LIST OF BRANDS AND VARIETY OF BRAND FOR PARTICIPANTS TO SELECT. USE
SCANNER DATA WITH BRAND BY MARKET SHARE TO DETERMINE CATEGORIES]:
1
CAMEL
2
EAGLE
3
KOOL
4
L&M
5
MARLBORO
6
MAVERICK
7
MISTY
8
NATURAL AMERICAN SPIRIT
9
NEWPORT
10
PALL MALL
11
PARLIAMENT
12
PYRAMID
13
SALEM
14
VIRGINIA SLIMS
15
WINSTON
888
Other (Please specify: ____________________________)
999
I don’t know
[Ask if SBA2=1]
SBA5. In the past 12 months, how have you received free samples of cigarettes? Remember: a
free sample does not include a promotion such as “buy one get one free”, but can be given to
you in person and also be a voucher or coupon you were given to redeem for a free sample at
no cost. Have you received free samples of cigarettes…? (Answer “Yes” or “No” for each):
YES
NO
1
2
a. In person (such as at a store, fair, or bar) GO TO SBA6
1
2
b. In or on a tobacco product package
3
Page 78 of 143
c. In the mail
d. In an e-mail
e. On a cell phone or tablet app (such as “Spot You More”, “Cartwheel”,
or “Marlboro MHQ”)
f. In a text message
g. Through social media (such as Instagram, Facebook, or Twitter)
h. On a website
i. Some other way
1
2
1
2
1
2
1
2
1
2
1
2
1
2
[Ask if SBA5_a=1]
SBA6. In the past 12 months, did you receive free samples of cigarettes in person at the
following locations? (Answer “Yes” or “No” for each):
YES
NO
1
2
a. A hookah bar or café
1
2
b. A vape shop or vapor lounge
1
2
c. A mall kiosk
1
2
d. A cigar bar
1
2
e. An event (such as music festival, concert, or fair)
1
2
f. A convenience store or gas station
1
2
g. A supermarket, grocery store, or drug store
1
2
h. A warehouse club, such as Sam’s or Costco
1
2
i. A smoke shop, tobacco specialty store, or tobacco outlet store
1
2
j. A duty free shop or military retail outlet
1
2
k. A store on an Indian reservation
1
2
l. A liquor store
1
2
m. A bar, pub, restaurant, or casino
1
2
n. Somewhere else
[Ask if SBA2=1]
SBA7. You said that you received free samples of cigarettes. For the next questions, please
think of the most recent free sample of cigarettes that you received. What did you do with the
most recent free sample of cigarettes that you received?
1
Used it GO TO SBA8
2
Did not use it GO TO SBA9
[Ask if SBA7=1]
SBA8. How likely are you to purchase this product?
1
Not at all likely
2
Not too likely
3
Somewhat likely
4
Very likely
[Ask to all Respondents]
SBA9. The next questions are about discount coupons and website promo codes for cigarettes.
A discount coupon (also known as a “coupon”) makes cigarettes cheaper, but not free.
Discount coupons do not include vouchers or coupons that you can redeem for a free sample
at no cost. Discount coupons and website promo codes offer discounts such as: dollar off
rebates, buy 1 get 1 free, 2 for the price of 1, and 50% off.
4
Page 79 of 143
How likely are you to buy cigarettes if you have a discount coupon for them?
1
Not at all likely
2
Not too likely
3
Somewhat likely
4
Very likely
[Ask to all Respondents]
SBA10. In the past 12 months, have you received a discount coupon for cigarettes?
1
Yes GO TO SBA11
2
No GO TO SBA20
[Ask if SBA10=1]
SBA11. For the following questions, think about the discount coupons that you have received
that made your cigarettes cheaper. In the past 12 months, would you say that on average, you
received fewer than 10 discount coupons, 10-15 discount coupons, 16-20 discount coupons, or
more than 20 discount coupons?
1
Fewer than 10 discount coupons
2
10-15 discount coupons
3
16-20 discount coupons
4
More than 20 discount coupons
[Ask if SBA10=1]
SBA12. What brands of cigarettes were the discount coupons that you received for? Please
select all that apply from the list below.
[DISPLAY LIST OF BRANDS AND VARIETY OF BRAND FOR PARTICIPANTS TO SELECT. USE
SCANNER DATA WITH BRAND BY MARKET SHARE TO DETERMINE CATEGORIES]:
1
CAMEL
2
EAGLE
3
KOOL
4
L&M
5
MARLBORO
6
MAVERICK
7
MISTY
8
NATURAL AMERICAN SPIRIT
9
NEWPORT
10
PALL MALL
11
PARLIAMENT
12
PYRAMID
13
SALEM
14
VIRGINIA SLIMS
15
WINSTON
888
Other (Please specify: ____________________________)
999
I don’t know
[Ask if SBA10=1]
5
Page 80 of 143
SBA13. In the past 12 months, have you received discount coupons for cigarettes in the
following ways? Please select all that apply.
1
In person (such as at a store, fair, or bar) GO TO SBA14
2
In or on a tobacco product package
3
In the mail
4
In an e-mail
5
On a cell phone or tablet app (such as “Spot You More”, “Cartwheel”, or “Marlboro MHQ”)
6
In a text message
7
Through social media (such as Instagram, Facebook, or Twitter)
8
On a website
9
Some other way
[Ask if SBA13_a=1]
SBA14. In the past 12 months, did you receive discount coupons for cigarettes in person at the
following locations? Please select all that apply.
1
A hookah bar or cafe
2
A vape shop or vapor lounge
3
A mall kiosk
4
A cigar bar
5
An event (such as music festival, concert, or fair)
6
A convenience store or gas station
7
A supermarket, grocery store, or drug store
8
A warehouse club, such as Sam’s or Costco
9
A smoke shop, tobacco specialty store, or tobacco outlet store
10
A duty free shop or military retail outlet
11
A store on an Indian reservation
12
A liquor store
13
A bar, pub, restaurant, or casino
14
Somewhere else
[Ask if SBA10=1]
SBA15. You said that you received a discount coupon for cigarettes in the past 12 months. Did
you use any of these coupons to purchase cigarettes?
1
Yes GO TO SBA16
2
No GO TO SBA20
[Ask if SBA15=1]
SBA16. In the past 12 months, would you say that on average, you used fewer than 10
discount coupons, 10-15 discount coupons, 16-20 discount coupons, or more than 20 discount
coupons?
1
Fewer than 10 discount coupons
2
10-15 discount coupons
3
16-20 discount coupons
4
More than 20 discount coupons
[Ask if SBA15=1]
SBA17. Did you use the discount coupons to make your cigarettes cheaper at the following
locations? Please select all that apply.
6
Page 81 of 143
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
A hookah bar or cafe
A vape shop or vapor lounge
A mall kiosk
A cigar bar
An event (such as music festival, concert, or fair)
A convenience store or gas station
A supermarket, grocery store, or drug store
A warehouse club, such as Sam’s or Costco
A smoke shop, tobacco specialty store, or tobacco outlet store
A duty free shop or military retail outlet
A store on an Indian reservation
A liquor store
On a cell phone or tablet app (such as “Spot You More”, “Cartwheel”, or “Marlboro MHQ”)
In an online purchase through a website
Mail order purchase (by catalogue order or order by phone)
A bar, pub, restaurant, or casino
Somewhere else
[Ask if SBA15=1]
SBA18. You said that you used a discount coupon for cigarettes in the past 12 months. Think
about the most recent discount coupon that you used. What made you decide to use the
coupon? Please select all that apply.
1
Wanted to try a different type of tobacco product that I don’t usually use
2
Wanted to try a different brand of cigarettes
3
Wanted to try a different flavor (menthol or non-menthol) of my usual cigarettes
4
Wanted to try a different sub-brand or style of my usual cigarettes
5
Wanted to save money on my usual brand of cigarettes
6
Wanted to save money on a brand I used to use until the price went up and I
switched to cheaper brand
7
Some other reason
[Ask if SBA15=1]
SBA19. Think about the most recent cigarette purchase you made using a discount coupon.
How likely are you to purchase this product again?
1
Not at all likely
2
Not too likely
3
Somewhat likely
4
Very likely
[Ask to all Respondents]
SBA20. The next questions ask about your cigarette use. Have you ever smoked a cigarette,
even one or two puffs?
1
Yes GO TO SBA21
2
No GO TO SBA22
[Ask if SBA20=1]
SBA21. Have you smoked at least 100 cigarettes in your entire life?
1
Yes
7
Page 82 of 143
2
No
[Ask to all Respondents]
SBA22. Do you think you will smoke a cigarette within the next year? Would you say…?
1
Definitely yes
2
Probably yes
3
Probably not
4
Definitely not
[Ask if SBA20=1; Else skip to SBB_INTRO (Module B: Cigars)]
SBA23. Do you now smoke cigarettes every day, some days, or not at all?
1
Every day GO TO SBA24
2
Some days GO TO SBA25
3
Not at all GO TO SBB_INTRO (Module B: Cigars)
[PROGRAMMER: Define “Current Cigarette Smoker”=1 IF SBA21=1 AND (SBA23=1 OR 2)]
[Ask Current Cigarette Smokers who smoke every day, SBA21=1 AND SBA23=1]
SBA24. On the average, about how many cigarettes do you now smoke a day? Please enter
the number of cigarettes below. You can use the chart below, which tells you how many
cigarettes are in a pack.
¼ PACK = 5
½ PACK = 10
¾ PACK = 15
1 PACK = 20
1-1/4 PACKS = 25
1-1/2 PACKS = 30
1-3/4 PACKS = 35
2 PACKS = 40
2-1/4 PACKS = 45
2-1/2 PACKS = 50
2-3/4 PACKS = 55
3 PACKS = 60
______ Number of cigarettes (RANGE 1-99)
RANGE CHECK: Please enter a number between 1 and 99.
[Ask Current Cigarette Smokers who smoke some days, SBA21=1 AND SBA23=2]
SBA25. On how many of the past 30 days did you smoke a cigarette?
_______Number of days (RANGE 0-30)
RANGE CHECK: Please enter a number between 0 and 30.
[Ask Current Cigarette Smokers who smoke some days, SBA21=1 AND SBA23=2]
SBA26. On the average, on days when you smoked cigarettes during the past 30 days, about
how many did you smoke a day?
¼ PACK = 5
½ PACK = 10
¾ PACK = 15
1 PACK = 20
1-1/4 PACKS = 25
1-1/2 PACKS = 30
1-3/4 PACKS = 35
2 PACKS = 40
2-1/4 PACKS = 45
2-1/2 PACKS = 50
2-3/4 PACKS = 55
3 PACKS = 60
______ Number of cigarettes (RANGE 1-99)
8
Page 83 of 143
RANGE CHECK: Please enter a number between 1 and 99.
[Ask Current Cigarette Smokers SBA21=1 AND (SBA23=1 OR 2)]
SBA27. Do you usually smoke menthol or non-menthol cigarettes?
1
Menthol
2
Non-menthol
3
No usual type
[Ask Current Cigarette Smokers SBA21=1 AND (SBA23=1 OR 2)]
SBA28. In the past 12 months, have you purchased cigarettes from any of the following
locations? Please select all that apply.
1
A convenience store or gas station
2
A supermarket, grocery store, or drug store
3
A warehouse club, such as Sam’s or Costco
4
A smoke shop, tobacco specialty store, or tobacco outlet store
5
A duty free shop or military retail outlet
6
A bar, pub, restaurant, or casino
7
A friend or relative
8
A swap meet or flea market
9
A store on an Indian reservation
10
A liquor store
11
Online (e.g. website or phone app)
12
Somewhere else (Please specify):_________________
13
I don’t buy my own cigarettes
[Ask Current Cigarette Smokers SBA21=1 AND (SBA23=1 OR 2)]
SBA29. Are you seriously considering quitting cigarettes within the next 6 months?
1
Yes
2
No
[Ask Current Cigarette Smokers SBA21=1 AND (SBA23=1 OR 2)]
SBA30. During the past 3 months, have you stopped using cigarettes for more than one day
because you were trying to quit?
1
Yes
2
No
9
Page 84 of 143
B. CIGAR MODULE [Ask to all Respondents]
[PROGRAMMER: DISPLAY A PICTURE OF CIGAR PRODUCT TYPES]
SBB_INTRO: These questions are about regular cigars, cigarillos, and little filtered cigars.
REGULAR CIGAR: A cigar that typically contains at least ½ ounce of tobacco (as much as a pack
of cigarettes) and usually takes 1-2 hours to smoke.
CIGARILLO: Medium cigars that sometimes are sold with plastic or wooden tips. Some
common brands are Black and Mild, Swisher Sweets, Dutch Masters, and Phillies Blunts.
Cigarillos are usually sold individually or in packs of 5 or fewer.
LITTLE FILTERED CIGAR: Look like cigarettes and are usually brown in color. Like cigarettes,
little filtered cigars have a spongy filter and are sold in packs of 20. Some common brands are
Prime Time and Winchester.
The first questions are about free samples of regular cigars, cigarillos, and little filtered cigars.
A free sample is a full size, trial size, or puff of a regular cigar, cigarillo, or little filtered cigar
given to you for no cost. This does not include promotions where you have to buy something
in order to receive free regular cigars, cigarillos, or little filtered cigars, such as, “buy one get
one free” coupons, membership programs with “punch cards”, or when a friend or family
member gives you regular cigars, cigarillos, and little filtered cigars. You can receive free
samples that are given to you in person or a voucher or coupon that you can redeem at no
cost at another time.
[Ask to all Respondents]
SBB1. In the past 12 months, have you seen free samples of regular cigars, cigarillos, or little
filtered cigars being handed out?
1
Yes
2
No
[Ask to all Respondents]
SBB2. In the past 12 months, have you received free samples of regular cigars, cigarillos, or
little filtered cigars? Remember: a free sample does not include a promotion such as “buy one
get one free” but can be a voucher or coupon you were given to redeem for a free sample at
no cost.
1
Yes GO TO SBB3
2
No GO TO SBB9
[Ask if SBB2=1]
SBB3. In the past 12 months, how many times have you received a free sample of regular
cigars, cigarillos, or little filtered cigars?
1
1 time
2
2-4 times
3
5 or more times
10
Page 85 of 143
[Ask if SBB2=1]
SBB4. What brands of regular cigars, cigarillos, or little filtered cigars were the free samples?
Please select all that apply from the list below.
[DISPLAY LIST OF BRANDS AND VARIETY OF BRAND FOR PARTICIPANTS TO SELECT. USE
SCANNER DATA WITH BRAND BY MARKET SHARE TO DETERMINE CATEGORIES]:
[PROGRAMMER: DISPLAY SCREEN REFERENCES TEXT AND RESPONSE OPTION 777 FOR WEB.]
REGULAR CIGARS (SBB4_RC)
(Cigarillos and Little Filtered
Cigar lists are on the next
screens)
1
2
3
4
5
6
7
8
9
10
ACID
ANTONIO Y CLEOPATRA
CUBAN ROUNDS
DUTCH MASTERS
ENTOURAGE
GARCIA Y VEGA
HAVANA HONEYS
MACANUDO
PARTAGAS
PHILLIES
PUNCH
ROCKY PATEL
13
ROMEO Y JULIETA
14
SWISHER SWEETS
15
WHITE OWL
888
Other (Please specify:
_______________)
999
I don’t know
777
Did not receive
REGULAR CIGAR free samples
11
12
CIGARILLOS (SBB4_C)
LITTLE FILTERED CIGARS (SBB4_LFC)
(Regular Cigars list is on
(Regular Cigars and Cigarillos
previous screen and Little
lists are on the previous
Filtered Cigars list is on
screens)
next screen)
1
1
AL CAPONE
305’S
2
2
BACKWOODS
AMERICAN MADE
3
3
BLUNT VILLE
CAPTAIN BLACK
4
4
DUTCH MASTERS
CHEYENNE
5
5
G GOODIES
CLIPPER
6
6
GARCIA Y VEGA
DJARUM
7
7
GOOD TIMES
MIDDLETON’S BLACK & MILD
8
8
HAV-A-TAMPA
PHILLIES
9
9
JACKPOT
PRIME TIME
10
MIDDLETON’S BLACK & 10
SANTA FE
MILD
11
11
OPTIMO
SENECA
12
12
POM POM
SMOKER’S CHOICE
13
13
SWISHER SWEETS
SWISHER SWEETS
14
14
WHITE OWL
TALON
15
15
ZIG ZAG
WINCHESTER
888
888
Other (Please specify:
Other (Please specify:
_______________)
_______________)
999
999
I don’t know
I don’t know
777
777
Did not receive
Did not receive LITTLE
CIGARILLOS free samples
FILTERED CIGAR free samples
[Ask if SBB2=1]
SBB5. In the past 12 months, how have you received free samples of regular cigars, cigarillos,
or little filtered cigars? Remember: a free sample does not include a promotion such as “buy
one get one free” but can be given to you in person and also be a voucher or coupon you were
given to redeem for a free sample at no cost. Have you received free samples of regular cigars,
cigarillos, or little filtered cigars …? (Answer “Yes” or “No” for each):
YES
NO
1
2
a. In person (such as at a store, fair, or bar) GO TO SBB6
1
2
b. In or on a tobacco product package
1
2
c. In the mail
1
2
d. In an e-mail
11
Page 86 of 143
e. On a cell phone or tablet app (such as “Spot You More”, “Cartwheel”,
or “Marlboro MHQ”)
f. In a text message
g. Through social media (such as Instagram, Facebook, or Twitter)
h. On a website
i. Some other way
1
2
1
2
1
2
1
2
1
2
[Ask if SBB5_a=1]
SBB6. In the past 12 months, did you receive free samples of regular cigars, cigarillos, or little
filtered cigars in person at the following locations? (Answer “Yes” or “No” for each):
YES
NO
1
2
a. A hookah bar or café
1
2
b. A vape shop or vapor lounge
1
2
c. A mall kiosk
1
2
d. A cigar bar
1
2
e. An event (such as music festival, concert, or fair)
1
2
f. A convenience store or gas station
1
2
g. A supermarket, grocery store, or drug store
1
2
h. A warehouse club, such as Sam’s or Costco
1
2
i. A smoke shop, tobacco specialty store, or tobacco outlet store
1
2
j. A duty free shop or military retail outlet
1
2
k. A store on an Indian reservation
1
2
l. A liquor store
1
2
m. A bar, pub, restaurant, or casino
1
2
n. Somewhere else
[Ask if SBB2=1]
SBB7. You said that you received free samples of regular cigars, cigarillos, or little filtered
cigars. For the next questions, please think of the most recent free sample of regular cigars,
cigarillos, or little filtered cigars that you received. What did you do with the most recent free
sample that you received?
1
Used it GO TO SBB8
2
Did not use it GO TO SBB9
[Ask if SBB7=1]
SBB8. How likely are you to purchase this product?
1
Not at all likely
2
Not too likely
3
Somewhat likely
4
Very likely
[Ask to all Respondents]
SBB9. The next questions are about discount coupons and website promo codes for regular
cigars, cigarillos, and little filtered cigars. A discount coupon (also known as a “coupon”)
makes regular cigars, cigarillos, and little filtered cigars cheaper, but not free. Discount
coupons do not include vouchers or coupons that you can redeem for a free sample at no cost.
Discount coupons and website promo codes offer discounts such as: dollar off rebates, buy 1
get 1 free, 2 for the price of 1, and 50% off.
12
Page 87 of 143
How likely are you to buy regular cigars, cigarillos, or little filtered cigars if you have a discount
coupon for them?
1
Not at all likely
2
Not too likely
3
Somewhat likely
4
Very likely
[Ask to all Respondents]
SBB10. In the past 12 months, have you received a discount coupon for regular cigars,
cigarillos, or little filtered cigars?
1
Yes GO TO SBB11
2
No GO TO SBB20
[Ask if SBB10=1]
SBB11. For the following questions, think about the discount coupons that you have received
that made your regular cigars, cigarillos, or little filtered cigars cheaper. In the past 12 months,
would you say that on average, you received fewer than 10 discount coupons, 10-15 discount
coupons, 16-20 discount coupons, or more than 20 discount coupons?
1
Fewer than 10 discount coupons
2
10-15 discount coupons
3
16-20 discount coupons
4
More than 20 discount coupons
[Ask if SBB10=1]
SBB12. What brands of regular cigars, cigarillos, or little filtered cigars were the discount
coupons that you received for? Please select all that apply from the list below.
[DISPLAY LIST OF BRANDS AND VARIETY OF BRAND FOR PARTICIPANTS TO SELECT. USE
SCANNER DATA WITH BRAND BY MARKET SHARE TO DETERMINE CATEGORIES]:
13
Page 88 of 143
[PROGRAMMER: DISPLAY SCREEN REFERENCES TEXT AND RESPONSE OPTION 777 FOR WEB.]
REGULAR CIGARS (SBB12_RC)
(Cigarillos and Little Filtered
Cigar lists are on the next
screens)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
888
999
ACID
ANTONIO Y CLEOPATRA
CUBAN ROUNDS
DUTCH MASTERS
ENTOURAGE
GARCIA Y VEGA
HAVANA HONEYS
MACANUDO
PARTAGAS
PHILLIES
PUNCH
ROCKY PATEL
ROMEO Y JULIETA
SWISHER SWEETS
WHITE OWL
Other (Please specify:
_______________)
I don’t know
Did not receive
REGULAR CIGAR discount
coupons
777
CIGARILLOS (SBB12_C
LITTLE FILTERED CIGARS (SBB12_LFC)
(Regular Cigars list is on
(Regular Cigars and Cigarillos
previous screen and Little
lists are on the previous
Filtered Cigars list is on
screens)
next screen)
1
1
AL CAPONE
305’S
2
2
BACKWOOD
AMERICAN MADE
3
3
BLUNT VILLE
CAPTAIN BLACK
4
4
DUTCH MASTERS
CHEYENNE
5
5
G GOODIES
CLIPPER
6
6
GARCIA Y VEGA
DJARUM
7
7
GOOD TIMES
MIDDLETON’S BLACK & MILD
8
8
HAV-A-TAMPA
PHILLIES
9
9
JACKPOT
PRIME TIME
10
10
MIDDLETON’S BLACK
SANTA FE
& MILD
11
11
OPTIMO
SENECA
12
12
POM POM
SMOKER’S CHOICE
13
13
SWISHER SWEETS
SWISHER SWEETS
14
14
WHITE OWL
TALON
15
15
ZIG ZAG
WINCHESTER
888
888
Other (Please specify:
Other (Please specify:
_______________)
_______________)
999
999
I don’t know
I don’t know
777
Did not receive
Did not receive Little
CIGARILLOS discount coupons LITTLE FILTERED CIGAR discount
coupons
777
[Ask if SBB10=1]
SBB13. In the past 12 months, have you received discount coupons for regular cigars,
cigarillos, or little filtered cigars in the following ways? Please select all that apply.
1
In person (such as at a store, fair, or bar) GO TO SBB14
2
In or on a tobacco product package
3
In the mail
4
In an e-mail
5
On a cell phone or tablet app (such as “Spot You More”, “Cartwheel”, or “Marlboro MHQ”)
6
In a text message
7
Through social media (such as Instagram, Facebook, or Twitter)
8
On a website
9
Some other way
[Ask if SBB13_a=1]
SBB14. In the past 12 months, did you receive discount coupons for regular cigars, cigarillos, or
little filtered cigars in person at the following locations? Please select all that apply.
14
Page 89 of 143
1
2
3
4
5
6
7
8
9
10
11
12
13
14
A hookah bar or cafe
A vape shop or vapor lounge
A mall kiosk
A cigar bar
An event (such as music festival, concert, or fair)
A convenience store or gas station
A supermarket, grocery store, or drug store
A warehouse club, such as Sam’s or Costco
A smoke shop, tobacco specialty store, or tobacco outlet store
A duty free shop or military retail outlet
A store on an Indian reservation
A liquor store
A bar, pub, restaurant, or casino
Somewhere else
[Ask if SBB10=1]
SBB15. You said that you received a discount coupon for regular cigars, cigarillos, or little
filtered cigars in the past 12 months. Did you use any of these coupons to purchase regular
cigars, cigarillos, or little filtered cigars?
1
Yes GO TO SBB16
2
No GO TO SBB20
[Ask if SBB15=1]
SBB16. In the past 12 months, would you say that on average, you used fewer than 10
discount coupons, 10-15 discount coupons, 16-20 discount coupons, or more than 20 discount
coupons?
1
Fewer than 10 discount coupons
2
10-15 discount coupons
3
16-20 discount coupons
4
More than 20 discount coupons
[Ask if SBB15=1]
SBB17. Did you use the discount coupons to make your regular cigars, cigarillos, or little
filtered cigars cheaper at the following locations? Please select all that apply.
1
A hookah bar or café
2
A vape shop or vapor lounge
3
A mall kiosk
4
A cigar bar
5
An event (such as music festival, concert, or fair)
6
A convenience store or gas station
7
A supermarket, grocery store, or drug store
8
A warehouse club, such as Sam’s or Costco
9
A smoke shop, tobacco specialty store, or tobacco outlet store
10
A duty free shop or military retail outlet
11
A store on an Indian reservation
12
A liquor store
13
On a cell phone or tablet app (such as “Spot You More”, “Cartwheel”, or “Marlboro MHQ”)
14
In an online purchase through a website
15
Page 90 of 143
15
16
17
Mail order purchase (by catalogue order or order by phone)
A bar, pub, restaurant, or casino
Somewhere else
[Ask if SBB15=1]
SBB18. You said that you used a discount coupon for regular cigars, cigarillos, or little filtered
cigars in the past 12 months. Think about the most recent discount coupon that you used.
What made you decide to use the coupon? Please select all that apply.
1
Wanted to try a different type of tobacco product that I don’t usually use
2
Wanted to try a different brand of regular cigars, cigarillos, or little filtered cigars
3
Wanted to try a different flavor of my usual regular cigars, cigarillos, or little filtered
cigars
4
Wanted to try a different sub-brand or style of my usual regular cigars, cigarillos, or
little filtered cigars
5
Wanted to save money on my usual brand of regular cigars, cigarillos, or little
filtered cigars
6
Wanted to save money on a brand I used to use until the price went up and I
switched to cheaper brand
7
Some other reason
[Ask if SBB15=1]
SBB19. Think about the most recent purchase of regular cigars, cigarillos, or little filtered
cigars you made using a discount coupon. How likely are you to purchase this product again?
1
Not at all likely
2
Not too likely
3
Somewhat likely
4
Very likely
[Ask to all Respondents]
SBB20. Now we are going to ask you some questions about your cigar use. Have you ever used
a regular cigar, cigarillo, or little filtered cigar, even one or two puffs?
1
Yes
2
No
16
Page 91 of 143
[Ask to all Respondents]
SBB21. Do you think you will smoke a regular cigar, cigarillo, or little filtered cigar within the
next year? Would you say…?
1
Definitely yes
2
Probably yes
3
Probably not
4
Definitely not
[Ask if SBB20=1. If SBB20=2, go to SBC_INTRO (Module C: Smokeless Tobacco)]
SBB22. Do you now smoke regular cigars, cigarillos, or little filtered cigars every day, some
days or not at all?
1
Every day GO TO SBB23
2
Some days GO TO SBB23
3
Not at all GO TO SBC_INTRO (Module C: Smokeless Tobacco)
[Ask if SBB22=1,2]
SBB23. A picture of each type of cigar product is shown [IF WEB: on the following screens/IF
MAIL: below/to the right], along with a brief description. Please select each product that you
now smoke. If you smoke more than one of these cigar types, please select every product you
currently use.
[DISPLAY CIGAR PRODUCT IMAGES AND DESCRIPTIONS]
a. Do you now smoke regular cigars?
1
Yes
2
No
b. Do you now smoke cigarillos?
1
Yes
2
No
c. Do you now smoke little filtered cigars?
1
Yes
2
No
[Ask Current Cigar Smokers SBB22=1,2]
[IF WEB: IF ONLY 1 PRODUCT SELECTED IN SBB23a-c, FILL CIGAR TYPE IN SBB25-SBB27. ELSE,
ASK SBB24]
SBB24. Which of these cigar products do you use most often? Please select one answer.
1
Regular Cigars
2
Cigarillos
3
Little Filtered Cigars
[Ask Current Cigar Smokers SBB22=1,2]
SBB25. For the questions in this section, please think about the type of cigar product you
smoke most often, that is, [IF WEB, FILL CIGAR TYPE: regular cigars, cigarillos, or little filtered
cigars/IF MAIL: the type of product you selected from the previous question, SBB24).
17
Page 92 of 143
On the average, about how many [FILL CIGAR TYPE: regular cigars, cigarillos, little filtered
cigars from SBB5/IF MAIL: of this type of product] a day do you now smoke? Please enter the
number below.
____ Number of [IF WEB, FILL CIGAR TYPE: regular cigars, cigarillos, little filtered
cigars/IF MAIL: regular cigars, cigarillos, or little filtered cigars] (RANGE 1-99)
RANGE CHECK: Please enter a number between 1 and 99.
[Ask Current Cigar Smokers SBB22=1,2]
SBB26. Are the [FILL CIGAR TYPE: regular cigars, cigarillos, little filtered cigars from SBB5/IF
MAIL: Is the cigar product] that you smoked in the past 30 days flavored to taste like…?
(Please select all that apply.):
1
Tobacco or non-flavored
2
Menthol flavored
3
Mint, wintergreen, spearmint, or frost
4
Clove or spice
5
Fruit
6
Chocolate
7
An alcoholic drink (such as wine, cognac, margarita, or other cocktails)
8
Candy or other sweets
9
Some other flavor
[Ask Current Cigar Smokers SBB22=1,2]
SBB27. In the past 12 months, have you purchased [FILL CIGAR TYPE: regular cigars, cigarillos,
little filtered cigars from SBB4/IF MAIL: regular cigars, cigarillos, or little filtered cigars] from
any of the following locations? Please select all that apply.
1
A cigar bar
2
A convenience store or gas station
3
A supermarket, grocery store, or drug store
4
A warehouse club, such as Sam’s or Costco
5
A smoke shop, tobacco specialty store, or tobacco outlet store
6
A duty free shop or military retail outlet
7
A bar, pub, restaurant, or casino
8
A friend or relative
9
A swap meet or flea market
0
A store on an Indian reservation
11
A liquor store
12
Online (e.g. website or phone app)
13
Somewhere else (Please specify):_________________
14
I don’t buy my own regular cigars, cigarillos, or little filtered cigars
18
Page 93 of 143
[Ask Current Cigar Smokers SBB22=1,2]
SBB28. Are you seriously considering quitting regular cigars, cigarillos, or little filtered cigars
within the next 6 months?
1
Yes
2
No
[Ask Current Cigar Smokers SBB22=1,2]
SBB29. During the past 3 months, have you stopped using regular cigars, cigarillos, or little
filtered cigars for more than one day because you were trying to quit?
1
Yes
2
No
19
Page 94 of 143
C. SMOKELESS TOBACCO MODULE [Ask to all Respondents]
[PROGRAMMER: DISPLAY A PICTURE OF SMOKELESS TOBACCO PRODUCT TYPES]
SBC_INTRO: These questions are about smokeless tobacco products. Smokeless tobacco
products are placed in the mouth or nose and can include chewing tobacco, snuff, dip, or snus.
Some examples of these products are Skoal, Copenhagen, Grizzly, Levi Garrett, or Red Man.
The first questions are about free samples of smokeless tobacco. A free sample is a full size,
trial size, or pouch of a smokeless tobacco given to you for no cost. This does not include
promotions where you have to buy something in order to receive free smokeless tobacco,
such as “buy one get one free” coupons, membership programs with “punch cards”, or when a
friend or family member gives you smokeless tobacco. You can receive free samples that are
given to you in person or a voucher or coupon that you can redeem at no cost at another time.
[Ask to all Respondents]
SBC1. In the past 12 months, have you seen free samples of smokeless tobacco being handed
out?
1
Yes
2
No
[Ask to all Respondents]
SBC2. In the past 12 months, have you received free samples of smokeless tobacco?
Remember: a free sample does not include a promotion such as “buy one get one free” but
can be a voucher or coupon you were given to redeem for a free sample at no cost.
1
Yes GO TO SBC3
2
No GO TO SBC9
[Ask if SBC2=1]
SBC3. In the past 12 months, how many times have you received a free sample of smokeless
tobacco?
1
1 time
2
2-4 times
3
5 or more times
20
Page 95 of 143
[Ask if SBC2=1]
SBC4. What brands of smokeless tobacco were the free samples? Please select all that apply
from the list below.
[DISPLAY LIST OF BRANDS AND VARIETY OF BRAND FOR PARTICIPANTS TO SELECT. USE
SCANNER DATA WITH BRAND BY MARKET SHARE TO DETERMINE CATEGORIES]:
1
CAMEL
2
COPENHAGEN
3
GENERAL
4
GRIZZLY
5
HUSKY
6
KAYAK
7
KODIAK
8
LEVI GARRETT
9
LONGHORN
10
RED MAN
11
RED SEAL
12
SKOAL
13
STOKER’S
14
TIMBER WOLF
15
ZYN
888
Other (Please specify: ____________________________)
999
I don’t know
[Ask if SBC2=1]
SBC5. In the past 12 months, how have you received free samples of smokeless tobacco?
Remember: a free sample does not include a promotion such as “buy one get one free” but
can be given to you in person and also be a voucher or coupon you were given to redeem for a
free sample at no cost. Have you received free samples of smokeless tobacco…? (Answer
“Yes” or “No” for each.):
YES
NO
1
2
a. In person (such as at a store, fair, or bar) GO TO SBC6
1
2
b. In or on a tobacco product package
1
2
c. In the mail
1
2
d. In an e-mail
e. On a cell phone or tablet app (such as “Spot You More”, “Cartwheel”,
1
2
or “Marlboro MHQ”)
1
2
f. In a text message
1
2
g. Through social media (such as Instagram, Facebook, or Twitter)
1
2
h. On a website
1
2
i. Some other way
[Ask if SBC5_a=1]
SBC6. In the past 12 months, did you receive free samples of smokeless tobacco in person at
the following locations? (Answer “Yes” or “No” for each.):
YES
NO
1
2
a. A hookah bar or café
1
2
b. A vape shop or vapor lounge
21
Page 96 of 143
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
A mall kiosk
A cigar bar
An event (such as music festival, concert, or fair)
A convenience store or gas station
A supermarket, grocery store, or drug store
A warehouse club, such as Sam’s or Costco
A smoke shop, tobacco specialty store, or tobacco outlet store
A duty free shop or military retail outlet
A store on an Indian reservation
A liquor store
A bar, pub, restaurant, or casino
Somewhere else
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
[Ask if SBC2=1]
SBC7. You said that you received free samples of smokeless tobacco. For the next questions,
please think of the most recent free sample of smokeless tobacco that you received. What did
you do with the most recent free sample of smokeless tobacco that you received?
1
Used it GO TO SBC8
2
Did not use it GO TO SBC9
[Ask if SBC7=1]
SBC8. How likely are you to purchase this product?
1
Not at all likely
2
Not too likely
3
Somewhat likely
4
Very likely
[Ask to all Respondents]
SBC9. The next questions are about discount coupons and website promo codes for smokeless
tobacco. A discount coupon (also known as a “coupon”) makes smokeless tobacco cheaper,
but not free. Discount coupons do not include vouchers or coupons that you can redeem for a
free sample at no cost. Discount coupons and website promo codes offer discounts such as:
dollar off rebates, buy 1 get 1 free, 2 for the price of 1, and 50% off.
How likely are you to buy smokeless tobacco if you have a discount coupon for it?
1
Not at all likely
2
Not too likely
3
Somewhat likely
4
Very likely
SBC10. In the past 12 months, have you received a discount coupon for smokeless tobacco?
1
Yes GO TO SBC11
2
No GO TO SBC20
22
Page 97 of 143
[Ask if SBC10=1]
SBC11. For the following questions, think about the discount coupons that you have received
that made your smokeless tobacco cheaper. In the past 12 months, would you say that on
average, you received fewer than 10 discount coupons, 10-15 discount coupons, 16-20
discount coupons, or more than 20 discount coupons?
1
Fewer than 10 discount coupons
2
10-15 discount coupons
3
16-20 discount coupons
4
More than 20 discount coupons
[Ask if SBC10=1]
SBC12. What brands of smokeless tobacco were the discount coupons that you received for?
Please select all that apply from the list below.
[DISPLAY LIST OF BRANDS AND VARIETY OF BRAND FOR PARTICIPANTS TO SELECT. USE
SCANNER DATA WITH BRAND BY MARKET SHARE TO DETERMINE CATEGORIES]:
1
CAMEL
2
COPENHAGEN
3
GENERAL
4
GRIZZLY
5
HUSKY
6
KAYAK
7
KODIAK
8
LEVI GARRETT
9
LONGHORN
10
RED MAN
11
RED SEAL
12
SKOAL
13
STOKER’S
14
TIMBER WOLF
15
ZYN
888
Other (Please specify: ____________________________)
999
I don’t know
[Ask if SBC10=1]
SBC13. In the past 12 months, have you received discount coupons for smokeless tobacco in
the following ways? Please select all that apply.
1
In person (such as at a store, fair, or bar) GO TO SBC14
2
In or on a tobacco product package
3
In the mail
4
In an e-mail
5
On a cell phone or tablet app (such as “Spot You More”, “Cartwheel”, or “Marlboro MHQ”)
6
In a text message
7
Through social media (such as Instagram, Facebook, or Twitter)
8
On a website
9
Some other way
23
Page 98 of 143
[Ask if SBC13_a=1]
SBC14. In the past 12 months, did you receive discount coupons for smokeless tobacco in
person at the following locations? Please select all that apply.
1
A hookah bar or cafe
2
A vape shop or vapor lounge
3
A mall kiosk
4
A cigar bar
5
An event (such as music festival, concert, or fair)
6
A convenience store or gas station
7
A supermarket, grocery store, or drug store
8
A warehouse club, such as Sam’s or Costco
9
A smoke shop, tobacco specialty store, or tobacco outlet store
10
A duty free shop or military retail outlet
11
A store on an Indian reservation
12
A liquor store
13
A bar, pub, restaurant, or casino
14
Somewhere else
[Ask if SBC10=1]
SBC15. You said that you received a discount coupon for smokeless tobacco in the past 12
months. Did you use any of these coupons to purchase smokeless tobacco?
1
Yes GO TO SBC16
2
No GO TO SBC20
[Ask if SBC15=1]
SBC16. In the past 12 months, would you say that on average, you used fewer than 10
discount coupons, 10-15 discount coupons, 16-20 discount coupons, or more than 20 discount
coupons?
1
Fewer than 10 discount coupons
2
10-15 discount coupons
3
16-20 discount coupons
4
More than 20 discount coupons
[Ask if SBC15=1]
SBC17. Did you use the discount coupons to make your smokeless tobacco cheaper at the
following locations? Please select all that apply.
1
A hookah bar or cafe
2
A vape shop or vapor lounge
3
A mall kiosk
4
A cigar bar
5
An event (such as music festival, concert, or fair)
6
A convenience store or gas station
7
A supermarket, grocery store, or drug store
8
A warehouse club, such as Sam’s or Costco
9
A smoke shop, tobacco specialty store, or tobacco outlet store
10
A duty free shop or military retail outlet
11
A store on an Indian reservation
12
A liquor store
24
Page 99 of 143
13
14
15
16
17
On a cell phone or tablet app (such as “Spot You More”, “Cartwheel”, or “Marlboro MHQ”)
In an online purchase through a website
Mail order purchase (by catalogue order or order by phone)
A bar, pub, restaurant, or casino
Somewhere else
[Ask if SBC15=1]
SBC18. You said that you used a discount coupon for smokeless tobacco in the past 12
months. Think about the most recent discount coupon that you used. What made you decide
to use the coupon? Please select all that apply:
1
Wanted to try a different type of tobacco product that I don’t usually use
2
Wanted to try a different brand of smokeless tobacco
3
Wanted to try a different flavor of my usual smokeless tobacco
4
Wanted to try a different sub-brand or style of my usual smokeless tobacco
5
Wanted to save money on my usual brand of smokeless tobacco
6
Wanted to save money on a brand I used to use until the price went up and I
switched to cheaper brand
7
Some other reason
[Ask if SBC15=1]
SBC19. Think about the most recent purchase of smokeless tobacco you made using a discount
coupon. How likely are you to purchase this product again?
1
Not at all likely
2
Not too likely
3
Somewhat likely
4
Very likely
[Ask to all respondents]
SBC20. Now we would like to ask you about your smokeless tobacco use. Have you ever used
smokeless tobacco products even one or two times?
1
Yes
2
No
[Ask to all respondents]
SBC21. Do you think you will use smokeless tobacco within the next year? Would you say…?
1
Definitely yes
2
Probably yes
3
Probably not
4
Definitely not
[Ask If SBC20=1. If SBC20=2, go to SBD_INTRO (Module D: E-Cigarettes)]
SBC22. Do you now use smokeless tobacco every day, some days, or not at all?
1
Every day GO TO SBC23
2
Some days GO TO SBC24
3
Not at all GO TO SBD_INTRO (Module D: E-Cigarettes)
25
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[Ask to respondents who are every day smokeless tobacco users SBC22=1]
SBC23. On the average, about how many times do you now use smokeless tobacco a day?
____Number of times (RANGE 1-25)
RANGE CHECK: Please enter a number between 1 and 25.
[Ask to respondents who are some day smokeless tobacco users SBC22=2]
SBC24. On how many of the past 30 days did you use smokeless tobacco?
____Number of days (Range 0-30)
RANGE CHECK: Please enter a number between 1 and 30.
[Ask to respondents who are some day smokeless tobacco users SBC22=2]
SBC25. On the average, on days when you used smokeless tobacco during the past 30 days,
about how many times did you use a day?
_____Number of times (RANGE 1-25)
RANGE CHECK: Please enter a number between 1 and 25.
[Ask Current Smokeless Users SBC22=1,2]
[PROGRAMMER: DISPLAY A PICTURE OF SMOKELESS TOBACCO PRODUCT TYPES]
SBC26. Smokeless tobacco comes in different packaging such as metal or plastic tins, plastic
tubs, or foil pouches. In a typical week, about how many tins, tubs, or packages of smokeless
tobacco do you use each week? Please enter the number of tins, tubs or packages per week
below.
______ Number of tins, tubs, or packages per week (RANGE 1-50)
RANGE CHECK: Please enter a number between 1 and 50.
[Ask Current Smokeless Users SBC22=1,2]
SBC27. Is the smokeless tobacco you used in the past 30 days flavored to taste like….? (Please
select all that apply):
1
Tobacco or non-flavored
2
Menthol flavored
3
Mint, wintergreen, spearmint, or frost
4
Clove or spice
5
Fruit
6
Chocolate
7
An alcoholic drink (such as wine, cognac, margarita, or other cocktails)
8
Candy or other sweets
9
Some other flavor
26
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[Ask Current Smokeless Users SBC22=1,2]
SBC28. In the past 12 months, have you purchased smokeless tobacco from any of the
following locations? Please select all that apply.
1
A convenience store or gas station
2
A supermarket, grocery store, or drug store
3
A warehouse club, such as Sam’s or Costco
4
A smoke shop, tobacco specialty store, or tobacco outlet store
5
A duty free shop or military retail outlet
6
A bar, pub, restaurant, or casino
7
A friend or relative
8
A swap meet or flea market
9
A store on an Indian reservation
10
A liquor store
11
Online (e.g. website or phone app)
12
Somewhere else (Please specify):_________________
13
I don’t buy my own smokeless tobacco
[Ask Current Smokeless Users SBC22=1,2]
SBC29. Are you seriously considering quitting smokeless tobacco within the next 6 months?
1
Yes
2
No
[Ask Current Smokeless Users SBC22=1,2]
SBC30. During the past 3 months, have you stopped using smokeless tobacco for more than
one day because you were trying to quit?
1
Yes
2
No
27
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D. ELECTRONIC CIGARETTES MODULE [Ask to all Respondents]
[PROGRAMMER: DISPLAY A PICTURE OF ELECTRONIC CIGARETTE PRODUCT TYPES]
SBD_INTRO: These next questions are about electronic cigarettes. You may also know them
as e-cigarettes, vape-pens, mods, or e-vaporizers. Some look like cigarettes, and others look
like pens or small pipes. These are battery-powered, usually contain liquid nicotine, and
produce vapor instead of smoke. E-cigarettes and similar products can be bought as one-time
disposable devices, as devices that use pre-filled pods or cartridges, as devices with refillable
pods, tanks, or cartridges, or as mods that can be customized by the user. These usually
contain a liquid, often called an “e-liquid” or “e-juice.” Some common brands are JUUL, Vuse,
MarkTen, Blu, Logic, and NJOY.
The first questions are about free samples of e-cigarettes. A free sample is a working ecigarette device, an e-cigarette liquid or cartridge refill, or a puff of an e-cigarette given to you
for no cost. This does not include promotions where you have to buy something in order to
receive free e-cigarettes, such as “buy one get one free” coupons, membership programs with
“punch cards”, or when a friend or family member gives you e-cigarettes. You can receive free
samples that are given to you in person or a voucher or coupon that you can redeem at no
cost at another time.
[Ask to all Respondents]
SBD1. In the past 12 months, have you seen free samples of e-cigarettes being handed out?
1
Yes
2
No
[Ask to all Respondents]
SBD2. In the past 12 months, have you received free samples of e-cigarettes? Remember: a
free sample does not include a promotion such as “buy one get one free”, but can be a
voucher or coupon you were given to redeem for a free sample at no cost.
1
Yes GO TO SBD3
2
No GO TO SBD10
[Ask if SBD2=1]
SBD3. In the past 12 months, what type of e-cigarette free sample did you receive?
1
Puff, drag, or hit of an e-cigarette or vape pen
2
Tank
3
Complete Device, such as an e-cigarette or vape pen
4
E-liquid or E-juice
[Ask if SBD2=1]
SBD4. In the past 12 months, how many times have you received a free sample of ecigarettes?
1
1 time
2
2-4 times
3
5 or more times
28
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[Ask if SBD2=1]
SBD5. What brands of e-cigarettes were the free samples? Please select all that apply from the
list below.
[DISPLAY LIST OF BRANDS AND VARIETY OF BRAND FOR PARTICIPANTS TO SELECT. USE
SCANNER DATA WITH BRAND BY MARKET SHARE TO DETERMINE CATEGORIES]:
1
21ST CENTURY SMOKE
2
BLU
3
CUE
4
EONSMOKE
5
HAUS
6
JAK
7
JUUL
8
LOGIC
9
MARKTEN
10
MISTIC
11
NJOY
12
SQUARE
13
V2 CIGS
14
VAPIN PLUS
15
VUSE
888
Other (Please specify: ____________________________)
999
I don’t know
[Ask if SBD2=1]
SBD6. In the past 12 months, how have you received free samples of e-cigarettes? Remember:
a free sample does not include a promotion such as “buy one get one free” but can be given to
you in person and also be a voucher or coupon you were given to redeem for a free sample at
no cost. Have you received free samples of e-cigarettes…? (Answer “Yes” or “No” for each.):
YES
NO
1
2
a. In person (such as at a store, fair, or bar) GO TO SBD7
1
2
b. In or on a tobacco product package
1
2
c. In the mail
1
2
d. In an e-mail
e. On a cell phone or tablet app (such as “Spot You More”, “Cartwheel”,
1
2
or “Marlboro MHQ”)
1
2
f. In a text message
1
2
g. Through social media (such as Instagram, Facebook, or Twitter)
1
2
h. On a website
1
2
i. Some other way
[Ask if SBD6=1]
SBD7. In the past 12 months, did you receive free samples of e-cigarettes in person at the
following locations? (Answer “Yes” or “No” for each.):
YES
NO
1
2
a. A hookah bar or café
1
2
b. A vape shop or vapor lounge
1
2
c. A mall kiosk
29
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d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
A cigar bar
An event (such as music festival, concert, or fair)
A convenience store or gas station
A supermarket, grocery store, or drug store
A warehouse club, such as Sam’s or Costco
A smoke shop, tobacco specialty store, or tobacco outlet store
A duty free shop or military retail outlet
A store on an Indian reservation
A liquor store
A bar, pub, restaurant, or casino
Somewhere else
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
[Ask if SBD2=1]
SBD8. You said that you received free samples of e-cigarettes. For the next questions, please
think of the most recent free sample of e-cigarettes that you received. What did you do with
the most recent free sample of e-cigarettes that you received?
1
Used it GO TO SBD9
2
Did not use it GO TO SBD10
[Ask if SBD8=1]
SBD9. How likely are you to purchase this product?
1
Not at all likely
2
Not too likely
3
Somewhat likely
4
Very likely
[Ask to all Respondents]
SBD10. The next questions are about discount coupons and website promo codes for ecigarettes. A discount coupon (also known as a “coupon”) makes e-cigarettes cheaper, but not
free. Discount coupons do not include vouchers or coupons that you can redeem for a free
sample at no cost. Discount coupons and website promo codes offer discounts such as: dollar
off rebates, buy 1 get 1 free, 2 for the price of 1, and 50% off.
How likely are you to buy e-cigarettes if you have a discount coupon for them?
1
Not at all likely
2
Not too likely
3
Somewhat likely
4
Very likely
[Ask to all Respondents]
SBD11. In the past 12 months, have you received a discount coupon for e-cigarettes?
1
Yes GO TO SBD12
2
No GO TO SBD21
[Ask if SBD11=1]
SBD12. For the following questions, think about the discount coupons that you have received
that made your e-cigarettes cheaper. In the past 12 months, would you say that on average,
30
Page 105 of 143
you received fewer than 10 discount coupons, 10-15 discount coupons, 16-20 discount
coupons, or more than 20 discount coupons?
1
Fewer than 10 discount coupons
2
10-15 discount coupons
3
16-20 discount coupons
4
More than 20 discount coupons
[Ask if SBD11=1]
SBD13. What brands of e-cigarettes were the discount coupons that you received for? Please
select all that apply from the list below.
[DISPLAY LIST OF BRANDS AND VARIETY OF BRAND FOR PARTICIPANTS TO SELECT. USE
SCANNER DATA WITH BRAND BY MARKET SHARE TO DETERMINE CATEGORIES]:
1
21ST CENTURY SMOKE
2
BLU
3
CUE
4
EONSMOKE
5
HAUS
6
JAK
7
JUUL
8
LOGIC
9
MARKTEN
10
MISTIC
11
NJOY
12
SQUARE
13
V2 CIGS
14
VAPIN PLUS
15
VUSE
888
Other (Please specify: ____________________________)
999
I don’t know
[Ask if SBD11=1]
SBD14. In the past 12 months, have you received discount coupons for e-cigarettes in the
following ways? Please select all that apply.
1
In person (such as at a store, fair, or bar) GO TO SBD15
2
In or on a tobacco product package
3
In the mail
4
In an e-mail
5
On a cell phone or tablet app (such as “Spot You More”, “Cartwheel”, or “Marlboro MHQ”)
6
In a text message
7
Through social media (such as Instagram, Facebook, or Twitter)
8
On a website
9
Some other way
[Ask if SBD14_a=1]
SBD15. In the past 12 months, did you receive discount coupons for e-cigarettes in-person at
the following locations? Please select all that apply.
1
A hookah bar or cafe
31
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2
3
4
5
6
7
8
9
10
11
12
13
14
A vape shop or vapor lounge
A mall kiosk
A cigar bar
An event (such as music festival, concert, or fair)
A convenience store or gas station
A supermarket, grocery store, or drug store
A warehouse club, such as Sam’s or Costco
A smoke shop, tobacco specialty store, or tobacco outlet store
A duty free shop or military retail outlet
A store on an Indian reservation
A liquor store
A bar, pub, restaurant, or casino
Somewhere else
[Ask if SBD11=1]
SBD16. You said that you received a discount coupon for e-cigarettes in the past 12 months.
Did you use any of these coupons to purchase e-cigarettes?
1
Yes GO TO SBD17
2
No GO TO SBD21
[Ask if SBD16=1]
SBD17. In the past 12 months, would you say that on average, you used fewer than 10
discount coupons, 10-15 discount coupons, 16-20 discount coupons, or more than 20 discount
coupons?
1
Fewer than 10 discount coupons
2
10-15 discount coupons
3
16-20 discount coupons
4
More than 20 discount coupons
[Ask if SBD16=1]
SBD18. Did you use the discount coupons to make your e-cigarettes cheaper at the following
locations? Please select all that apply.
1
A hookah bar or cafe
2
A vape shop or vapor lounge
3
A mall kiosk
4
A cigar bar
5
An event (such as music festival, concert, or fair)
6
A convenience store or gas station
7
A supermarket, grocery store, or drug store
8
A warehouse club, such as Sam’s or Costco
9
A smoke shop, tobacco specialty store, or tobacco outlet store
10
A duty free shop or military retail outlet
11
A store on an Indian reservation
12
A liquor store
13
On a cell phone or tablet app (such as “Spot You More”, “Cartwheel”, or “Marlboro MHQ”)
14
In an online purchase through a website
15
Mail order purchase (by catalogue order or order by phone)
16
A bar, pub, restaurant, or casino
32
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17
Somewhere else
[Ask if SBD16=1]
SBD19. You said that you used a discount coupon for e-cigarettes in the past 12 months. Think
about the most recent discount coupon that you used. What made you decide to use the
coupon? Please select all that apply.
1
Wanted to try a different type of tobacco product that I don’t usually use
2
Wanted to try a different brand of e-cigarettes
3
Wanted to try a different flavor of my usual e-cigarettes
4
Wanted to try a different sub-brand or style of my usual e-cigarettes
5
Wanted to save money on my usual brand of e-cigarettes
6
Wanted to save money on a brand I used to use until the price went up and I
switched to cheaper brand
7
Some other reason
[Ask if SBD16=1]
SBD20. Think about the most recent purchase of e-cigarettes you made using a discount
coupon. How likely are you to purchase this product again?
1
Not at all likely
2
Not too likely
3
Somewhat likely
4
Very likely
[Ask to all Respondents]
SBD21. In the past 12 months, besides free samples or coupons, did you get e-cigarettes for
less than $1 (NOT from a friend or family member)?
1
Yes
2
No
[Ask to all Respondents]
SBD22. Now we would like to ask you about your e-cigarette use. Have you ever used an ecigarette, even one or two times?
1
Yes
2
No
[Ask to all Respondents]
SBD23. Do you think you will use an e-cigarette within the next year? Would you say…?
1
Definitely yes
2
Probably yes
3
Probably not
4
Definitely not
[Ask if SBD22=1. If SBD22=2, go to SBE_INTRO (Module E: Hookah/Waterpipe)]
SBD24. Do you now use e-cigarettes every day, some days, or not at all?
33
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1
2
3
Every day GO TO SBD25
Some days GO TO SBD25
Not at all GO TO SBE_INTRO (Module E: Hookah/Waterpipe)]
[Ask Current e-cigarette Users SBD24=1,2]
SBD25. Are the e-cigarettes you used in the past 30 days flavored to taste like….? (Please
select all that apply.):
1
Tobacco or non-flavored
2
Menthol flavored
3
Mint, wintergreen, spearmint, or frost
4
Clove or spice
5
Fruit
6
Chocolate
7
An alcoholic drink (such as wine, cognac, margarita, or other cocktails)
8
Candy or other sweets
9
Some other flavor
[Ask Current e-cigarette Users SBD24=1,2]
SBD26. In the past 12 months, have you purchased e-cigarette refills or devices from any of
the following locations? Please select all that apply.
1
A vape shop or vapor lounge
2
A mall kiosk
3
A convenience store or gas station
4
A supermarket, grocery store, or drug store
5
A warehouse club, such as Sam’s or Costco
6
A smoke shop, tobacco specialty store, or tobacco outlet store
7
A duty free shop or military retail outlet
8
A bar, pub, restaurant, or casino
9
A friend or relative
10
A swap meet or flea market
11
A store on an Indian reservation
12
A liquor store
13
Online (e.g. website or phone app)
14
Somewhere else (Please specify):_________________
15
I don’t buy my own e-cigarettes
[Ask Current e-cigarette Users SBD24=1,2]
SBD27. Are you seriously considering quitting e-cigarettes within the next 6 months?
1
Yes
2
No
[Ask Current e-cigarette Users SBD24=1,2]
SBD28. During the past 3 months, have you stopped using e-cigarettes for more than one day
because you were trying to quit?
1
Yes
2
No
34
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E. HOOKAH/WATERPIPES MODULE [Ask to all Respondents]
[PROGRAMMER: DISPLAY A PICTURE OF WATERPIPE TOBACCO PRODUCT TYPES]
SBE_INTRO: These questions are about smoking tobacco in a hookah, which is a type of water
pipe. It is sometimes called “shisha” or a “narghile” pipe. Some common brands are Fumari,
Starbuzz, Al Fakher, MYA Saray, or Evolution Hookah. People often smoke tobacco in hookah
in groups at cafes or in hookah bars.
The first questions are about free samples of hookah tobacco. A free sample is a full size, trial
size, or puff of hookah tobacco given to you for no cost. This does not include promotions
where you have to buy something in order to receive free hookah tobacco, such as “buy one
get one free” coupons, membership programs with “punch cards”, or when a friend or family
member gives you hookah tobacco. You can receive free samples that are given to you in
person or a voucher or coupon that you can redeem at no cost at another time.
[Ask to all Respondents]
SBE1. In the past 12 months, have you seen free samples of hookah tobacco being handed
out?
1
Yes
2
No
[Ask to all Respondents]
SBE2. In the past 12 months, have you received free samples of hookah tobacco? Remember:
a free sample does not include a promotion such as “buy one get one free”, but can be a
voucher or coupon you were given to redeem for a free sample at no cost.
1
Yes GO TO SBE3
2
No GO TO SBE9
[Ask if SBE2=1]
SBE3. In the past 12 months, how many times have you received a free sample of hookah
tobacco?
1
1 time
2
2-4 times
3
5 or more times
[Ask if SBE2=1]
SBE4. What brands of hookah tobacco were the free samples? Please select all that apply from
the list below.
[DISPLAY LIST OF BRANDS AND VARIETY OF BRAND FOR PARTICIPANTS TO SELECT. USE
SCANNER DATA WITH BRAND BY MARKET SHARE TO DETERMINE CATEGORIES]:
1
2
3
4
5
6
7
AL FAKHER
ALCHEMIST TOBACCO
AL-TAWAREG TOBACCO
EASTERN TOBACCO
FANTASIA
FUMARI
HAZE TOBACCO
35
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8
9
10
888
999
NAKHLA
SOCIAL SMOKE
STARBUZZ
Other (Please specify: ____________________________)
I don’t know
[Ask if SBE2=1]
SBE5. In the past 12 months, how have you received free samples of hookah tobacco?
Remember: a free sample does not include a promotion such as “buy one get one free” but
can be given to you in person and also be a voucher or coupon you were given to redeem for a
free sample at no cost. Have you received free samples of hookah tobacco…? (Answer “Yes” or
“No” for each.):
YES
NO
1
2
a. In person (such as at a store, fair, or bar) GO TO SBE6
1
2
b. In or on a tobacco product package
1
2
c. In the mail
1
2
d. In an e-mail
e. On a cell phone or tablet app (such as “Spot You More”, “Cartwheel”,
1
2
or “Marlboro MHQ”)
1
2
f. In a text message
1
2
g. Through social media (such as Instagram, Facebook, or Twitter)
1
2
h. On a website
1
2
i. Some other way
[ASK if SBE5_a=1]
SBE6. In the past 12 months, did you receive free samples of hookah tobacco in person at the
following locations? (Answer “Yes” or “No” for each.):
YES
NO
1
2
a. A hookah bar or café
1
2
b. A vape shop or vapor lounge
1
2
c. A mall kiosk
1
2
d. A cigar bar
1
2
e. An event (such as music festival, concert, or fair)
1
2
f. A convenience store or gas station
1
2
g. A supermarket, grocery store, or drug store
1
2
h. A warehouse club, such as Sam’s or Costco
1
2
i. A smoke shop, tobacco specialty store, or tobacco outlet store
1
2
j. A duty free shop or military retail outlet
1
2
k. A store on an Indian reservation
1
2
l. A liquor store
1
2
m. A bar, pub, restaurant, or casino
1
2
n. Somewhere else
[Ask if SBE2=1]
SBE7. You said that you received free samples of hookah tobacco. For the next questions,
please think of the most recent free sample of hookah tobacco that you received. What did
you do with the most recent free sample of hookah tobacco that you received?
36
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1
2
Used it GO TO SBE8
Did not use it GO TO SBE9
[Ask if SBE7=1]
SBE8. How likely are you to purchase this product?
1
Not at all likely
2
Not too likely
3
Somewhat likely
4
Very likely
[Ask to all Respondents]
SBE9. The next questions are about discount coupons and website promo codes for hookah
tobacco. A discount coupon (also known as a “coupon”) makes hookah tobacco cheaper, but
not free. Discount coupons do not include vouchers or coupons that you can redeem for a free
sample at no cost. Discount coupons and website promo codes offer discounts such as: dollar
off rebates, buy 1 get 1 free, 2 for the price of 1, and 50% off.
How likely are you to buy hookah tobacco if you have a discount coupon for it?
1
Not at all likely
2
Not too likely
3
Somewhat likely
4
Very likely
[Ask to all Respondents]
SBE10. In the past 12 months, have you received a discount coupon for hookah tobacco?
1
Yes GO TO SBE11
2
No GO TO SBE20
[Ask if SBE10=1]
SBE11. For the following questions, think about the discount coupons that you have received
that made your hookah tobacco cheaper. In the past 12 months, would you say that on
average, you received fewer than 10 discount coupons, 10-15 discount coupons, 16-20
discount coupons, or more than 20 discount coupons?
1
Fewer than 10 discount coupons
2
10-15 discount coupons
3
16-20 discount coupons
4
More than 20 discount coupons
[Ask if SBE10=1]
SBE12. What brands of hookah tobacco were the discount coupons that you received for?
Please select all that apply from the list below.
[DISPLAY LIST OF BRANDS AND VARIETY OF BRAND FOR PARTICIPANTS TO SELECT. USE
SCANNER DATA WITH BRAND BY MARKET SHARE TO DETERMINE CATEGORIES]:
1
2
3
4
AL FAKHER
ALCHEMIST TOBACCO
AL-TAWAREG TOBACCO
EASTERN TOBACCO
37
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5
6
7
8
9
10
888
999
FANTASIA
FUMARI
HAZE TOBACCO
NAKHLA
SOCIAL SMOKE
STARBUZZ
Other (Please specify: ____________________________)
I don’t know
[Ask if SBE10=1]
SBE13. In the past 12 months, have you received discount coupons for hookah tobacco in the
following ways? Please select all that apply.
1
In person (such as at a store, fair, or bar) GO TO SBE14
2
In or on a tobacco product package
3
In the mail
4
In an e-mail
5
On a cell phone or tablet app (such as “Spot You More”, “Cartwheel”,
or “Marlboro MHQ”)
6
In a text message
7
Through social media (such as Instagram, Facebook, or Twitter)
8
On a website
9
Some other way
[Ask if SBE13=1]
SBE14. In the past 12 months, did you receive discount coupons for hookah tobacco in person
at the following locations? Please select all that apply.
1
A hookah bar or cafe
2
A vape shop or vapor lounge
3
A mall kiosk
4
A cigar bar
5
An event (such as music festival, concert, or fair)
6
A convenience store or gas station
7
A supermarket, grocery store, or drug store
8
A warehouse club, such as Sam’s or Costco
9
A smoke shop, tobacco specialty store, or tobacco outlet store
10
A duty free shop or military retail outlet
11
A store on an Indian reservation
12
A liquor store
13
A bar, pub, restaurant, or casino
14
Somewhere else
[Ask if SBE10=1]
SBE15. You said that you received a discount coupon for hookah tobacco in the past 12
months. Did you use any of these coupons to purchase hookah tobacco?
1
Yes GO TO SBE16
2
No GO TO SBE20
38
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[Ask if SBE15=1]
SBE16. In the past 12 months, would you say that on average, you used fewer than 10
discount coupons, 10-15 discount coupons, 16-20 discount coupons, or more than 20 discount
coupons?
1
Fewer than 10 discount coupons
2
10-15 discount coupons
3
16-20 discount coupons
4
More than 20 discount coupons
[Ask if SBE15=1]
SBE17. Did you use the discount coupons to make your hookah tobacco cheaper at the
following locations? Please select all that apply.
1
A hookah bar or cafe
2
A vape shop or vapor lounge
3
A mall kiosk
4
A cigar bar
5
An event (such as music festival, concert, or fair)
6
A convenience store or gas station
7
A supermarket, grocery store, or drug store
8
A warehouse club, such as Sam’s or Costco
9
A smoke shop, tobacco specialty store, or tobacco outlet store
10
A duty free shop or military retail outlet
11
A store on an Indian reservation
12
A liquor store
13
On a cell phone or tablet app (such as “Spot You More”, “Cartwheel”, or “Marlboro MHQ”)
14
In an online purchase through a website
15
Mail order purchase (by catalogue order or order by phone)
16
A bar, pub, restaurant, or casino
17
Somewhere else
[Ask if SBE15=1]
SBE18. You said that you used a discount coupon for hookah tobacco in the past 12 months.
Think about the most recent coupon that you used. What made you decide to use the
coupon? Please select all that apply.
1
Wanted to try a different type of tobacco product that I don’t usually use
2
Wanted to try a different brand of hookah tobacco
3
Wanted to try a different flavor of my usual hookah tobacco
4
Wanted to try a different sub-brand or style of my usual hookah tobacco
5
Wanted to save money on my usual brand of hookah tobacco
6
Wanted to save money on a brand I used to use until the price went up and I
switched to cheaper brand
7
Some other reason
[Ask if SBE15=1]
39
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SBE19. Think about the most recent purchase of hookah tobacco you made using a discount
coupon. How likely are you to purchase this product again?
1
Not at all likely
2
Not too likely
3
Somewhat likely
4
Very likely
[Ask to all Respondents]
SBE20. In the past 12 months, besides free samples or coupons, did you get hookah tobacco
for less than $1 (NOT from a friend or family member)?
1
Yes
2
No
[Ask to All Respondents]
SBE21. Now we would like to ask you about your hookah use. Have you ever smoked tobacco
in a hookah or waterpipe, even one or two puffs?
1
Yes
2
No
[Ask to All Respondents]
SBE22. Do you think you will smoke tobacco in a hookah within the next year? Would you
say…?
1
Definitely yes
2
Probably yes
3
Probably not
4
Definitely not
[Ask if SBE21=1. If SBE21=2, go to SBF1]
SBE23. Do you now smoke hookah every day, some days, or not at all?
1
Every day GO TO SBE24
2
Some days GO TO SBE24
3
Not at all GO TO SBF1
[Ask Current Waterpipe Users SBE23=1,2]
SBE24. Is the tobacco you used in a hookah in the past 30 days flavored to taste like….?
(Please select all that apply.):
1
Tobacco or non-flavored
2
Menthol flavored
3
Mint, wintergreen, spearmint, or frost
4
Clove, spice, or herb flavored
5
Fruit
6
Chocolate
7
An alcoholic drink (such as wine, cognac, margarita, or other cocktails)
8
Candy or other sweets
9
Some other flavor
[Ask Current Waterpipe Users SBE23=1,2]
40
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SBE25. In the past 12 months, have you purchased shisha or hookah from any of the following
locations? Please select all that apply.
1
A hookah bar or café
2
A convenience store or gas station
3
A supermarket, grocery store, or drug store
4
A warehouse club, such as Sam’s or Costco
5
A smoke shop, tobacco specialty store, or tobacco outlet store
6
A duty free shop or military retail outlet
7
A bar, pub, restaurant, or casino
8
A friend or relative
9
A swap meet or flea market
10
A store on an Indian reservation
11
A liquor store
12
Online (e.g. website or phone app)
13
Somewhere else (Please specify): __________________
14
I don’t buy my own shisha or hookah
[Ask Current Waterpipe Users SBE23=1,2]
SBE26. Are you seriously considering quitting hookah within the next 6 months?
1
Yes
2
No
[Ask Current Waterpipe Users SBE23=1,2]
SBE27. During the past 3 months, have you stopped using hookah for more than one day
because you were trying to quit?
1
Yes
2
No
41
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F. TOBACCO COMPANY COMMUNICATIONS MODULE [Ask to all Respondents]
[Ask to all Respondents]
SBF1. Have you ever shared your address, e-mail, or phone number to sign up for coupons,
discounts or sweepstakes from a tobacco or e-cigarette company?
1
Yes GO TO SBF2
2
No GO TO SBF3
[Ask if SBF1=1]
SBF2. How did you share your address, e-mail, or phone number to sign up for coupons,
discounts or sweepstakes from a tobacco or e-cigarette company? Please select all that apply.
1
I mailed my information
2
I e-mailed my information
3
I gave my information online
4
I gave my information over the phone
5
I gave my information to someone in person (for example at a bar, music club,
concert, festival or fair)
6
I gave my information some other way
7
I did not share my information
[Ask to all Respondents]
SBF3. Have you “liked” or “followed” any tobacco or e-cigarette companies on Instagram,
Facebook, Twitter or other social media sites?
1
Yes GO TO SBF4
2
No GO TO SBJ_INTRO
[Ask if SBF3=1]
SBF4. Did you “like” or “follow” the tobacco or e-cigarette companies on social media to
receive coupons or discounts or free gifts from them?
1
Yes
2
No
42
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MODULE J: SUPPLEMENTAL COUPON QUESTIONS [For WEB Panelists ONLY]
SBJ_INTRO. The next questions are about the most recent discount coupon you received.
[Ask to all Respondents who received a coupon for ANY tobacco product; if SBA10 OR SBB10
OR SBC10 OR SBD11 OR SBE10 = 1]
SBJ1. Do you have a picture or screenshot of the most recent coupon you received for a
tobacco product (such as cigarettes, e-cigarettes, cigars, smokeless tobacco, or other tobacco
products)?
1
Yes (Go to “Upload coupon” prompt for respondent to upload
screenshot/picture. After upload is complete, then go to SBJ3. If respondent
declines to upload coupon, or upload isn’t successful, Go to Next Question])
2
No
SBJ1 UPLOAD COUPON PROMPT SERIES
PROGRAMMER: SET WEBSITE TIMEOUT PERIOD TO 15 MINUTES TO MINIMIZE TIMEOUTS
DURING THIS PROCESS.
J_UPLOAD: We are interested in seeing the most recent tobacco product coupon you
received. This can be a picture or screenshot from your mobile device or personal
computer. For example, you may have a picture of a paper coupon or a screenshot of a
coupon you received via text or email message.
Would you submit a picture or screenshot of the coupon?
1
Yes CONTINUE IMAGE SUBMISSION PROCESS
2
No GO TO SBJ2
J1_UPLOAD: Please select and submit a picture or screenshot of your most recent coupon.
The image file can be in any commonly used format (for example: .jpg, .png, .pdf). The
image file must be 10 MB or smaller in size.
Step 1: Select the coupon image file you want to submit.
PROGRAMMER: SHOW CHOOSE FILE/BROWSE BOX HERE WITH A [REMOVE] LINK
TO CLEAR THE SELECTION IF THE R CHOOSES THE WRONG FILE
Step 2: Click the [Submit Image] button below.
PROGRAMMER: SHOW [SUBMIT IMAGE] BUTTON HERE. THEN SHOW STATUS OF
SUBMISSION WHEN COMPLETED (E.G., SUCCESSFUL OR NOT):
Please select a file to upload. (DISPLAY IF R HAS NOT SELECTED A FILE BEFORE
CLICKING THE [Submit Image] BUTTON)
Image submitted successfully. Press [Next] to continue with the survey GO TO
SBJ3
43
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Image not submitted successfully. Image not in acceptable file format (.png, .jpg,
.jpeg, .gif, .tif, .pdf). Please select and submit a new image or press [Next] to continue
with the survey.
Image not submitted successfully. Image exceeds maximum file size of 10 MB.
Please select and submit a new image or press [Next] to continue with the survey.
PROGRAMMER: IF IMAGE NOT UPLOADED SUCCESSFULLY AND THE R SELECTS [NEXT] TO
MOVE FORWARD, GO TO SBJ2.
[Partly open ended question. Ask If SBJ1=2; If SBJ1=1 and respondent declines to upload
image, ask SBJ2]
SBJ2. Please describe the most recent coupon you received for a tobacco product.
[PROGRAMMER: REPEAT QUESTION STEM ON TOP OF SCREENS FOR b, c, AND d; DISPLAY IN
PARENTHESES.]
a. Was it a paper coupon or an online coupon?
Paper coupon
Online coupon
b. The type of tobacco product
Cigarettes
Little Filtered Cigars
Dip
E-Cigarette
Regular Cigars
Chewing Tobacco
Snuff
Pipe tobacco
Cigarillos
Snus
Hookah/Waterpipe
Other, Specify_______________
c. The brand of tobacco product
[DISPLAY LIST OF BRANDS AND VARIETY OF BRAND FOR PARTICIPANTS TO SELECT.
USE SCANNER DATA WITH BRAND BY MARKET SHARE TO DETERMINE CATEGORIES]:
888
999
Other (Please specify: ____________________________)
I don’t know
d. Did the coupon allow you to (Please select one answer):
1
Buy One Get One Free?
2
Buy One Get One 50% off?
3
Get 5% to 50% off?
4
Get more than 50% off?
5
Get $0.50 or more off?
6
Get some other discount? Please specify______________________
[Ask to all Respondents who used a coupon for ANY tobacco product; if SBA15 OR SBB15 OR
SBC15 OR SBD16 OR SBE15 = 1]
44
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SBJ3. Think of the most recent discount coupon you used for a tobacco product. How much
money did you save on this tobacco product by using this coupon?
$|__|__|__|.|__|__|
[RANGE: $0.01 - $100]
RANGE CHECK: Please enter a number between $0.01 and $100.
LAUNCH CONTACT INFORMATION UPDATE MODULE TO CONFIRM/UPDATE BASELINE DATA
AND ENSURE INCENTIVE PAYMENT REACHES CORRECT ADDRESS.
WEB MODE END: Thank you for answering this TCS survey. Your $15 [IF SB_INCENTIVE = 1
(VISA GIFT CARD), FILL: digital VISA gift card will be emailed to you within 3-4 business days/IF
SB_INCENTIVE = 2 (CASH), FILL: cash payment will be mailed to you in the next 1-2 weeks,
although delivery may take longer.] If you have any questions or comments about this survey,
please contact us toll-free at 1-800-613-0326 or via email at tcs@rti.org.
Please allow 24 hours for your completion of this survey to register in our system.
MAIL MODE END:
Thank you for completing the survey!
Your $15 cash payment will be mailed to you in the next 1-2 weeks.
Please place your questionnaire in the provided envelope and return to RTI International. If
the envelope has been misplaced, please mail the questionnaire to:
RTI International – [0214634.024.XXX.XXX]
5265 Capital Boulevard
Raleigh, NC 27616-2925
[DISPLAY FOR WEB/MAIL]: Paperwork Reduction Act Statement: The public reporting burden for this
information collection has been estimated to average 20 minutes per response to complete the survey
questions. Send comments regarding this burden estimate or any other aspects of this information
collection, including suggestions for reducing burden, to PRAStaff@fda.hhs.gov.
45
Page 120 of 143
Attachment 1-19. Study C Questionnaire
National Panel of Tobacco Consumer Studies
Study C Questionnaire
Study C: Hypothetical Product Standards
OMB Number: 0910-0815
Expiration Date: 02/28/2023
PROGRAMMER: INSERT PROMPTS IF AN ITEM IS LEFT BLANK SO R CAN CHOOSE DK
OR RE RESPONSE: “PLEASE ENTER A RESPONSE. SELECT “CHANGE ANSWER” TO
ENTER A RESPONSE. SELECT “KEEP ANSWER AND CONTINUE” TO SKIP THIS
QUESTION.” ASSIGN -99 TO INDICATE RESPONDENT LEFT THE ITEM BLANK. FOR
NUMERIC ITEMS, THE RANGE CHECK PROMPT IS: PLEASE ENTER A NUMBER BETWEEN
[FILL LOWER RANGE] AND [FILL UPPER RANGE].
INTRODUCTION AND CONSENT
SC_INTRO. We are excited that you are participating in the TCS survey panel. This
study will collect information about what people think about tobacco use. The
questions will take about 15 minutes to complete and you will receive $15 as a token
of our appreciation. Your participation is voluntary and you can skip any question
you do not want to answer. Your answers to the questions will be kept private to the
fullest extent required by law.
[FILL BASED ON ENROLLMENT/RE-CONSENT STATUS: There may be opportunities for
TCS researchers to use, share, or release deidentified panel data for similar research
in the future. ”Deidentified” means that we will remove your personal identifying
information before the data are used, shared, or released to others. Although we
cannot guarantee that no one can reidentify these data, it is highly unlikely that this
will occur. We will not ask for your additional informed consent if we use, share, or
release deidentified panel data for future research.]
IF WEB SURVEY: Do you agree to participate in the survey?
1
2
Yes GO TO SC_INCENTIVE
No EXIT SURVEY: Thank you for your time. Have a nice
day/evening. (ASSIGN CODE 1410 REFUSAL BY SUBJECT)
[IF WEB]: SC_INCENTIVE. Due to the coronavirus (COVID-19) pandemic, we are offering two ways for you
to receive $15 for completing the survey. You can choose to receive a $15 digital VISA gift card or $15
cash for completing the survey. If you choose the $15 digital VISA gift card, it will be emailed to you
within 3-4 business days after you complete the survey. If you choose $15 cash, it will be mailed to you in
about 1-2 weeks, although delivery may take longer.
How would you like to receive the $15 token of appreciation for completing the survey?
1
2
$15 digital VISA gift card via email – GO TO SC_EMAIL1
$15 cash in the mail CONTINUE WITH SURVEY
1
Page 121 of 143
[PROGRAMMER: IMPLEMENT HARD CHECK FOR SC_INCENTIVE. IF RESPONDENT DOES NOT ANSWER,
DISPLAY: Please enter a response.]
SC_EMAIL1. Please enter your email address.
EMAIL ADDRESS: __________________________
[PROGRAMMER: RESTRICT TO EMAIL FORMAT. IF RESPONDENT DOES NOT ENTER EMAIL ADDRESS OR
EMAIL ADDRESS IS INVALID, DISPLAY HARD CHECK: We must have a valid email address to send a digital
VISA gift card. Please enter your email address. Else, select the [PREVIOUS] button to return to the
previous question and change your answer to “$15 cash in the mail” to have the $15 mailed to you after
you complete the survey.
SC_EMAIL2. Please confirm your email address.
CONFIRM EMAIL ADDRESS: _______________________
[PROGRAMMER: RESTRICT TO EMAIL FORMAT. IF EMAIL2 DOES NOT MATCH EMAIL1, DISPLAY HARD
CHECK: The second email address does not match the first email address. Please re-enter email to
confirm your email address. Else, select the [PREVIOUS] button to change your answer to “$15 cash in the
mail” to have the $15 mailed to you after you complete the survey.
[IF MAIL MODE: Please use blue or black ink to complete the survey. Once you
complete the survey, please place it in the enclosed business reply envelope and
return it to us at no charge. Your completion and return of the survey indicates your
consent to participate.]
If you have any questions about the survey, please call the TCS toll-free project line
at 1-800-613-0326. If you have questions about your rights as a study participant,
please call RTI’s Office of Research Protection at 1‐866‐214-2043 (a toll‐free
number).
Thank you for your participation.
Please complete the survey in a private setting.
SECTION A: TOBACCO USE UPDATE [TOBACCO USE]
First, we would like to ask you a few questions background questions about your use
of tobacco products.
SCA1. How old are you?
________ Age [PROGRAMMER: NUMERIC TEXT FIELD, WHOLE NUMBERS ONLY.
RANGE 18-99]
IF LESS THAN 18 YEARS OLD, GO TO END [DISPLAY IF MODE=MAIL]
CHECK BOX 1: IF SCA1 < 18, TERMINATE; DISPLAY ON A NEW SCREEN: Thank you for your
interest in this study. Unfortunately, you are not eligible to complete this survey.
IF SCA1 IS LEFT BLANK, HARD CHECK WITH: Proving age is important to ensure you are
eligible to participate in the study. Please provide your age.
2
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SCA2. Have you ever smoked a cigarette, even one or two puffs?
1
2
Yes
No GO TO SCA5 [DISPLAY IF MODE=MAIL]
[ASK IF SCA2 = 1]
SCA3. On how many of the past 30 days did you smoke a cigarette?
|__|__| Days [RANGE 0-30]
[ASK IF SCA2 = 1]
SCA4. Have you smoked at least 100 cigarettes in your entire life?
1
2
Yes
No
SCA5. These questions are about regular cigars, cigarillos, and little filtered cigars.
“Cigarillos” are medium cigars that sometimes are sold with plastic or wooden
tips. Some common brands are Black and Mild, Swisher Sweets, Dutch Masters,
and Phillies Blunts. Cigarillos are usually sold individually or in packs of 5 or
fewer. Little filtered cigars look like cigarettes and are usually brown in color.
Like cigarettes, little filtered cigars have a spongy filter and are sold in packs
of 20. Some common brands are Prime Time or Winchester.
[DISPLAY CIGAR PRODUCT IMAGES]
Have you ever smoked a regular cigar, cigarillo, or little filtered cigar, even
one or two puffs?
1
2
Yes
No GO TO SCA7 [DISPLAY IF MODE=MAIL]
[ASK IF SCA5 = 1]
SCA6. On how many of the past 30 days did you smoke regular cigars, cigarillos, or
little filtered cigars?
|__|__| Days [RANGE 0-30]
SCA7. Now, we’d like to ask you about smokeless tobacco products. Smokeless
tobacco products are placed in the mouth or nose and can include chewing
tobacco, snuff, dip, snus (snoose), or dissolvable tobacco. Some examples of
these product brands are Skoal, Copenhagen, Grizzly, Levi Garrett, and Red
Man.
[DISPLAY SMOKELESS TOBACCO PRODUCT IMAGES]
Have you ever used smokeless tobacco even one or two times?
1
2
Yes
No GO TO SCB2 [DISPLAY IF MODE=MAIL]
3
Page 123 of 143
[ASK IF SCA7 = 1]
SCA8. On how many of the past 30 days did you use smokeless tobacco?
|__|__| Days [RANGE 0-30]
CHECK BOX 2: CREATE NEW VARIABLES THAT CATEGORIZE RESPONDENTS ACCORDING TO
THE FOLLOWING (NOT MUTUALLY EXCLUSIVE) CRITERIA:
IF (SCA3 >= 1) AND SCA4 = 1, VARIABLE “CURRENT CIGARETTE SMOKER”=1; ELSE
CURRENT CIGARETTE SMOKER=0;
IF SCA6 >= 1 AND <= 30, “CURRENT CIGAR SMOKER”=1; ELSE CURRENT CIGAR SMOKER=0;
IF SCA8 >= 1 AND <= 30, “CURRENT SMOKELESS TOBACCO USER”=1; ELSE CURRENT
SMOKELESS TOBACCO USER=0.
SECTION B: AWARENESS OF FDA AUTHORITY [REGULATING TOBACCO PRODUCTS]
CHECK BOX 3: IF MODE=WEB, GO TO SCB1; ELSE, GO TO SCB2.
SCB1. Who do you believe regulates tobacco products in the U.S.? (Please select all
that apply.)
[RANDOMIZE ORDER OF OPTIONS 1-6, FIX 7 AT END]
1
2
3
4
5
6
7
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
SCB2. Has the government put rules in place designed to make tobacco products less
harmful?
1
2
2
Yes
No
I don’t know
SECTION C: FDA CREDIBILITY (DO NOT DISPLAY SECTION HEADING IN MAIL OR
WEB MODE)
The U.S. Food and Drug Administration (FDA) regulates tobacco products in the U.S.
SCC1. How much do you agree or disagree with the following [IF MODE=MAIL:
statements/IF MODE=WEB: statement]?
[RANDOMIZE ORDER OF SCC1_1 to SCC1_11 IN WEB MODE. FOR WEB, DISPLAY QUESTION
STEM (SCC1) AT TOP OF WEB SCREENS. KEEP IN CURRENT, FIXED ORDER IN MAIL MODE.]
SCC1_1. The FDA is interested in the public’s well-being when it makes rules about
tobacco product advertising.
4
Page 124 of 143
1
2
3
4
5
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
SCC1_2. The FDA cares about the public when it limits how tobacco companies can
market tobacco products.
1
2
3
4
5
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
SCC1_3. The FDA has my interest in mind when it makes rules about the
manufacturing of tobacco products.
1
2
3
4
5
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
SCC1_4. The FDA is watching out for the public by limiting how cigarettes can be
sold.
1
2
3
4
5
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
SCC1_5. The FDA treats the public with respect when it makes rules about tobacco
products.
1
2
3
4
5
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
SCC1_6. Information from the FDA about tobacco products is fair and balanced.
1
2
3
4
5
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
SCC1_7. The FDA knows about the risks of tobacco use.
5
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1
2
3
4
5
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
SCC1_8. Information from the FDA about tobacco use is written by experts.
1
2
3
4
5
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
SCC1_9. The FDA has the expertise to communicate about the risks of tobacco
products to the public.
1
2
3
4
5
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
SCC1_10. The FDA is an expert at making rules about the harms of tobacco use.
1
2
3
4
5
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
SCC1_11. The FDA has experience making sure rules about tobacco products are
followed.
1
2
3
4
5
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
SECTION D: CURRENT TOBACCO USE AND CESSATION [OTHER TOBACCO USE]
CHECK BOX 4: IF MODE=MAIL, GO TO SCD4_INTRO. IF MODE=WEB AND “CURRENT
CIGARETTE SMOKER” = 1, GO TO SCD1; ELSE, GO TO SCD2.
SCD1. During the past 12 months, have you stopped smoking cigarettes for one day
or longer because you were trying to quit smoking cigarettes?
1
2
Yes
No
6
Page 126 of 143
CHECK BOX 5: IF MODE=WEB AND “CURRENT CIGAR SMOKER” = 1, GO TO SCD2; ELSE, GO
TO SCD3.
SCD2. During the past 12 months, have you stopped smoking regular cigars,
cigarillos, or little filtered cigars for one day or longer because you were trying
to quit smoking regular cigars, cigarillos, or little filtered cigars?
1
2
Yes
No
CHECK BOX 6: IF MODE=WEB AND “CURRENT SMOKELESS TOBACCO USER” = 1 GO TO SCD3;
ELSE, GO TO SCD4_INTRO.
SCD3. During the past 12 months, have you stopped using smokeless tobacco for one
day or longer because you were trying to quit using smokeless tobacco?
1
2
Yes
No
SCD4_INTRO. These next questions are about electronic cigarettes or e-cigarettes.
You may also know them as vape pens, mods, or e-vaporizers. Some look like
cigarettes, and others look like pens or small pipes. These are batterypowered, usually contain liquid nicotine, and produce vapor instead of smoke.
E-cigarettes and similar products can be bought as one-time disposable
devices, as devices that use pre-filled pods or cartridges, as devices with
refillable pods, tanks, or cartridges, or as mods that can be customized by the
user. These usually contain a liquid, often called an “e-liquid” or “e-juice.”
Some common brands are JUUL, Vuse, MarkTen, Blu, Logic, and NJOY.
[DISPLAY E-CIGARETTE PRODUCT IMAGES]
SCD4. Have you ever used an e-cigarette, even one or two times?
1
2
Yes
No GO TO SCD7 [DISPLAY IF MODE=MAIL]
[IF SCD4 = 1, GO TO SCD5. ELSE GO TO SCD7]
SCD5. On how many of the past 30 days did you use an e-cigarette?
|__|__| Days [RANGE 0-30]
IF 0, GO TO SCD7 [DISPLAY IF MODE=MAIL]
CHECK BOX 7: IF SCD5 >= 1, “CURRENT E-CIGARETTE USER”=1, ELSE CURRENT ECIGARETTE USER=0.
IF CURRENT E-CIGARETTE USER=1 GO TO SCD6, ELSE GO TO SCD7.
SCD6. During the past 12 months, have you stopped using e-cigarettes for one day or
longer because you were trying to quit using e-cigarettes?
1
Yes
7
Page 127 of 143
2
No
SCD7. These next questions are about smoking tobacco in a hookah, which is a type
of water pipe. It is sometimes called a “narghile” pipe. There are many types
of hookahs. People often smoke tobacco in a hookah in groups at cafes or in
hookah bars. When answering questions about hookah do not include
electronic hookahs or e-hookahs.
[DISPLAY HOOKAH PRODUCT IMAGES]
Have you ever smoked tobacco in a hookah or water pipe, even one or two
puffs?
1
2
Yes
No GO TO SCE1 [DISPLAY IF MODE=MAIL]
[IF SCD7 = 1, GO TO SDD8, ELSE GO TO SCE1]
SCD8. On how many of the past 30 days did you smoke tobacco in a hookah or water
pipe?
|__|__| Days [RANGE 0-30]
IF 0, GO TO SCE1 [DISPLAY IF MODE=MAIL]
CHECK BOX 8: IF SCD8 >= 1, “CURRENT HOOKAH USER”=1, ELSE CURRENT HOOKAH
USER=0.
IF CURRENT HOOKAH USER=1 GO TO SCD9, ELSE GO TO SCE1.
SCD9. During the past 12 months, have you stopped smoking tobacco in a hookah or
waterpipe for one day or longer because you were trying to quit smoking
tobacco in a hookah or waterpipe?
1
2
Yes
No
SECTION E: HPHC KNOWLEDGE [CHEMICALS]
SCE1. Which, if any, of the following [IF MODE=WEB DISPLAY: chemicals have you
heard of / ELSE DISPLAY: chemicals, listed in alphabetical order, have you
heard of]? (Please select all that apply)
[IF MODE=WEB RANDOMIZE ORDER OF OPTIONS 1-20; FIX 21 AT END. FIX IN
CURRENT ORDER IF MODE= MAIL.]
1
2
3
4
5
6
7
8
1,3-Butadiene
1-Aminonaphthalene
2-Aminonaphthalene
4-Aminobiphenyl
Acetaldehyde
Acrolein
Acrylonitrile
Ammonia
8
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Arsenic
Benzene
Benzo[a]pyrene
Cadmium
Carbon monoxide
Crotonaldehyde
Formaldehyde
Isoprene
Nicotine (total)
NNK (also known as 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone))
NNN (also known as N-nitrosonornicotine)
Toluene
None of the above
9
10
11
12
13
14
15
16
17
18
19
20
21
SECTION X: STIMULI EXPOSURE [REGULATING CHEMICALS IN TOBACCO]
CHECK BOX 9: IF MODE=MAIL, GO TO SECTION H. ADMINISTER SECTION X TO WEB MODE
ONLY. SEE APPENDIX A FOR PROGRAMMING INSTRUCTIONS.
SCX1_INTRO. Next, we would like you to read a statement, and then answer a few
questions about the statement.
[SHOW THE FOLLOWING STATEMENT ON A SINGLE SCREEN. INSERT PIPED TEXT
(SC1A, SC1B, SC2A AND SC2B COMBINATIONS) ACCORDING TO TABLE 3 IN APPENDIX
A. FORCE 5-SECOND EXPOSURE]
FDA has required that tobacco manufacturers reduce the level of a chemical in
all [FILL: PRODUCT TYPE]. This change will reduce the number of new cases of
[FILL: HEALTH OUTCOME].
SECTION F: ATTITUDES ABOUT PRODUCT STANDARD [DO NOT SHOW HEADING IN
WEB MODE]
CHECK BOX 10: ADMINISTER SECTION F TO WEB MODE ONLY.
DISPLAY STIMULI STATEMENT ABOVE SCF_INTRO. KEEP STIMULI VISIBLE THROUGHOUT
SECTION F.
SCF_INTRO. Now, we would like to ask you a few questions about the statement
above.
[NEXT PAGE]
SCF1. Please indicate how much you agree or disagree:
[RANDOMIZE ORDER OF ITEMS. FOR WEB, DISPLAY QUESTION STEM (SCFI) ON EACH
SCREEN.]
This change will…
SCF1_1. Make [FILL: PRODUCT] safer
1
2
3
4
Strongly disagree
Disagree
Neither agree nor disagree
Agree
9
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5
Strongly agree
SCF1_2. Make [FILL: PRODUCT] less harmful to health
1
2
3
4
5
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
SCF1_3. Make [FILL: PRODUCT] more appealing to me
1
2
3
4
5
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
SCF1_4. Make [FILL: PRODUCT] more appealing to other people.
1
2
3
4
5
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
SCF2. How believable is it that [PRODUCT TYPE] could be made with less chemicals
that are harmful to health?
1
2
3
4
Not at all believable
A little believable
Somewhat believable
Very believable
SCF3. How believable is it that reducing the level of a chemical in [PRODUCT TYPE]
could reduce the number of new cases of [HEALTH OUTCOME]?
1
2
3
4
Not at all believable
A little believable
Somewhat believable
Very believable
SECTION G: FUTURE TOBACCO BEHAVIOR INTENTIONS USING TOBACCO IN THE
FUTURE]
CHECK BOX 11: ADMINISTER SECTION G TO WEB MODE ONLY.
[ASK IF CURRENT CIGARETTE SMOKER=1; ELSE GO TO SCG3]
SCG1. Which of the following describes you? (Please select one answer.)
1
2
3
4
5
6
I
I
I
I
I
I
don’t want to stop smoking cigarettes.
think I should stop smoking cigarettes but don’t really want to.
want to stop smoking cigarettes but haven’t thought about when.
REALLY want to stop smoking cigarettes but I don’t know when I will.
want to stop smoking cigarettes and hope to soon.
REALLY want to stop smoking cigarettes and intend to in the next 3 months.
10
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7
I REALLY want to stop smoking cigarettes and intend to in the next month.
SCG2. In the next 3 months, do you think you will…(Please select one answer):
1
Smoke the same amount of cigarettes that you do now
2
Increase the amount of cigarettes that you smoke
3
Decrease the amount of cigarettes that you smoke
4
Quit smoking cigarettes altogether
[ASK IF CURRENT CIGAR SMOKER=1; ELSE GO TO SCG5]
SCG3. Which of the following describes you? (Please select one answer.)
1
I don’t want to stop smoking regular cigars, cigarillos, or little filtered cigars.
2
I think I should stop smoking regular cigars, cigarillos, or little filtered cigars
but don’t really want to.
3
I want to stop smoking regular cigars, cigarillos, or little filtered cigars but
haven’t thought about when.
4
I REALLY want to stop smoking regular cigars, cigarillos, or little filtered cigars
but I don’t know when I will.
5
I want to stop smoking regular cigars, cigarillos, or little filtered cigars and
hope to soon.
6
I REALLY want to stop smoking regular cigars, cigarillos, or little filtered cigars
and intend to in the next 3 months.
7
I REALLY want to stop smoking regular cigars, cigarillos, or little filtered cigars
and intend to in the next month.
SCG4. In the next 3 months, do you think you will…(Please select one answer):
1
Smoke the same amount of regular cigars, cigarillos, or little filtered cigars that
you do now
2
Increase the amount of regular cigars, cigarillos, or little filtered cigars that you
smoke
3
Decrease the amount of regular cigars, cigarillos, or little filtered cigars that
you smoke
4
Quit smoking regular cigars, cigarillos, or little filtered cigars altogether
[ASK IF CURRENT SMOKELESS TOBACCO USER=1; ELSE GO TO SCG7]
SCG5. Which of the following describes you? (Please select one answer.)
1
I don’t want to stop using smokeless tobacco.
2
I think I should stop using smokeless tobacco but don’t really want to.
3
I want to stop using smokeless tobacco but haven’t thought about when.
4
I REALLY want to stop using smokeless tobacco but I don’t know when I will.
5
I want to stop using smokeless tobacco and hope to soon.
6
I REALLY want to stop using smokeless tobacco and intend to in the next 3
months.
7
I REALLY want to stop using smokeless tobacco and intend to in the next
11
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month.
SCG6. In the next 3 months, do you think you will…(Please select one answer):
1
Use the same amount of smokeless tobacco that you do now
2
Increase the amount of smokeless tobacco that you use
3
Decrease the amount of smokeless tobacco that you use
4
Quit using smokeless tobacco altogether
[ASK IF CURRENT E-CIGARETTE USER=1; ELSE GO TO SCG9]
SCG7. Which of the following describes you? (Please select one answer.)
1
I don’t want to stop using e-cigarettes.
2
I think I should stop using e-cigarettes but don’t really want to.
3
I want to stop using e-cigarettes but haven’t thought about when.
4
I REALLY want to stop using e-cigarettes but I don’t know when I will.
5
I want to stop using e-cigarettes and hope to soon.
6
I REALLY want to stop using e-cigarettes and intend to in the next 3 months.
7
I REALLY want to stop using e-cigarettes and intend to in the next month.
SCG8. In the next 3 months, do you think you will…(Please select one answer):
1
Use the same amount of e-cigarettes that you do now
2
Increase the amount of e-cigarettes that you use
3
Decrease the amount of e-cigarettes that you use
4
Quit using e-cigarettes altogether
[ASK IF CURRENT HOOKAH USER=1; ELSE GO TO SCG11]
SCG9. Which of the following describes you? (Please select one answer.)
1
I don’t want to stop smoking tobacco in a hookah or water pipe.
2
I think I should stop smoking tobacco in a hookah or waterpipe but don’t really
want to.
3
I want to stop smoking tobacco in a hookah or water pipe but haven’t thought
about when.
4
I REALLY want to stop smoking tobacco in a hookah or water pipe but I don’t
know when I will.
5
I want to stop smoking tobacco in a hookah or water pipe and hope to soon.
6
I REALLY want to stop smoking tobacco in a hookah or water pipe and intend to
in the next 3 months.
7
I REALLY want to stop smoking tobacco in a hookah or water pipe and intend to
in the next month.
SCG10. In the next 3 months, do you think you will…(Please select one answer):
1
Smoke the same amount of tobacco in a hookah or waterpipe that you do now
2
Increase the amount of tobacco in a hookah or waterpipe that you smoke
12
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3
Decrease the amount of tobacco in a hookah or waterpipe that you smoke
4
Quit smoking tobacco in a hookah or waterpipe altogether
[ASK IF CURRENT CIGARETTE SMOKER=0, ELSE GO TO SCG12]
SCG11. How likely would you be to try smoking cigarettes in the next 3 months?
1
Very unlikely
2
Unlikely
3
Neither likely nor unlikely
4
Likely
5
Very likely
[ASK IF CURRENT CIGAR SMOKER=0; ELSE GO TO SCG13]
SCG12. How likely would you be to try smoking regular cigars, cigarillos, or little
filtered cigars in the next 3 months?
1
Very unlikely
2
Unlikely
3
Neither likely nor unlikely
4
Likely
5
Very likely
[ASK IF CURRENT SMOKELESS TOBACCO USER=0; ELSE GO TO SCG14]
SCG13. How likely would you be to try using smokeless tobacco in the next 3
months?
1
Very unlikely
2
Unlikely
3
Neither likely nor unlikely
4
Likely
5
Very likely
[ASK IF CURRENT E-CIGARETTE USER=0; ELSE GO TO SCG15]
SCG14. How likely would you be to try using e-cigarettes in the next 3 months?
1
Very unlikely
2
Unlikely
3
Neither likely nor unlikely
4
Likely
5
Very likely
[ASK IF CURRENT HOOKAH USER=0; ELSE GO TO SECTION H]
SCG15. How likely would you be to try smoking tobacco in a hookah or water pipe in
the next 3 months?
1
Very unlikely
2
Unlikely
13
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3
Neither likely nor unlikely
4
Likely
5
Very likely
SECTION H: PRODUCT HARM PERCEPTIONS [POTENTIAL RISKS FROM USING
TOBACCO]
We will now ask you to rate the risk of getting different health problems from using
different tobacco products. This is not a test of your scientific knowledge. We just
want to know your opinions. If you aren't sure how to answer, give your best guess.
[WEB MODE: NEXT PAGE]
CHECK BOX 12: RANDOMIZE ORDER OF SCH1, SCH2, AND SCH3 IN WEB MODE. FIX ORDER
IN MAIL MODE.
SCH1. If you were to smoke cigarettes every day, how likely is it that you would…
[RANDOMIZE ORDER OF ITEMS IN WEB MODE. FOR WEB, DISPLAY QUESTION STEM (SCH1)
ON EACH SCREEN. FIX ORDER IN MAIL MODE.]
SCH1_1. Harm your overall health
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH1_2. Have a shorter life
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH1_3. Get sick often
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH1_4. Get cancer
14
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1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH1_5. Get a life-threatening disease
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH1_6. Have heart problems
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH1_7. Get addicted
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH1_8. Have breathing problems
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH1_9. Damage your teeth
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
15
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SCH2. If you were to smoke regular cigars, cigarillos, or little filtered cigars every
day, how likely is it that you would…
[RANDOMIZE ORDER OF ITEMS IN WEB MODE. FOR WEB, DISPLAY QUESTION STEM (SCH2)
ON EACH SCREEN. FIX ORDER IN MAIL MODE.]
SCH2_1. Harm your overall health
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH2_2. Have a shorter life
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH2_3. Get sick often
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH2_4. Get cancer
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH2_5. Get a life-threatening disease
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
16
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SCH2_6. Have heart problems
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH2_7. Get addicted
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH2_8. Have breathing problems
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH2_9. Damage your teeth
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH3. If you were to use smokeless tobacco every day, how likely is it that you
would…
[RANDOMIZE ORDER OF ITEMS IN WEB MODE. FOR WEB, DISPLAY QUESTION STEM (SCH3)
ON EACH SCREEN. FIX ORDER IN MAIL MODE.]
SCH3_1. Harm your overall health
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
17
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SCH3_2. Have a shorter life
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH3_3. Get sick often
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH3_4. Get cancer
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH3_5. Get a life-threatening disease
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH3_6. Have heart problems
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH3_7. Get addicted
1
Not at all likely
2
Slightly likely
3
Somewhat likely
18
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4
Very likely
5
Extremely likely
SCH3_8. Have breathing problems
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SCH3_9. Damage your teeth
1
Not at all likely
2
Slightly likely
3
Somewhat likely
4
Very likely
5
Extremely likely
SECTION J: HPHC HARM PERCEPTIONS (DO NOT DISPLAY HEADING IN WEB OR MAIL
MODE)
SCJ1. Please indicate how much you agree or disagree with the following [IF
MODE=MAIL, FILL: statement/IF MODE=WEB, FILL: statements]:
[RANDOMIZE ORDER OF ITEMS. FOR WEB, DISPLAY QUESTION STEM (SCJ1) ON EACH
SCREEN.]
SCJ1_1. If you can’t quit, you should switch to a tobacco product with fewer
chemicals.
1
2
3
4
5
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
[ASK IF MODE=WEB; ELSE GO TO SCK1]
SCJ1_2. It’s much safer to [IF PRODUCT GROUP = 1 (CIGARETTES), “smoke
cigarettes”; IF PRODUCT GROUP = 2 (SMOKELESS TOBACCO), “use smokeless
tobacco”] with fewer chemicals.
1
2
3
4
5
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
19
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SECTION K: DEMOGRAPHICS [PANEL MEMBER INFORMATION]
SCK1. Which of the following best describes you? (Please select one answer.)
1
Female
2
Male
3
Other
SCK2. Are you Hispanic, [IF WEB MODE AND SCK1 = 1, “Latina”; IF WEB MODE AND
SCK1 = 2, “Latino”; IF WEB MODE AND SCK1 = 3, “Latino/a”; IF MAIL MODE,
“Latino/a”], or of Spanish origin?
1
Yes
2
No
SCK3. What is your race? Please select one or more.
1
White
2
Black or African American
3
American Indian or Alaska Native
4
Asian
5
Native Hawaiian or Other Pacific Islander
6
Other
-2
Refused
SCK4. What is the highest grade or year of school you have completed?
1
Less than high school
2
High school graduate or GED
3
Some college/vocational school (no degree)
4
2-year college/vocational/Associate’s degree
5
4-year college degree or higher (e.g., BA, BS, MA, MS, Ph.D)
Don’t know
Refused
-1
-2
SCK5. What was the total combined income of all members of your family during the
past 12 months? This includes money from jobs, net income from business,
farm or rent, pensions, dividends, interest, social security payments and any
other money income received by members of your family who are 18 years of
age or older. Would you say it was…
1
2
3
4
5
6
7
-1
-2
Under $30,000
$30,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $124,999
$125,000 to $149,999
$150,000 or more
Don’t know
Refused
20
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SCK6. Including yourself, how many people live in your household?
_____ People [RANGE 1–99]
LAUNCH CONTACT INFORMATION UPDATE MODULE TO CONFIRM/UPDATE BASELINE
DATA AND ENSURE INCENTIVE PAYMENT REACHES CORRECT ADDRESS.
WEB MODE END: Thank you for answering this TCS survey. Your $15 [IF
SC_INCENTIVE = 1 (VISA GIFT CARD), FILL: digital VISA gift card will be emailed to
you within 3-4 business days/IF SC_INCENTIVE = 2 (CASH), FILL: cash payment will
be mailed to you in the next 1-2 weeks, although delivery may take longer.
FDA sponsored this survey.
We showed you a statement that FDA has required that tobacco manufacturers
reduce the level of a chemical in all [PRODUCT TYPE].
It’s important for you to know that FDA has not actually required that tobacco
manufacturers reduce the level of a chemical in all [PRODUCT TYPE]. This statement
was made up for the sake of this study.
Please allow 24 hours for your completion of this survey to register in our system.
MAIL MODE END:
Thank you for completing the survey!
Your $15 cash payment will be mailed to you in the next 1-2 weeks.
Please place your questionnaire in the provided envelope and return to RTI International. If
the envelope has been misplaced, please mail the questionnaire to:
RTI International – [0214634.024.XXX.XXX]
3040 Cornwallis Rd.
Research Triangle Park, NC 27709
[DISPLAY FOR WEB/MAIL]: Paperwork Reduction Act Statement: The public reporting burden for this
information collection has been estimated to average 20 minutes per response to complete the survey
questions. Send comments regarding this burden estimate or any other aspects of this information
collection, including suggestions for reducing burden, to PRAStaff@fda.hhs.gov
21
Page 141 of 143
APPENDIX A: PROGRAMMING INSTRUCTIONS FOR MAIL AND WEB MODES
PROCEDURES FOR WEB MODE: RANDOMLY ASSIGN WEB MODE RESPONDENTS TO ONE OF 8
CONDITIONS WITH VARIATION IN STUDY CONDITION, PRODUCT TYPE, AND HEALTH
OUTCOME FACTORS. TABLE 1 ILLUSTRATES THE STUDY DESIGN.
TABLE 1. EXPERIMENTAL CONDITIONS IN WEB MODE SURVEY
STUDY CONDITION
TREATMENT (T)
COMPARISON (C)
PRODUCT TYPE
CIGARETTES (1)
SMOKELESS TOBACCO (2)
CIGARETTES (1)
SMOKELESS TOBACCO (2)
HEALTH OUTCOME
HEART
CANCER (A)
ATTACK AND
STROKE (B)
T_A1
T_B1
T_A2
T_B2
C_A1
C_B1
C_A2
C_B2
SURVEY FLOW WILL VARY ACCORDING TO STUDY CONDITION FOR THE WEB MODE SURVEY.
TABLE 2 ILLUSTRATES THE SURVEY FLOW FOR EACH CONDITION IN THE WEB MODE SURVEY.
TABLE 2. WEB MODE SURVEY FLOW, BY STUDY CONDITION
TREATMENT (T)
COMPARISON (C)
SECTION A: TOBACCO USE UPDATE
SECTION A: TOBACCO USE UPDATE
SECTION B: AWARENESS OF FDA AUTHORITY
SECTION B: AWARENESS OF FDA
AUTHORITY
SECTION C: FDA CREDIBILITY
SECTION C: FDA CREDIBILITY
SECTION D: CURRENT TOBACCO USE AND
CESSATION
SECTION D: CURRENT TOBACCO USE
AND CESSATION
SECTION E: HPHC KNOWLEDGE
SECTION E: HPHC KNOWLEDGE
SECTION X: STIMULI EXPOSURE
SECTION F: ATTITUDES ABOUT PRODUCT
STANDARD
SECTION G: FUTURE TOBACCO BEHAVIOR
INTENTIONS
SECTION G: FUTURE TOBACCO
BEHAVIOR INTENTIONS
SECTION H: PRODUCT HARM
PERCEPTIONS
SECTION J: HPHC HARM PERCEPTIONS
SECTION H: PRODUCT HARM PERCEPTIONS
SECTION X: STIMULI EXPOSURE
SECTION J: HPHC HARM PERCEPTIONS
SECTION F: ATTITUDES ABOUT
PRODUCT STANDARD
SECTION K: DEMOGRAPHICS
SECTION K: DEMOGRAPHICS
IN SECTION X, WEB MODE RESPONDENTS WILL BE SHOWN A STATEMENT WITH PIPED TEXT
THAT VARIES ACCORDING TO PRODUCT TYPE AND HEALTH OUTCOME. BELOW IS THE
INTRODUCTORY TEXT AND THE STIMULI STATEMENT.
STIMULI:
SCX1_INTRO. Next, we would like you to read a statement, and then answer a few questions
about the statement.
FDA has required that tobacco manufacturers reduce the level of a chemical in all [PRODUCT
TYPE]. This change will reduce [HEALTH OUTCOME].
TABLE 3 BELOW ILLUSTRATES THE TEXT TO BE PIPED ACCORDING TO EACH OF THESE
FACTORS.
22
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TABLE 3. PIPED TEXT FOR EACH PRODUCT TYPE AND HEALTH OUTCOME FACTOR
CONSTRUCT
PRODUCT TYPE
CIGARETTES (1)
SMOKELESS TOBACCO (2)
HEALTH OUTCOME
CANCER (A)
HEART ATTACK AND STROKE (B)
TEXT
“cigarettes”
“smokeless tobacco products”
“the number of new cases of cancer”
“the number of new cases of heart attack
and stroke”
PROCEDURES FOR MAIL MODE: TABLE 4 ILLUSTRATES THE SURVEY FLOW FOR THE MAIL
MODE SURVEY. THE MAIL MODE INCLUDES ALL OF SECTIONS A, C, E, H, AND K AND
SELECTED ITEMS FROM SECTIONS B, D, AND J AS INDICATED IN THE TABLE. SECTIONS X, F,
AND G ARE NOT INCLUDED IN THE MAIL MODE.
TABLE 4. SURVEY FLOW FOR MAIL MODE
SECTION
ADMINISTRATION INSTRUCTIONS
SECTION A: TOBACCO USE UPDATE
ADMINISTER FULL SECTION
SECTION B: AWARENESS OF FDA AUTHORITY
ADMINISTER SCB2 ONLY
SECTION C: FDA CREDIBILITY
ADMINISTER FULL SECTION
SECTION D: CURRENT TOBACCO USE AND
CESSATION
ADMINISTER SCD4_INTRO – SCD9
SECTION E: HPHC KNOWLEDGE
ADMINISTER FULL SECTION
SECTION H: PRODUCT HARM PERCEPTIONS
ADMINISTER FULL SECTION
SECTION J: HPHC HARM PERCEPTIONS
ADMINISTER SCJ1_1 ONLY
SECTION K: DEMOGRAPHICS
ADMINISTER FULL SECTION
23
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| File Type | application/pdf |
| Author | shk |
| File Modified | 2020-04-23 |
| File Created | 2020-02-24 |