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pdfNational Cancer Institute
Part I, To Be Completed by Study Participant
OMB No. 09250645, Expiry Date 12/31/2014
Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintain the data needed, and completing and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing the burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 208927974, ATTN: PRA (09250645).
Do not return the completed form to this address.
1. How old were you when you smoked a whole cigarette for the first time?
In years:
2. How old were you when you first started smoking cigarettes every day?
In years:
3. On average, how many cigarettes do you now smoke a day?
Number of cigarettes:
4. How soon after you awake in the morning do you usually smoke your first cigarette?
Number of minute(s):
and/or Number of hour(s):
5. Have you EVER stopped smoking for one day or longer because you were trying to quit
smoking?
j Yes
k
l
m
n
j No
k
l
m
n
Part I, To Be Completed by Study Participant
6. During the PAST 12 MONTHS, have you stopped smoking for one day or longer
because you were trying to quit smoking?
j Yes
k
l
m
n
j No
k
l
m
n
Part I, To Be Completed by Study Participant
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National Cancer Institute
Each rung on this ladder represents where various smokers are in their thinking about
quitting.
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National Cancer Institute
7. Indicate the number where you are now.
j 10
k
l
m
n
j 9
k
l
m
n
j 8
k
l
m
n
j 7
k
l
m
n
j 6
k
l
m
n
j 5
k
l
m
n
j 4
k
l
m
n
j 3
k
l
m
n
j 2
k
l
m
n
j 1
k
l
m
n
j 0
k
l
m
n
Part I, To Be Completed by Study Participant
8. During the past 30 days, what brand (and type) of cigarettes did you smoke most often?
Be as specific as you can.
5
6
9. Do you usually smoke menthol or nonmenthol cigarettes?
j Menthol
k
l
m
n
j NonMenthol
k
l
m
n
Part I, To Be Completed by Study Participant
In the following questions, we will be asking you about a tobacco product called Snus (or Swedish Snuff). This is a new
tobacco product that is available in the United States that comes in different variations. Snus is used in a similar way as
dipping tobacco, but there is no need to spit. Snus comes in a small white pouch (like a small teabag), which is placed
in the cheek or between the teeth and gums, without chewing, for extended periods of time. A package of Snus usually
contains 15 pouches.
10. Before this survey, had you ever heard of a tobacco product called Snus?
j Yes
k
l
m
n
j No
k
l
m
n
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National Cancer Institute
11. Have you EVER used Snus?
j No, I have never used it
k
l
m
n
j I used it once
k
l
m
n
j I have used it multiple times
k
l
m
n
j I currently use it some days
k
l
m
n
j I currently use it every day
k
l
m
n
12. If offered a free package of Snus today, what would be the likelihood that you would
use Snus in the next 7 days?
Extremely unlikely
Unlikely
Neither likely nor unlikely
Likely
Extremely likely
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
13. What is the likelihood that you would use Snus instead of cigarettes in situations
where you are not allowed to smoke (for instance, on an airplane or another public place
where smoking was not allowed)?
Extremely unlikely
Unlikely
Neither likely nor unlikely
Likely
Extremely likely
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
14. What is the likelihood that you would switch to Snus completely and give up
cigarettes?
Extremely unlikely
Unlikely
Neither likely nor unlikely
Likely
Extremely likely
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
15. To what extent do you disagree or agree with the following statement:
“Snus is harmful to one’s health.”
Strongly disagree
Disagree
Agree
Strongly agree
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
16. Do you believe that Snus is less or more harmful to one’s health than ordinary
cigarettes?
Much less harmful
Less harmful
About the same
More harmful
Much more harmful
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
17. To what extent do you disagree or agree with the following statement:
“Snus is addictive.”
Strongly disagree
Disagree
Agree
Strongly agree
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
18. Do you believe that Snus is less or more addictive than ordinary cigarettes?
Much less addictive
Less addictive
About the same
More addictive
Much more addictive
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
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National Cancer Institute
Part I, To Be Completed by Study Participant
19. What is your marital status?
j Married
k
l
m
n
j Living as married
k
l
m
n
j Divorced
k
l
m
n
j Widowed
k
l
m
n
j Separated
k
l
m
n
j Single, never been married
k
l
m
n
20. What is your current occupational status ?
j Employed
k
l
m
n
j Unemployed
k
l
m
n
j Homemaker
k
l
m
n
j Student
k
l
m
n
j Retired
k
l
m
n
j Disabled
k
l
m
n
Other (please specify)
21. What is the highest grade or level of schooling you completed?
j Less than 8 years
k
l
m
n
j 8 through 11 years
k
l
m
n
j 12 years or completed high school
k
l
m
n
j Post high school training other than college (vocational or technical)
k
l
m
n
j Some college
k
l
m
n
j College graduate
k
l
m
n
j Postgraduate
k
l
m
n
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National Cancer Institute
Thank you for completing Part I of this survey. Please let the survey administrator know
that you are finished.
Part II, To Be Completed by Study Administrator
Advertisement 1
OMB No. 09250645, Expiry Date 12/31/2014
Public reporting burden for this collection of information is estimated to range from 15 to 50 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 208927974.
22. Name of first advertisement shown
23. What is the main message you got from this advertisement?
5
6
24. Was there anything else about this advertisement you want to mention?
5
6
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National Cancer Institute
25. Do you believe that the Snus product in THIS advertisement is less or more harmful to
one’s health than ordinary cigarettes? Would you say the Snus product in this
advertisement is...
Much less harmful
Less harmful
About the same
More harmful
Much more harmful
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Comments:
26. Do you believe that the Snus product in THIS advertisement is less or more addictive
than ordinary cigarettes? Would you say the Snus product in this advertisement is...
Much less addictive
Less addictive
About the same
More addictive
Much more addictive
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Comments:
Part II, To Be Completed by Study Administrator
Advertisement 2
27. Name of second advertisement shown
28. What is the main message you got from this advertisement?
5
6
29. Was there anything else about this advertisement you want to mention?
5
6
30. Do you believe that the Snus product in THIS advertisement is less or more harmful to
one’s health than ordinary cigarettes? Would you say the Snus product in this
advertisement is...
Much less harmful
Less harmful
About the same
More harmful
Much more harmful
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Comments:
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National Cancer Institute
31. Do you believe that the Snus product in THIS advertisement is less or more addictive
than ordinary cigarettes? Would you say the Snus product in this advertisement is...
Much less addictive
Less addictive
About the same
More addictive
Much more addictive
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Comments:
Part II, To Be Completed by Study Administrator
Advertisement 3
32. Name of third advertisement shown
33. What is the main message you got from this advertisement?
5
6
34. Was there anything else about this advertisement you want to mention?
5
6
35. Do you believe that the Snus product in THIS advertisement is less or more harmful to
one’s health than ordinary cigarettes? Would you say the Snus product in this
advertisement is...
Much less harmful
Less harmful
About the same
More harmful
Much more harmful
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Comments:
36. Do you believe that the Snus product in THIS advertisement is less or more addictive
than ordinary cigarettes? Would you say the Snus product in this advertisement is...
Much less addictive
Less addictive
About the same
More addictive
Much more addictive
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Comments:
Part II, To Be Completed by Study Administrator
Advertisement 4
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National Cancer Institute
37. Name of fourth advertisement shown
38. What is the main message you got from this advertisement?
5
6
39. Was there anything else about this advertisement you want to mention?
5
6
40. Do you believe that the Snus product in THIS advertisement is less or more harmful to
one’s health than ordinary cigarettes? Would you say the Snus product in this
advertisement is...
Much less harmful
Less harmful
About the same
More harmful
Much more harmful
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Comments:
41. Do you believe that the Snus product in THIS advertisement is less or more addictive
than ordinary cigarettes? Would you say the Snus product in this advertisement is...
Much less addictive
Less addictive
About the same
More addictive
Much more addictive
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Comments:
Part II, To Be Completed by Study Administrator
Advertisement 5
42. Name of fifth advertisement shown
43. What is the main message you got from this advertisement?
5
6
44. Was there anything else about this advertisement you want to mention?
5
6
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National Cancer Institute
45. Do you believe that the Snus product in THIS advertisement is less or more harmful to
one’s health than ordinary cigarettes? Would you say the Snus product in this
advertisement is...
Much less harmful
Less harmful
About the same
More harmful
Much more harmful
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Comments:
46. Do you believe that the Snus product in THIS advertisement is less or more addictive
than ordinary cigarettes? Would you say the Snus product in this advertisement is...
Much less addictive
Less addictive
About the same
More addictive
Much more addictive
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Comments:
47. (If the participant has not mentioned this previously):
Did you notice a warning on this advertisement?
j Yes
k
l
m
n
j No
k
l
m
n
Comments:
48. Did you notice a warning on any of the other advertisements?
j Yes
k
l
m
n
j No
k
l
m
n
Comments:
49. If you did notice a warning, do you recall what the warning said?
5
6
Page 10
| File Type | application/pdf |
| File Modified | 2013-05-31 |
| File Created | 2013-05-31 |