Form 0920-1083 Smoker Survey - Wave A

SMOKER SURVEY
BASE: If DOV_SMOKER=1
OMB_SMOKER [DISP]
Form Approved
OMB No. 0920-1083
Exp. Date 3/31/2023
Extended Evaluation of the National Tobacco Prevention and Control Public Education
Campaign Smoker Questionnaire
Public reporting burden of this collection of information is estimated to average 20 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 CDC/ATSDR Reports
Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA
(0920-1083).
BASE: If A3=2 or ((DOV_SURVEY_1R=1 and ALL_S5=2) or (DOV_SURVEY_1R NE 1 and
ABS_S3D=2)) (R is a some day smoker)
A5 [N with range 0-30]
The next few questions are about tobacco use and smoking cessation.
During the past 30 days, that is since [DOV_DATE1], on how many days did you smoke
cigarettes?
____ Number of days
Scripter: If A3=1 or ((DOV_SURVEY_1R=1 and ALL_S5=1) or (DOV_SURVEY_1R NE 1 and
ABS_S3D=1)) (R is an every day smoker), autofill A5=30
BASE: If DOV_SMOKER=1
B1 [N with range 1-200]
On the average, about how many cigarettes a day do you now smoke? Enter '1' if less than 1
cigarette.
____ Number of cigarettes
BASE: If DOV_SMOKER=1
B2 [S]
On the days that you smoke, how soon after you wake up do you usually have your first
cigarette? Would you say…
1. Within 5 minutes
2. 6-30 minutes

3. From more than 30 minutes to 1 hour
4. After more than 1 hour
BASE: If DOV_SMOKER=1

B3 [S]
Currently, when you smoke cigarettes, do you usually smoke menthol cigarettes?
1. Yes
2. No
3. Don’t know/ Not sure
4. Refused
BASE: If DOV_SMOKER=1 AND MENTHOL = 1
B4 [Grid, S Across]
For each of the following, please indicate whether it’s a reason you usually smoke menthol
cigarettes. Please answer “yes” or “no” for each.
Statements in row (randomize and record response order):
B4_1. They are less harmful than non-menthol cigarettes.
B4_2. They have a better flavor than non-menthol cigarettes.
B4_3. They are less harsh on your THROAT than non-menthol cigarettes.
B4_4. They are less harsh on your CHEST than non-menthol cigarettes. B4_5. They
are easier to smoke than non-menthol cigarettes.
Answers in columns:
1. Yes
2. No
BASE: If DOV_SMOKER=1
C2 [N with range 0-999]
The next few questions ask about your attempts to quit smoking regular cigarettes at
different times over the past year. In answering, please think specifically about the timeframe
for each question.
During the past 3 months, that is, since [DOV_DATE2], how many times have you stopped
smoking for one day or longer because you were trying to quit smoking cigarettes for good?
____ Number of times
BASE: If DOV_SMOKER=1
C2a [N with range C2 value-999]
During the past 6 months, that is since [DOV_DATE4], how many times have you stopped
smoking for one day or longer because you were trying to quit smoking cigarettes for good?
____ Number of times
BASE: If DOV_SMOKER=1

2

C1 [N with range C2a value-999; if C2a is refused, range C2 value-999] During the
past 12 months, that is, since [DOV_DATE3], how many times have you stopped smoking
for one day or longer because you were trying to quit smoking cigarettes for good?
____ Number of times

BASE: If C1>0 or C2>0 or C2a>0
C4 [Grid, S Across]
When you last tried to quit smoking, did you do any of the following?
Statements in row (randomize and record response order):
C4_1. Give up cigarettes all at once
C4_2. Gradually cut back on cigarettes
C4_3. Switch completely to e-cigarettes, vapes, or mods (popular brands include NJOY,
Blu, Logic, Vuse, and JUUL)
C4_4. Substitute some of your regular cigarettes with e-cigarettes, vapes, or mods (popular
brands include NJOY, Blu, Logic, Vuse, Puff Bar, and JUUL)
C4_4a. Switch completely to heated tobacco products (using “heat not burn” tobacco
products, iQOS [eye-kos], Glo, or Eclipse)
C4_4b. Substitute some of your regular cigarettes with heated tobacco products (using “heat
not burn” tobacco products, iQOS [eye-kos], Glo, or Eclipse)
C4_5. Switch to a different brand of cigarettes
C4_5. Switch to smokeless tobacco (such as snuff, chew, or snus) or dissolvable tobacco.
C4_6. Use nicotine replacements medications like the nicotine patch, nicotine gum, nicotine
lozenges, nicotine nasal spray, or nicotine inhaler
C4_7. Use medications like Wellbutrin, Zyban, buproprion, Chantix, or varenicline
C4_8. Get help from a telephone quit line
C4_9. Get help from a website such as Smokefree.gov or CDC.gov/Tips
C4_10. Get help from a doctor or other health professional
C4_11. Get help from a pharmacist
C4_12. Use a mobile App to help you quit smoking
C4_13. Use a texting program to help you quit smoking
Answers in columns:
1. Yes
2. No
BASE: If C1>0 or C2>0 or C2a>0
C5 [Grid, S Across]
When you last tried to quit smoking, did any of the following motivate you to try to quit?
Statements in row:
C5_1. A family member or friend encouraged me to try to quit
C5_2. Anti-tobacco television commercials, online ads or videos, radio ads, or other types of
advertisements that focus on the health consequences of smoking C5_3. My doctor or other
health professional advised me to quit smoking
C5_4. Workplace restrictions on smoking
C5_5. Cost of cigarettes is too high
C5_6. Concern about COVID-19
C5_7. Other, please specify: [O] _____
Answers in columns:
1. Yes
3

2. No
Scripter: If C5_5 = “Yes” but nothing is entered in the verbatim, prompt with “Please tell us
what else motivated you to quit smoking.”
BASE: If DOV_SMOKER=1
C6a [S]
Do you want to quit smoking cigarettes for good?
1. Yes
2. No
BASE: If C6a=1
C7b [S]
How much do you want to quit smoking? Would you say you want to quit…
1. Not at all
2. A little
3. Somewhat
4. A lot
Scripter: If C6a=2, autopunch C7b=1 (not at all)
BASE: If C6a=1
C9 [S]
Do you plan to quit smoking for good…
1. In the next 7 days
2. In the next 30 days
3. In the next 6 months
4. In the next 1 year
5. More than 1 year from now
6. I do not plan to quit smoking cigarettes for good
7. Not sure/Uncertain
Scripter: If C6a=2, autopunch C9=6 (I do not plan to quit smoking cigarettes for good)
BASE: If DOV_SMOKER=1
C10 [S]
If you decided to give up smoking altogether in the next 12 months, how likely do you think
you would be to succeed? Would you say…
1. Extremely likely
2. Very likely
3. Somewhat likely
4. Very unlikely
5. Extremely unlikely
BASE: All smoker respondents
C14 [S]
Among close friends, do…
1. All of the smoke?
4

2. Most of them smoke?
3. Most of them not smoke?
4. None of them smoke?
BASE: If DOV_SMOKER=1
B8 [S]
The next questions are about electronic or e-cigarettes. You may also know them as vape
pens, e-hookah, vapes, or mods. Some popular brands include NJOY, Blu, Logic, Vuse, Puff
Bar, and JUUL. Please do not include marijuana, cannabis, and THC products
(including concentrates, waxes or hash oils) for these questions.

[SHOW IMAGE “UPDATED E-CIG PRODUCT IMAGE.PNG” centered on screen] Have you
ever vaped, even one time?
1. Yes
2. No
BASE: If B8=1
B8a [S]
During the past 30 days, on how many days did you vape?
1. 0 days
2. 1 or 2 days
3. 3 to 5 days
4. 6 to 9 days
5. 10 to 19 days
6. 20 to 29 days
7. All 30 days
BASE: If B8=1
B9 [S]
Do you now vape…
1. Every day
2. Some days
3. Not at all
BASE: If B9=1 or B9=2
B9b [S]
Do you usually vape with disposable devices, rechargeable devices that use pods or
cartridges or rechargeable devices that use large refillable tanks?
Please indicate the type of e-cigarette that you use the most.
1.
2.
3.
4.

Disposable devices that are not rechargeable or refillable
Rechargeable devices that use pods or cartridges, like JUULs
Rechargeable devices that have large refillable tanks
Unknown device type

BASE: If B9=1 or B9=2
B9b_1 [S]
When you vape, does the liquid/contents usually contain nicotine?
5

1. Yes
2. No
3. Don’t know
BASE: If B9=1 or B9=2
B9b_2 [M]
Which flavors of vapes have you used in the past 30 days? Choose all that apply.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Unflavored
Tobacco-flavored
Menthol
Mint
Cooling, ice, or frosty
Clove or spice
Fruit
An alcoholic drink (such as wine, cognac, margarita, or other cocktails)
A non-alcoholic drink (such as coffee, soda, energy drinks, or other beverages)
Candy, chocolate, desserts, or other sweets
Some other flavor [specify]: _______________________

BASE: If B8=1 and B9 not refused
B10 [M]
Are any of the following a reason why you [B9=3: first tried / B9=1 or 2: currently use]
electronic vapor products?
Randomize and record response order, with B10_10 always last
B10_1. I can vape when or where smoking cigarettes is not allowed
B10_2. Vaping might be less harmful to me than smoking cigarettes
B10_3. I like the flavors
B10_4. Vaping can help me quit or cut back on smoking cigarettes
B10_5. Vaping helps me deal with cravings to smoke
B10_6. A friend or family member suggested I vape as a way to quit smoking
B10_7. A friend or family member [B9=3: shared / B9=1 or 2: shares] their vaping device with
me
B10_8. Vaping is popular among people my age
B10_9. I [B9=3: was / B9=1 or 2: am] curious about vaping
B10_10. Other, specify: [O] _____ [anchor]
BASE: If B9=1 or B9=2
B13 [Grid; S Across]
Do you believe that e-cigarettes and vape products are less harmful, equally harmful, or
more harmful to your health than smoking regular cigarettes?
Scripter: Show numbers before answer text.
1.
2.
3.
4.

Less harmful
Equally harmful
More harmful
I don’t know

BASE: If B9=1 or B9=2
6

B14
Do you want to quit vaping for good?
1. Yes
2. No
BASE: If DOV_SMOKER=1
C20 [S]
A telephone quitline is a free telephone-based service that connects people who smoke
cigarettes with someone who can help them quit. Have you heard of 1-800-QUIT-NOW?
1. Yes
2. No
BASE: If C20=1
C20a [S]
Have you called 1-800-QUIT-NOW or any other telephone quit line in the past 3 months
since [DOV_DATE2]?
1. Yes
2. No
BASE: If C20a=1
C22 [S]
In the past 3 months, did you receive any of the following medications for free from the
1800-QUIT-NOW smokers’ quitline: nicotine patches, gum, lozenges, nasal spray, inhaler, or
pills such as Wellbutrin, Zyban, buproprion, Chantix, or varenicline?
1. Yes
2. No
BASE: If DOV_SMOKER=1
C23 [S]
SmokefreeTXT is a free text-based service that connects people who smoke cigarettes with
mobile text message-based support to help them quit smoking. Have you heard of
SmokefreeTXT?
1. Yes
2. No
BASE: If DOV_SMOKER=1
C23a [S]
Have you heard of any other text messaging services to help you quit smoking?
1. Yes
2. No
BASE: If DOV_SMOKER=1; IF C23=1
C23b [S]
Have you used SmokefreeTXT or any other text-based quitting smoking program in the past
3 months since [DOV_DATE2]?
1. Yes
2. No
7

BASE: If DOV_SMOKER=1
D18_19 [Grid, S across]
The next few questions will ask about your opinions related to smoking, tobacco use, and
cessation.
Please tell us if you strongly disagree, disagree, agree, or strongly agree with the following
statements.
Randomize and record response order
Statements in row (randomize list):
D10. I get upset when I think about my smoking.
D11. I am disappointed in myself because I smoke.
D12. I get upset when I hear or read about illnesses caused by smoking.
D13. Warnings about the health risks of smoking upset me.
D15. Using e-cigarettes and vape products can result in serious lung injury or death.
D18. Smoking can cause immediate damage to your body.
D19. Smoking can cause medical complications and diseases that require surgeries and
medical procedures to treat.
D19a. Menthol cigarettes are just as damaging as other cigarettes.
D19b. Tobacco companies aggressively target communities with menthol cigarette advertising.
Answers in columns:
1. Strongly disagree
2. Disagree
3. Agree
4. Strongly agree
BASE: If DOV_SMOKER=1
D20 [S]
How likely do you think you are to develop a smoking-related disease as a result of smoking?
1. Extremely likely
2. Very likely
3. Somewhat likely
4. Very unlikely
5. Extremely unlikely
BASE: If DOV_SMOKER=1
D21 [GRID, S ACROSS]
Do you believe cigarette smoking is related to:
Statements in row (randomize and record response order):
D21_1. Lung Cancer
D21_2. Cancer of the mouth or throat
D21_3. Heart Disease
D21_4. Diabetes
D21_5. Emphysema
D21_6. Stroke
D21_7. Hole in throat (stoma or tracheotomy)
D21_8. Buerger’s Disease
D21_9. Amputations (removal of limbs)
D21_10. Asthma
8

D21_11. Gallstones
D21_12. COPD or Chronic bronchitis
D21_13. Periodontal or Gum Disease
D21_14. Premature birth
D21_15. Colorectal Cancer
D21_16. Macular degeneration or blindness
D21_17. Depression
D21_18. Anxiety Disorder
D21_19. Colon Cancer
D21_20. COVID-19
D21_21. Kidney Disease
D21_22. Walking difficulties due to artery blockage
D21_23. Premature death
Answers in columns:
1. Yes
2. No
BASE: If DOV_SMOKER=1
E1 [S]
Other than yourself, does anyone who lives in your home smoke cigarettes now?
1. Yes
2. No
BASE: If DOV_SMOKER=1
E2 [S]
Not counting decks, porches, or garages inside your home, is smoking….
1. Always allowed
2. Allowed only at some times or in some places
3. Never allowed
BASE: If DOV_SMOKER=1
E2a [S]
Are you seriously considering increasing restrictions on smoking in your household?

BASE: If DOV_SMOKER=1
E3 [S]
During the past 3 months, that is since [DOV_DATE2], have you talked to any family
members or friends about the dangers of smoking?
1. Yes
2. No
BASE: If DOV_SMOKER=1
E8a [S]
In your opinion, how likely is it that regularly breathing secondhand tobacco smoke from
cigarettes would worsen asthma among nonsmokers?
1. Extremely likely
2. Very likely
3. Somewhat likely
9

4. Very unlikely
5. Extremely unlikely
BASE: If DOV_SMOKER=1
E8b [S]
In your opinion, how likely is it that regularly breathing secondhand tobacco smoke from
cigarettes would cause infections or lung damage among nonsmokers?
1. Extremely likely
2. Very likely
3. Somewhat likely
4. Very unlikely
5. Extremely unlikely
BASE: If DOV_SMOKER=1
F1a [S]
The next few questions are about media use.
How do you usually watch television these days?
1.
2.
3.
4.
5.

A digital antenna
A cable or satellite subscription
A streaming service on the Internet
Some other way
Don’t watch television

BASE: If DOV_SMOKER=1
F1b [S]
How often do you watch television or movies, on a TV set or any other device? Do you do
this every day or almost every day, at least once a week, at least once a month, or less
often?
1.
2.
3.
4.
5.

Every day or almost every day
At least once a week
At least once a month
Less often
Never do this

BASE: If DOV_SMOKER=1
F1 [S]
On an average day, how much television do you watch?
1. None
2. Less than one hour
3. About 1 hour
4. About 2 hours 5. About 3 hours
6. About 4 hours
7. 5 hours or more
BASE: If DOV_SMOKER=1

10

F2 [S]
On an average day, how many hours do you listen to the radio?
1. None
2. Less than one hour
3. About 1 hour
4. About 2 hours 5. About 3 hours
6. About 4 hours
7. 5 hours or more
BASE: If DOV_SMOKER=1
F3 [GRID; S ACROSS]
On an average day, how many hours do you use the following social media platforms:
Statements in row (randomize and record response order):
F3_1. Facebook
F3_2. Instagram
F3_3. Twitter
F3_4. Snapchat
F3_5. TikTok
F3_6. Reddit
Answers in columns:
1. None
2. Less than one hour
3. About 1 hour
4. About 2 hours 5. About 3 hours
6. About 4 hours
7. 5 hours or more
BASE: If DOV_SMOKER=1
F13 [S]
Have you heard of the Website www.cdc.gov/Tips?
1. Yes
2. No
BASE: If F13=1
F13a [S]
Have you visited www.cdc.gov/Tips in the past 3 months, since [DOV_DATE2]?
1. Yes
2. No
BASE: If DOV_SMOKER=1
F17 [GRID; S ACROSS]
In the past 3 months, that is since [DOV_DATE2], have you seen or heard of any ads on
television or radio with the following themes or slogans?
Statements in row (randomize and record response order):
F17_1. Tips from Former Smokers
F17_2. Truth
F17_3. Every Try Counts
11

F17_4. This Free Life
F17_5. Fresh Empire
F17_6. The Real Cost
Answers in columns:
1. Yes
2. No
BASE: If DOV_SMOKER=1
F20_1 [S]
Have you seen the following Facebook page or group when you have been online in the past
3 months, since [DOV_DATE2]?
[SHOW IMAGE “Tips Facebook.png” centered on screen]
1. Yes
2. No
BASE: If DOV_SMOKER=1
F20_2 [S]
Have you seen the following YouTube channel or page when you have been online in the
past 3 months, since [DOV_DATE2]?
[SHOW IMAGE “Tips Youtube.png” centered on screen]
1. Yes
2. No
BASE: If DOV_SMOKER=1
F20_3 [S]
Have you seen the following Twitter page when you have been online in the past 3 months,
since [DOV_DATE2]?
[SHOW IMAGE “Tips Twitter.png” centered on screen]
1. Yes
2. No
BASE: If DOV_SMOKER=1
F21 [Grid, S Across]
Sometimes people use the Internet specifically for health-related reasons. In the past 30
days, have you used the Internet for any of the following reasons?
Statements in row (randomize and record response order):
F21_1. Looked for information about quitting smoking
F21_2. Looked for information about vaping (e.g., e-cigarettes or other vaping products)
F21_3. Looked for information about nicotine replacement therapies (e.g., patches, gum,
lozenges)
F21_4. Downloaded a mobile App to help you quit smoking
F21_5. Signed up for a texting program to help you quit smoking
F21_6. Created an online plan to help you quit smoking
Answers in columns:
12

1. Yes
2. No
SMOKER AD SECTION STARTS HERE.
BASE: If DOV_SMOKER=1
SMOKER_VID_INTRO [DISP]
Now, we would like you to view a series of advertisements that have been shown on
television and online in the U.S. Please make sure your computer’s volume is set to an
appropriate level. If the videos do not work, you’ll still be able to see images and descriptions
of the advertisements.
When you are ready, please click the "Next" button below to view the first advertisement.
Click or tap on each video to begin playback; the “Next” button will appear once the entire
video has been shown.
There is a total of [PPETHM<>4 and DOV_PPETHM_ABS<>4 and
ABS_NQRACE1_FRESH=1 (non-Hispanic): 7 ads / PPETHM=4 or DOV_PPETHM_ABS=4
or ABS_NQRACE1_FRESH=2-5 (Hispanic): 8 ads] to view. After you view each ad, there
will be a few questions that ask about your opinions of the ad.
BASE: If DOV_SMOKER=1
Scripter: Show all respondents ads 1-3:
1=ASAAD & LEAH OKAY_15SEC
2=TONYA PLUGGED IN_15SEC
3=DENISE & BRIAN TIME TOGETHER_15SEC
Scripter: Randomly select and show 3 of ads 6-11:
6=TERRIE I WISH_15SEC
7=BRETT_15SEC
8=ANTHEM_15SEC
9=GERI TEXTING_15SEC
10=CHRISTINE THOSE YOU LOVE_15SEC
11=MICHAEL LIES_15SEC
Scripter: If PPETHM=4 or DOV_PPETHM_ABS=4 or ABS_NQRACE1_FRESH=2-5 (R is
Hispanic), randomly select and show one of ads 12-14:
1412=BRETT & FELICITA_30SEC
1513=JESSICA_15SEC
1614=ROSE_15SEC
Scripter: Add “_X” to variable names below that map to ad ID# above. For example:
F21_1 indicates “Were you able to view this video” for ASAAD & LEAH
OKAY_15SEC.
F21_2 indicates “Were you able to view this video” for TONYA PLUGGED IN_15SEC.
F21_3 indicates “Were you able to view this video” for DENISE & BRIAN TIME
TOGETHER_15SEC.
Etc.
BASE: If DOV_SMOKER=1
F21_x [S; prompt once]
Were you able to view this video?
13

1. Yes
2. No
BASE: If F21_x=2 or refused
F23_x [DISP]
Now we would like to show you some screen shots from a television advertisement that has
been shown in the U.S. Please click the arrow to the right of each image to move to the next
image.
Once you have viewed all the images, please click the "Next" button below to continue with
the survey.
BASE: If F21_x=2 or refused
[DISPLAY STORYBOARD IMAGES FOR AD_X]
BASE: If DOV_SMOKER=1
F24_x [S; prompt once]
Have you seen this ad on television or online in the past 3 months, since March 1, 2021?
1. Yes
2. No
BASE: If F24_x=1
F24a_x_TV [S]
In the past 3 months, since March 1, 2021, how frequently have you seen this ad on
television?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Very often
BASE: If F24_x=1
F24a_x_COMPUTER [S]
In the past 3 months, since March 1, 2021, how frequently have you seen this ad on a
laptop or desktop computer?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Very often
BASE: If F24_x=1
F24a_x_MOBILE [S]
In the past 3 months, since March 1, 2021, how frequently have you seen this ad on a tablet
or smartphone?
1. Never
2. Rarely
14

3. Sometimes
4. Often
5. Very often
Scripter: Show F25_x – F28_3x for 4 randomly selected ads from ads 1-12
BASE: If DOV_SMOKER=1
F25_x [GRID; S Across]
Please tell us if you strongly agree, agree, neither agree nor disagree, disagree, or strongly
disagree with the following statements.
Statements in row (randomize and record response order):
F25a_x. This ad is worth remembering.
F25b_x. This ad grabbed my attention.
F25c_x. This ad is powerful.
F25d_x. This ad is informative.
F25e_x. This ad is meaningful to me.
F25f_x. This ad is convincing.
Answers in columns:
1. Strongly disagree
2. Disagree
3. Neither agree nor disagree
4. Agree
5. Strongly agree
BASE: If DOV_SMOKER=1
F26_x [GRID; S ACROSS]
On a scale of 1 to 5, where 1 means “not at all” and 5 means “very”, please indicate how
much this ad made you feel…
Statements in row (randomize and record response order):
F26a_x. Sad
F26b_x. Afraid
F26d_x. Ashamed
F26f_x. Hopeful
F26g_x. Motivated
F26h_x. Understood
Answers in columns:
1. Not at all
2. 3.
4.
5. Very
BASE: If DOV_SMOKER=1
NEXT_AD [DISP]
Now, we would like you to watch another ad.
Scripter: Repeat the sequence of questions (F21_X through F28_3X) for each of the
remaining ads per assignment protocol above
BASE: If DOV_SMOKER=1
15

SMOKER_RADIO_INTRO [DISP]
Now, we would like you to listen to a streaming radio advertisement that you may have heard
online in the U.S. Please make sure your computer’s volume is set to an appropriate level.
You may be prompted by your computer to download a program enabling audio playback.
When you are ready, please click on the link below to listen to the ad. After you listen to the
ad, there will be a few questions that ask about your recent recall of the ad.

[If African American, assign respondent to listen to one of the following ads]:
1=Roosevelt.mp3
2=Bill Diabetes.mp3
3=Rose.mp3
[If Hispanic, assign respondent to listen to one of the following ads]
3=Rose.mp3
4=Jessica.mp3
[If American Indian/Alaskan Native, assign respondent to listen to one of the following ads]:
5=Michael
6=Nathan

[PLAY RADIO AD CHOSEN]
[ADD “_X” TO VARIABLE NAMES BELOW THAT MAP TO AD ID # ABOVE. FOR
EXAMPLE:
F32_1 indicates “Were you able to listen to this ad” for Roosevelt.
F32_2 indicates “Were you able to listen to this ad” for Bill.
F32_3 indicates “Were you able to listen to this ad” for Rose.
F32_4 indicates “Were you able to listen to this ad” for Jessica.
F32_5 indicates “Were you able to listen to this ad” for Michael.
F32_6 indicates “Were you able to listen to this ad” for Nathan.
BASE: If DOV_SMOKER=1
F35_x [S]
Have you heard this ad streaming or online in the past 3 months, since March 1, 2021?
1. Yes
2. No
BASE: If IF F35_x=1
F35a_x [S]
In the past 3 months, since March 1, 2021 how frequently have you heard this ad streaming
or online?
1.
2.
3.
4.

Rarely
Sometimes
Often
Very often
16

BASE: If DOV_SMOKER=1
SMOKER_PRINT_WEB1 [DISP]
Next, you will see some advertisements that have recently appeared on websites. There is 1
set of images to view, followed by a question about whether you have seen these ads
before. When you are ready to view them, please click “Next.”
BASE: If DOV_SMOKER=1
SMOKER_PRINT_WEB2 [DISP]
[SHOW IMAGE “Tips 2021 Digital Collage.png” centered on screen]
Please click “Next” to proceed to the next set of questions.
BASE: If DOV_SMOKER=1
F36 [S]
In the past 3 months, since March 1, 2021, have you seen any of these ads on websites or
other places online?
1. Yes
2. No
BASE: If F36=1
F37 [S]
Did you see these ads on digital devices such as a smartphone or tablet?
1. Yes
2. No
BASE: If DOV_SMOKER=1
F39 [S]
Did you talk to anyone about any of these ads?
1. Yes
2. No
BASE: If DOV_SMOKER=1, IF F39=1
F40 [Grid, S Across]
When you talked about the ads, did you talk about any of the following topics?
Statements in row (randomize and record response order):
1. These ads were not good.
2. I should not smoke cigarettes.
3. The person I was talking to or someone else I know should not smoke cigarettes.
Answers in columns:
1. Yes
2. No
SMOKER AD SECTION ENDS HERE.
Demographic Section
BASE: All respondents
17

G1 [N with range 0-10; prompt once]
Next, how many children 17 or younger currently live in your household at least 50% of the
time? If none, enter “0”.
Include babies and small children.
Type in the number of children 17 years of age or younger.
Custom refusal prompt: Your answer will help represent the entire U.S. population and will be
kept confidential. Thank you!
BASE: All Respondents
QEDUC [S]
What is the highest level of school you have completed?
15. Some high school or less – no diploma or GED
9. High school graduate – high school diploma or the equivalent (GED)
10. Some college, no degree
11. Associate degree
12. Bachelor’s degree
13. Master’s degree
14. Professional or Doctorate degree
BASE: QEDUC=9
QEDUC_HSGED [S]
Do you have a high school diploma or a GED?
1. High school diploma
2. GED
3. Don’t Know
BASE: If QEDUC=15
QEDUCa [S]
What is the highest level of school you have completed?
1. No formal education
2. 1st, 2nd, 3rd, or 4th grade
3. 5th or 6th grade
4. 7th or 8th grade
5. 9th grade
6. 10th grade
7. 11th grade
8. 12th grade NO DIPLOMA

18

SCRIPTER: Create data-only variables:
Variable name: PPEDUC [S]
Variable Text: Education - categorical Response list:
1. No formal education
2. 1st, 2nd, 3rd or 4th grade
3. 5th or 6th grade
4. 7th or 8th grade
5. 9th grade
6. 10th grade
7. 11th grade
8. 12th grade NO DIPLOMA
9. HIGH SCHOOL GRADUATE – high school diploma or the equivalent (GED)
10. Some college, no degree
11. Associate degree
12. Bachelor’s degree
13. Master’s degree
14. Professional or Doctorate degree

QEDUC

QEDUCa
1
2
3
4
5
6
7
8

9

PPEDUC
1
2
3
4
5
6
7
8
9

10
11
12
13
14

10
11
12
13
14

Variable name: PPEDUCAT [S] Variable Text: Education - categorical Response list:
1. Less than HS
2. HS
3. Some college
4. Bachelor or higher
QEDUC
15

PPEDUCAT
1

9
10-11
12-14

2
3
4

BASE: If OFFPANEL=1
19

QINC [S; prompt once]
How much is the combined income of all members of YOUR HOUSEHOLD for the past 12
months?
Please include your income PLUS the income of all members living in your household
(including cohabiting partners and armed forces members living at home). Please count
income BEFORE TAXES and from all sources (such as wages, salaries, tips, net income
from a business, interest, dividends, child support, alimony, and Social Security, public
assistance, pensions, or retirement benefits).
1. Below $50,000
2. $50,000 or more
3. Don’t know [only show with the prompt if question is refused initially]
Custom refusal prompt: We realize that this is personal information. We will ONLY ASK the
range of your household income, NOT the exact amount.
BASE: QINC=1
QINC2 [S]
We would like to get a better estimate of your total HOUSEHOLD income in the past 12
months before taxes. Was it...
1.
2.
3.
4.

Less than $5,000
$5,000 to $7,499
$7,500 to $9,999
$10,000 to $12,499 5. $12,500 to $14,999 6. $15,000 to $19,999 7. $20,000 to $24,999
8. $25,000 to $29,999 9. $30,000 to $34,999 10. $35,000 to $39,999
11. $40,000 to $49,999
BASE: QINC=2
QINC3 [S]
We would like to get a better estimate of your total HOUSEHOLD income in the past 12
months before taxes. Was it...
3. $50,000 to $59,999 4.
$60,000 to $74,999 5.
$75,000 to $84,999
6. $85,000 to $99,999
7. $100,000 to $124,999 8. $125,000 to $149,999 9.
$150,000 to $174,999 10. $175,000 to $199,999
11. $200,000 to $249,999
12. $250,000 or more

20

SCRIPTER: Create data-only variable:
Variable name: PPINCIMP [S]
Variable Text: HH income – profile and imputed Response list:
1.
Less than $5,000
2.
$5,000 to $7,499
3.
$7,500 to $9,999
4.
$10,000 to $12,499 5. $12,500 to $14,999 6. $15,000 to $19,999 7. $20,000 to
$24,999 8. $25,000 to $29,999 9. $30,000 to $34,999
10. $35,000 to $39,999 11.
$40,000 to $49,999 12.
$50,000 to $59,999 13.
$60,000 to $74,999 14.
$75,000 to $84,999
15.
$85,000 to $99,999
16.
$100,000 to $124,999 17. $125,000 to $149,999 18.
$150,000 to $174,999 19. $175,000 to $199,999
20. $200,000 to $249,999
21. $250,000 or more

QINC2
1
2
3
4
5
6
7
8
9
10
11

QINC3

3
4
5
6
7
8
9
10
11
12

PPINCIMP
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

BASE: If OFFPANEL=1
21

QMARIT [S] Are
you now...?
1. Married
2. Widowed
3. Divorced
4. Separated
5. Never married
BASE: If QMARIT=2 to 5 or refused
QPRTNR [S]
Are you currently living with a partner to whom you are not married?
1. Yes
2. No
SCRIPTER: Create data-only variable PPMARIT by using the below logic involving
responses to QMARIT AND QPRTNR.
Create numeric variable, PPMARIT, range [1,6] compute PPMARIT=QMARIT.
if (QPRTNR=1 and QMARIT=5) PPMARIT=6 (living with partner)

BASE: All respondents
E100 [S; prompt once]
Do any of the following currently describe you?
Statements in row:
1. Employed full time (35 hours or more per week) for pay with an organization or company
2. Employed part time (less than 35 hours per week) for pay with an organization or
company
3. Self-employed full time (35 hours or more per week)
4. Self-employed part time (less than 35 hours per week)
Answers in columns:
1. Yes
2. No
SCRIPTER: Create DOV_EMPLOYED
If E100_1=1 or E100_2=1 or E100_3=1 or E100_4=1 DOV_EMPLOYED=1.
If E100A=2 and E100B=2 and E100C and E100D=2 DOV_EMPLOYED=2. Else
DOV_EMPLOYED=3.
1. Employed
2. Not employed
3. Refused
BASE: If DOV_EMPLOYED=2
E102 [GRID, S Across]
Do any of the following currently describe you?
Statements in row:
1. Looking for work
2. Unable to work due to a disability
22

3. On temporary layoff from a job
Answers in columns:
1. Yes
2. No
BASE: All respondents
E104 [GRID, S Across]
Do any of the following currently describe you?
Statements in row:
1. Retired
2. A student
3. A stay-at-home spouse or partner
4. Working in an unpaid job, such as an internship or volunteer position
Answers in columns:
1. Yes
2. No
SCRIPTER: Create data-only variable:
Variable name: QWORK [S]
Variable Text: Current employment status Response
list:
1. Working – as a paid employee
2. Working – self-employed
3. Not working – on temporary layoff from a job
4. Not working – looking for work
5. Not working – retired
6. Not working – disabled
7. Not working – other
Values must be assigned in the order below so that codes at the bottom of the table
overwrite codes at the top:
E100

DOV_EMPLOYED
3
2

E102

E104

E104_2=1
E104_3=1
E104_4=1
E102_2=1
E104_1=1
E102_1=1
E102_3=1
E100_4=1
E100_2=1
E100_3=1
E100_1=1

QWORK
Refused
7
7
7
7
6
5
4
3
2
1
2
1

23

BASE: If PPWORK=1 or 2 or QWORK=1 or 2
QWORK2 [S]
Altogether, how many jobs do you have?
1. One
2. Two
3. Three
4. Four or more
BASE: If (OFFPANEL=1 and (QWORK=1 or 2)) or ((PPWORK=1 or 2) and
XIND1=MISSING)
IND1 [S]
Think about the industry in which you currently work. Which of the following kinds of
industries is it?
[Alternate text if QWORK2=2, 3, or 4]
Think about the industry in which you currently work at your MAIN job. Which of the following
kinds of industries is it?
11. Agriculture, Forestry, Fishing and Hunting
21. Mining, Quarrying, and Oil and Gas Extraction
22. Utilities
23. Construction
31-33. Manufacturing
42. Wholesale Trade
44-45. Retail Trade
48-49. Transportation and Warehousing
51. Information
52. Finance and Insurance
53. Real Estate and Rental and Leasing
54. Professional, Scientific, and Technical Services
55. Management of Companies and Enterprises
56. Administrative and Support and Waste Management and Remediation Services
61. Educational Services
62. Health Care and Social Assistance
71. Arts, Entertainment, and Recreation
72. Accommodation and Food Services
81. Other Services and Community/Non-Profit Organizations (except Public Administration)
92. Public Administration
93. Armed Forces
94.Utilities, Waste Management, and Remediation Services
95. Administrative and Support Services (such as Call Centers, Security, Landscaping, and
Janitorial)
96. Child Day Care Services
97. Repairs and Maintenance
98. Personal Services (including Beauty, Pet Care, and Household)
100. Community/Non-Profit Organizations (including Religious and Political Organizations)
BASE: All respondents
G9 [S]
How many smoking or tobacco related web surveys like this have you completed during the
past year?
1. None
24

2. 1 survey
3. 2 surveys 4. 3 surveys
5. 4 surveys
6. 5 or more surveys
BASE: All respondents
G10 [S]
Please indicate your current military service status.
1. Active duty
2. Reserves
3. National Guard
4. Veteran or Armed Services Retiree
5. Veteran or Retiree with a service connected disability
6. Civilian: NO military service record
BASE: All respondents
G11 [GRID, S Across]
Are you CURRENTLY covered by any of the following types of health insurance or health
coverage plans? Mark “yes” or “no” for each type of coverage.
Statements in row:
G11_1. Insurance through a current or former employer or union
G11_2. Insurance purchased directly from an insurance company
G11_3. Medicare, for people age 65 and over, or people with certain disabilities G11_4.
Medicaid, or any kind of government assistance plan for those with low
incomes or
disability
G11_5. TRICARE or other military health care
G11_6. VA (including those who have ever enrolled for or use VA health care)
G11_7. Indian Health Service
G11_8. Any other type of health insurance or health coverage plan
Answers in columns:
1. Yes
2. No
BASE: All respondents
G15 [GRID; S Across]
Have you been diagnosed by a physician or other qualified medical professional with any of
the following medical conditions?
You may choose not to answer the question by simply clicking “Next”.
Statements in row (randomize and record response order, with G15_24 always last):
G15_1. Acid reflux disease
G15_2. ADHD or ADD
G15_3. Anxiety disorder
G15_4. Asthma, chronic bronchitis, or COPD
G15_5. Cancer (any type except skin cancer)
G15_6. Chronic pain (such as low back pain, neck pain, or Fibromyalgia)
G15_7. Depression
G15_8. Diabetes
G15_9. Heart attack
G15_10. Heart disease
25

G15_11. High blood pressure
G15_12. High cholesterol
G15_13. HIV/AIDS
G15_14. Kidney disease
G15_15. Mental health condition
G15_16. Multiple sclerosis
G15_17. Osteoarthritis, joint pain or inflammation
G15_18. Osteoporosis or osteopenia
G15_19. Rheumatoid arthritis
G15_20. Seasonal allergies
G15_21. Skin cancer
G15_22. Sleep disorders such as sleep apnea or insomnia
G15_23. Stroke
G15_23a. COVID-19
G15_23b. Peripheral artery disease
G15_24. Something else [anchor]
Answers in columns:
1. Yes
2. No
BASE: All respondents
G16 [GRID; S Across]
Over the last 2 weeks, how often have you been bothered by the following problems?
Statements in row:
G16_1. Little interest or pleasure in doing things
G16_2. Feeling down, depressed or hopeless
G16_3. Feeling nervous, anxious or on edge
G16_4. Not being able to stop or control worrying
Answers in columns:
1. Not at all
2. Several days
3. More than half the days
4. Nearly every day
BASE: All respondents
G17 [GRID; S Across]
In your day-to-day life, how often have any of the following things happened to you?
Statements in row:
G17_1. You are treated with less courtesy or respect than other people.
G17_2. You receive poorer service than other people at restaurants or stores.
G17_3. People act as if they think you are not smart.
G17_4. People act as if they are afraid of you.
G17_5. You are threatened or harassed.
Answers in columns:
1. Almost every day
2. At least once a week
3. A few times a month
4. A few times a year
5. Less than once a year
6. Never
26

BASE: IF G17_1 < 4 OR G17_2 < 4 OR G17_3 < 4 OR G17_4 < 4 OR G17_5 < 4
G18 [S]
What do you think is the main reason for these experiences?
1. Your ancestry or national origins
2. Your gender
3. Your race or ethnicity
4. Your age
5. Your religion
6. Your height
7. Your weight
8. Some other aspect of your physical appearance
9. Your sexual orientation
10. Your education or income level
11. A physical disability
12. Other [specify]: _____________________________
BASE: If OFFPANEL=1 and DOV_RECONTACT=1
G20 [S]
Do you or anyone in this household connect to the Internet from home?
1. Yes
2. No
BASE: If OFFPANEL=1 and DOV_RECONTACT=2
G21 [S]
Do you live in a metro or non-metro area?
1. Non-Metro (Rural)
2. Suburban
3. Urban
BASE: All respondents
NG22 [Grid; S Across]
Using the scale below, please tell us how much you agree or disagree with the following
statements.
NG21a. I feel safe in my area or neighborhood.
NG21b. If I had a problem, I would feel comfortable asking a neighbor for help.
Statements in row:
NG20a. I usually try new products before other people do.
NG20b. I often try new brands because I like variety and get bored with the same old thing.
NG20c. When I shop I look for what is new.
NG20d. I like to be the first among my friends and family to try something new. NG20e. I
like to tell others about new brands or technology.
Answers in columns:
1. Strongly agree
2. Somewhat agree
3. Neither agree nor disagree
4. Somewhat disagree
5. Strongly disagree
BASE: All respondents
27

G23 [S]
Which of the following best represents how you think of yourself?
1.
2.
3.
4.
5.

Gay (lesbian or gay)
Straight, this is not gay (or lesbian or gay)
Bisexual
Something else
I don’t know the answer

BASE: If OFFPANEL=0
KP_THANKS [DISP]
Thank you for completing today’s survey. Your input will greatly help researchers assess the
factors that impact quitting smoking.
You will be awarded 15,000 bonus points credited to your KnowledgePanel account for
completing the survey.
BASE: If OFFPANEL=1 and DOV_RECONTACT=1
ADD0 [S]
Those are all of our questions. Thanks so much for your participation in our survey. As a
token of our appreciation, we would like to send you $[IF SAMPLE=KP WITHDRAWN, $15;
IF SAMPLE=ABS, INSERT INCENTIVE VALUE FROM LOOKUP TABLE based on MNO; IF
SAMPLE=ABS and incentive value is missing from lookup table, insert: $20].
On the next screen, we would like to confirm your mailing information so that we may send
you the check. This information will only be used to send you the check and will only be
retained until February 2021. We’ll never sell or distribute this information. By completing the
following information, you consent to the use of your personal information for the purpose
described above.
1. I agree
2. No thank you
If ADD0=2, end survey.
BASE: If OFFPANEL=1 and DOV_RECONTACT=1
Scripter: Prompt if refused with custom text: “Complete and accurate information is needed in
order to successfully mail your check”
Scripter: Show MP box next to the NAME_FINAL, ADDRESS_FINAL, CITY_FINAL,
STATE_FINAL and ZIP_FINAL fields below
ADD1 [M]
Please verify your name and mailing address so that we can put the check in the mail.
To ensure that you will be able to deposit or cash the check, please be sure to provide us
with your full first AND last name. If you provide incomplete or inaccurate information, we
may not be able to process your check.
This information will not be connected with your survey responses in any way.
Please select the field(s) that you’d like to update. If all of the information is correct, please
select “All of the above are correct”.
28

1. Name: [Insert NAME_FINAL from lookup table based on MNO. If NAME_FINAL in look up
table is blank, insert: "not provided"]
[SPACE]
2. Mailing Address: [If any part of Address in lookup table (ADDRESS_FINAL, CITY_FINAL,
STATE_FINAL, or ZIP_FINAL) is blank, insert: "not provided"]
[Insert ADDRESS_FINAL from lookup table based on MNO]
[Insert CITY_FINAL from lookup table based on MNO]
[Insert STATE_FINAL from lookup table based on MNO]
[Insert ZIP_FINAL from lookup table based on MNO]
[SPACE]
3. All of the above are correct [S]
[SPACE]
4. Prefer not to receive an incentive. [S]
BASE: If Add1=1 or name is missing from spreadsheet and DOV_RECONTACT=1
Scripter: Prompt if refused with custom text “Complete and accurate information is needed in
order to successfully mail your check.”
ADD1_1 [O]
Please type in the name to whom you’d like us to send the incentive check:
Name (First/Last): [TEXTBOX]
BASE: If ADD1=2 or any part of address (address_final, city_final, state_final, or zip_final) is missing
from spreadsheet and recontact=1
Scripter: Prompt if refused with custom text “Complete and accurate information is needed in
order to successfully mail your check.”
ADD1_2 [O]
Please type in the address to where we should send the incentive check:
Street Address (If applicable, include unit number): [TEXTBOX]
City: [TEXTBOX]
State: [TEXTBOX]
Zip Code : [TEXTBOX]
BASE: [If ADD1=1-2]
Scripter: Prompt if refused with custom text “Complete and accurate information is needed in
order to successfully mail your check.”
ADD2. [S]
Is the contact information below now up-to-date?
Name: [If asked Add1_1, insert name from Add1_1. If asked Add1_1 and Add1_1= refused,
insert: Not provided. If not asked Add1_1, insert Name_Final from look up table based on
MNO.]
Mailing Address:
[If not asked Add1_2, insert address from look up table based on MNO]

29

[If asked Add1_2, insert Street Address from Add1_2. If asked Add1_2 and Street
Address=refused, insert: Street address: Not provided]
[If asked Add1_2, insert City from Q1_2. If asked Add1_2 and Add1_2_City=refused, insert:
City: Not provided], [If asked Add1_2, insert State from Add1_2. If asked Add1_2 and
Add1_2_State=refused, insert: State: Not provided] [If asked Add1_2, insert zip code from
Add1_2. If asked Add1_2 and Add1_2_zip=refused, insert: Zip Code: Not provided]
1. Yes
2. No
Scripter: if Add2=refused after prompt, record answer as if respondent had selected 2 (no)
Scripter: if Add2=2; Loop back to Add1
BASE: If sample=abs and DOV_RECONTACT=2
ADD0_NEW [S]
Those are all of our questions. Thanks so much for your participation in our survey. As a
token of our appreciation, we would like to send you [IF SAMPLE=KP WITHDRAWN, $15; IF
SAMPLE=ABS AND ABS_G20=1 or -1, $20; IF SAMPLE=ABS and ABS_G20=2: $40].
On the next screen, we would like to confirm your mailing information so that we may send
you the check. This information will only be used to send you the check and will only be
retained until February 2021. We’ll never sell or distribute this information. By completing the
following information, you consent to the use of your personal information for the purpose
described above.
1. I agree
2. No thank you
If ADD0_NEW=2, end survey.
BASE: If sample=abs and DOV_RECONTACT=2
Scripter: Prompt if refused with custom text “Complete and accurate information is needed in
order to successfully mail your check.”
ADD1_NEW. [O]
Please provide your name and mailing address so that we can put the check in the mail.
To ensure that you will be able to deposit or cash the check, please be sure to provide us
with your full first AND last name. If you provide incomplete or inaccurate information, we
may not be able to process your check.
This information will not be connected with your survey responses in any way.
After you have entered your information, please make sure to click “Next”.
Name (First/Last): [TEXTBOX]
Street Address (If applicable, include unit number): [TEXTBOX]
City: [TEXTBOX]
State: [TEXTBOX]
Zip Code: [TEXTBOX]
Prefer not to receive an incentive. [S]
30

BASE: If OFFPANEL=1
CONTACT_A [S]
Thank you for your participation in this important study! If you entered your address
information on the previous question, your check for participation will arrive in the next 4 – 6
weeks.
The CDC will also have the opportunity to do at least one more survey in the future, with
additional rewards and prizes for participation. Would you be willing to participate in another
survey for the CDC?
1. Yes
2. No
BASE: If CONTACT_A=1
CONTACT_A1 [S]
Is this the address where you would like us to send your next CDC survey invitation?
[Insert Address_Final from look up table based on MNO]
[Insert City_final from look up table based on MNO], [Insert State_final from look up table
based on MNO] [Insert Zip_final from look up table based on MNO]
1. Yes
2. No
BASE: If CONTACT_A1=2 or refused
CONTACT_A2. [O]
Please provide us with the address that you would like us to use to send you your next CDC
survey invitation.
Street Address (If applicable, include unit number): [TEXTBOX]
City: [TEXTBOX]
State: [TEXTBOX]
Zip Code: [TEXTBOX]
Omit KP closing question QF1

31