Att 2a_Online Questionnaire Recruitment Screener for Rough Cut Testing of Television Advertisements (English version)

Form Approved

OMB No. 0920-0910

Exp. Date 9/30/2026

National Tobacco Education Campaign

Online Questionnaire Recruitment Screener for

Rough Cut Testing of Television Advertisements

(English Version of Cycle 2 Spanish Ads, revised August 1, 2024)

Public reporting burden of this collection of information is estimated to average 2 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0910).

{Internal reference, do not display: PREAMBLE1}

On behalf of the Centers for Disease Control and Prevention (CDC), we're conducting a study about different health and smoking related advertising that you might see in the media, such as on TV or on the internet. Your opinions are very important to us! The purpose of this survey is to gather your opinions on advertisements encouraging people who smoke to quit; it is not to see products. We will not report your answers individually. We will report results from this survey for the group as a whole. Thank you for taking the time to help us! It will take about 2 minutes to determine your eligibility and about 10 minutes to complete the survey.

Your participation in this survey is voluntary. You may stop participating at any time.

{Internal reference, do not display: Demographic Information}

DAGE2. What is your current age, in years?

_ _ _ age in years

{Open-end}

999 Prefer not to answer {GENERAL SCREEN OUT MESSAGE}

{Terminate if <18 years old or >54 go to GENERAL SCREEN OUT MESSAGE}

{Terminate if automatically determined that respondent is not in the United States}

DEMO2: What state do you live in?

1. Alabama

2. Alaska

3. Arizona

4. Arkansas

5. California

6. Colorado

7. Connecticut

8. Delaware

9. Florida

10. Georgia

11. Hawaii

12. Idaho

13. Illinois

14. Indiana

15. Iowa

16. Kansas

17. Kentucky

18. Louisiana

19. Maine

20. Maryland

21. Massachusetts

22. Michigan

23. Minnesota

24. Mississippi

25. Missouri

26. Montana

27. Nebraska

28. Nevada

29. New Hampshire

30. New Jersey

31. New Mexico

32. New York

33. North Carolina

34. North Dakota

35. Ohio

36. Oklahoma

37. Oregon

38. Pennsylvania

39. Rhode Island

40. South Carolina

41. South Dakota

42. Tennessee

43. Texas

44. Utah

45. Vermont

46. Virginia

47. Washington

48. West Virginia

49. Wisconsin

50. Wyoming

51. District of Columbia

52. Guam

53. Other please specify

{Terminate if 53 Other Please Specify go to GENERAL SCREEN OUT MESSAGE}

SES1. What is the highest level of education you have completed or the highest degree you have received? If you received your education in another country, please indicate the equivalent level below.

1. Less than high school

2. Completed high school

03 Completed General Education Diploma (GED)

04 Job-specific training program(s) after high school

5. Some college, but no degree

6. Associate Degree

7. College (such as B.A., B.S.)

8. Some graduate school, but no degree

9. Graduate degree (such as MBA, MS, M.D., Ph.D.)

10. Prefer not to answer

SES2. Which of the following income categories best describes your total 2023 household income before taxes?

1. Less than $15,000

2. $15,000 to $19,999

3. $20,000 to $24,999

4. $25,000 to $29,999

5. $30,000 to $34,999

6. $35,000 to $49,999

7. $50,000 to $74,999

8. $75,000 to $99,999

9. $100,000 or more

10. Prefer not to answer

SES3. Which statement best describes your current employment status?

01 Working – as a paid employee

02 Working – self-employed

03 Not working – on temporary layoff from a job

04 Not working – looking for work

05 Not working – retired

06 Not working – disabled

07 Not working – other

08 Prefer not to answer {GENERAL SCREEN OUT MESSAGE}

DEMO3. Race/Ethnicity

What is your race and/or ethnicity?

Select all that apply.

1. American Indian or Alaska Native

For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

2. Asian

For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.

3. Black or African American

For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.

4. Hispanic or Latino

For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.

5. Middle Eastern or North African

For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.

6. Native Hawaiian or Pacific Islander

For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.

7. White

For example, English, German, Irish, Italian, Polish, Scottish, etc.

08 Prefer not to answer {GENERAL SCREEN OUT MESSAGE}

{Internal reference, do not display: Smoking Behavior}

{Internal reference, do not display: PREAMBLE1}

The next questions are about cigarettes, which are any form of tobacco wrapped in paper that does not contain tobacco. Cigarettes typically come in packages of 20, and some brand examples include Marlboro, Newport, Camel, Lucky Strike, and Pall Mall.

Please note that use of e-cigarettes should not be considered in your responses to the next three questions.

{Base = All respondents}

TS1. Have you smoked at least 100 cigarettes in your entire life?

1. Yes

2. No {GENERAL SCREEN OUT MESSAGE}

3. Don’t know/Not sure {GENERAL SCREEN OUT MESSAGE}

4. Prefer not to answer {GENERAL SCREEN OUT MESSAGE}
   
   

{Base = TS1 = 01}

TS2. Do you now smoke cigarettes every day, some days, or not at all?

1. I smoke every day

2. I smoke on some days

3. I do not smoke at all {GENERAL SCREEN OUT MESSAGE}

{Base = TS2 = 01, 02}

TS3. On how many of the past 30 days did you smoke cigarettes?

Enter number: _______

If 0, {GENERAL SCREEN OUT MESSAGE}

777 Don’t know/Not sure {GENERAL SCREEN OUT MESSAGE}

999 Prefer not to answer {GENERAL SCREEN OUT MESSAGE}

{Programmer instruction: Eligibility criteria for the sample are provided in Table 1. Randomize eligible participants to the 3 ads (outlined in Table 2) so that each participant views only 1 ad.

Table 1 Criteria for Spanish-Speaking Randomized Sample

Segment	Definition	Criteria	Minimum Quota
Spanish-Speaking Hispanic or Latino adults between ages 18-54 who smoke cigarettes	People between ages 18-54 who selected Hispanic or Latino and smoke cigarettes every day or some days	TS1 = 01 AND TS2 = 01 or 02 AND TS3 > 0 AND DAGE2 = 18-54 AND DEMO3 = 04	1,200 (randomized across 3 ads)

Table 2. TIPS® Campaign Cycle 2 Rough-Cut Testing of Spanish Ads: Planned Distribution of Spanish-Speaking Participants

Ad	Spanish-Speaking Hispanic or Latino Adults Who Smoke
Ad 10 Felicita R. Déjelo Tip (Spanish) :15	400
Ad 11 Felicita and Brett Tip (Dual Language) :30	400
Ad 12 Rose Memorial Tip (Spanish) :30	400
Total	1,200

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Thank you for your participation in this study. Unfortunately, your responses indicate that you do not fit the specific criteria needed for this study, or that we have already reached our required quota of responses from participants similar to you. We appreciate your enthusiasm for our study and hope you will join us on future surveys!

{Internal reference, do not display: GENERAL ELIGIBILITY MESSAGE}

Thank you for your participation in this study. Your responses indicate that you fit the specific criteria needed for this particular study. Click “next” to go to the next question.

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