Hello, my name is _______ and I'm calling from
_________. We aren't selling anything, but we are doing a survey about
the issue of smoking. To randomly select a person, could I speak with
the household member over 18 who had the most recent birthday? (If that
person is not there, ask for only his / her first name and record on
call sheet for a callback. Then say "Thanks, I will try that person
later" and end the interview.)
(If that person is on the line): Would you be willing
to participate in a survey about exposure to tobacco smoke and tobacco-related
issues? Participation is, of course, voluntary. You can choose to not
answer some questions and you can quit whenever you wish. All information
is confidential. It will take 10-15 minutes.
(When that person is on the line): Hello, my name
is ___ and I'm calling from . We're not selling anything. Would you
be willing to participate in a survey about exposure to tobacco smoke
and tobacco-related issues? Participation is, of course, voluntary.
You can choose to not answer some questions and you can quit whenever
you wish. All information is confidential. It will take 4-5 minutes.
(If people ask who is conducting the survey, indicate it is for the
Tobacco Control Coalitions of Cortland and Tompkins Counties.)
| 2nd HAND SMOKE HARM |
1. Do you think that breathing smoke from someone
else's cigarettes is:
1_____ Very harmful to one's health
2_____ Somewhat harmful to one's health
3_____ Not very harmful to one's health
4_____ Not harmful at all to one's health
5_____ Don't know/Not sure |
| 2ND HAND SMOKE EFFECTS 1 |
2. Are you bothered by secondhand smoke?
1_____ Yes
2_____ No
3_____ Don't know/Not sure
|
| HOME SMOKING POLICY |
3. Which statement best describes the rules about
smoking in your home?
1_____ Smoking is not allowed anywhere inside the home
2_____ Smoking is allowed in some places or at some times
3_____ Smoking is allowed anywhere inside the home
4_____ There are no rules about smoking inside the home
5_____ Don't know/Not sure |
| VEHICLE SMOKING POLICY |
4. Which statement best describes the rules about
smoking in your family car or cars?
1_____ Smoking is never allowed in any car
2_____ Smoking is allowed some times or in some cars
3_____ Smoking is allowed in all cars
4_____ Do not have a family car
5_____ Don't know/Not sure |
| CIA LAW POSITION |
5. The recently enacted New York State Clean Indoor
Air Act prohibits smoking in all workplaces, including bars and
restaurants. Do you strongly favor, favor, oppose, or strongly oppose
this new law? ..or doesn't it make any difference to you?
1_____ Strongly Favor
1_____ Favor
2_____ Oppose
1_____ Strongly Oppose
3_____ Makes no difference
4_____ Don't know/Not sure |
| **WORK COMPLIANCE 1 |
6. While working at your job, are you indoors most
of the time?
1_____ Yes
2_____ No
3_____Don't know/Not sure |
| **WORK COMPLIANCE 2 |
7. In the past seven days, has anyone smoked in
your work area or work vehicle?
1_____ Yes
2_____ No
3_____ Don't know/Not sure |
| **RESTAURANT COMPLIANCE 1 |
8. How often did you go to a restaurant in your
community in the past month?
________ times |
| **RESTAURANT COMPLIANCE 2 |
9. The last time you went to a restaurant in your
community in the past 30 days, did you see someone smoking indoors?
1_____ Yes
2_____ No
3_____ Don't know/Not sure |
| **BAR COMPLIANCE 1 |
10. How often did you go to a bar in your community
in the past month? _________ times |
| **BAR COMPLIANCE 2 |
11. The last time you went to a bar in your community
in the past 30 days, did you see someone smoking indoors? 1_____
Yes 2_____ No 3_____ Don't know/Not sure |
| EFFECT OF RESTAURANT BAN |
12. Since smoking was prohibited in restaurants
in New York State in July 2003, have you visited them more often,
less often, or the same as before smoking was prohibited? 1_____
More 2_____ Less 3_____ No change 4_____ Don't know/Not sure |
| EFFECT OF BAR BAN |
13. Since smoking was prohibited in bars in New
York State in July 2003, have you visited them more often, less
often, or the same as before smoking was prohibited? 1_____ More
2_____ Less 3_____ No change 4_____ Don't know/Not sure |
| **COMMUNITY COMPLIANCE |
14. In the past seven days, have you seen anyone
smoking in your community inside public places other than restaurants
or bars? 1_____ Yes 2_____ No PLEASE GO ON TO QUESTION 3_____ Don't
know/Not sure PLEASE GO ON TO QUESTION |
| **COMMUNITY COMPLIANCE |
15. {If yes} Do you remember where? _________________________________________________
3_____ Don't know/Not sure |
During the past 7 days on average,
how many hours a day did you:
[PLEASE ENTER THE TIME TO NEAREST HALF HOUR] |
| AVG TV HOURS |
16. Watch television? ___ ___ 2_____ Don't know/Not
sure 3_____ Don't have a television |
| AVG RADIO HOURS |
17. Listen to the radio? ___ ___ 2_____ Don't know/Not
sure 3_____ Don't listen to the radio |
| READ NEWSPAPER |
18. In the past 30 days how often have you read
a newspaper? 1_____ Every day 2_____ 2-3 times per week 3_____ Once
per week 4_____ Less than once per week 5_____ Never or rarely 6_____
Don't know/Not sure/Not applicable |
| READ PENNYSAVER/ SHOPPER |
19. In the past 30 days how often have you read
a penny saver or shopper? 1_____ Every issue 2_____ 2-3 times per
month 3_____ Once per month 4_____ Less than once per month 5_____
Never or rarely 6_____ Don't know/Not sure/Not applicable |
| In the past 30 days, have you
noticed ANTI-smoking advertising or information.. |
| TV ANTI-SMOKING |
20. .on television? 1_____ Every day 2_____ 2-3
times per day 3_____ Once per week 4_____ Less than once per week
5_____ Never 6_____ No opinion/Don't know/Not applicable |
| RADIO ANTI-SMOKING |
21. .on the radio? 1_____ Every day 2_____ 2-3 times
per day 3_____ Once per week 4_____ Less than once per week 5_____
Never 6_____ No opinion/Don't know/Not applicable |
| AD AWARENESS1 |
22. Have you recently seen an anti-tobacco advertisement
that shows _____"community partner specific ad" _________________
____________________________________________________ _____________________________________________________
1_____ Yes 2_____ No 3_____ Don't know/Not sure |
| SMOKING PORTRAYAL IN NEWS |
23. I'd now like you to think of any news stories
about smoking that you may have noticed on TV, radio, or in the
newspapers, in the past 30 days. In your opinion, how was smoking
portrayed in these news stories? 1_____ Positively 2_____ Negatively
3_____ Neither positively or negatively 4_____ Both negative and
positive 5_____ No opinion/Don't know/Not applicable |
| In the past 30 days, have you
noticed cigarettes or tobacco products being advertised or promoted
at any of the following. |
| POSTER/ BILLBOARD TOBACCO AD/PROMO |
24. .on posters or billboards? 1_____ Every day
2_____ 2-3 times per day 3_____ Once per week 4_____ Less than once
per week 5_____ Never 6_____ No opinion/Don't know/Not applicable
|
| NEWSPAPER/ MAGAZINE TOBACCO AD/PROMO |
25. .in newspapers or magazines? 1_____ Every day
2_____ 2-3 times per day 3_____ Once per week 4_____ Less than once
per week 5_____ Never 6_____ No opinion/Don't know/Not applicable
|
| TOBACCO SHOP TOBACCO AD/PROMO (retailer POP) |
26. . on shop windows or inside shops where tobacco
is sold? 1_____ Every day 2_____ 2-3 times per day 3_____ Once per
week 4_____ Less than once per week 5_____ Never 6_____ No opinion/Don't
know/Not applicable |
| SPORTING EVENT TOBACCO AD/PROMO |
27. .at sports events? 1_____ Every day 2_____ 2-3
times per day 3_____ Once per week 4_____ Less than once per week
5_____ Never 6_____ No opinion/Don't know/Not applicable |
| CULTURAL EVENT TOBACCO AD/PROMO |
28. .at cultural events? 1_____ Every day 2_____
2-3 times per day 3_____ Once per week 4_____ Less than once per
week 5_____ Never 6_____ No opinion/Don't know/Not applicable |
| TOBACCO SHOP TOBACCO AD/PROMO (retailer POP #2) |
29. When you go to a convenience store, supermarket,
or gas station, how often do you see ads for cigarettes and other
tobacco products or items that have tobacco names or pictures on
them? 1_____ All of the time 2_____ Most of the time 3_____ Some
of the time 4_____ Hardly ever 5_____ Never 6_____ I never go to
a convenience store, supermarket or gas station |
| TOBACCO PRODUCT ADVERTISING POSITION/BELIEF |
30. Do you think advertising of tobacco products
should be: always allowed, allowed under some conditions, or not
allowed at all? 1_____ Always allowed 2_____ Allowed under some
conditions 3_____ Not allowed at all 4_____ No opinion/Don't know
|
| QUITLINE AWARENESS |
31. Have you ever heard of the New York State Smokers'
Quitline? 1_____ Yes 2_____ No à PLEASE GO ON TO QUESTION 3_____
Don't know/Not sure à PLEASE GO ON TO QUESTION |
| QUITLINE AWARENESS SOURCE |
32. {If yes} Where did you hear about the New York
State Smokers' Quitline? (If multiple, ask which first, record only
one) 1_____ Television 2_____ Radio 3_____ Posters/billboards 4_____
Movies 5_____ Newspapers/magazines 6_____ Internet 7_____ Other
____________________ 8_____ Don't know/Not sure |
| QUITLINE USE 1 |
33. Have you ever called the New York State Smokers'
Quitline? 1_____ Yes 2_____ No à PLEASE GO ON TO QUESTION 3_____
Don't know/Not sure à PLEASE GO ON TO QUESTION |
| QUITLINE USE 2 |
34. Did you call for yourself, or for a friend or
family member? 1_____ Called for self 2_____ Called for someone
else 3_____ Other [Please Specify] ___________________________ ______________________________________________
|
| Please tell me how much you agree
or disagree with the following statements about tobacco use in movies.
|
| "R" MOVIE RATINGS |
35. Movies with a lot of smoking in them should
be rated "R". 1_____ Strongly agree 2--_____ Agree 3_____ Disagree
4_____ Strongly disagree 5_____ Don't know/Not sure |
| NO ACTORS SMOKING |
36. Movies rated G, PG, and PG-13 should not show
actors smoking. 1_____ Strongly agree 2--_____ Agree 3_____ Disagree
4_____ Strongly disagree 5_____ Don't know/Not sure |
| ACTORS ENCOURAGE SMOKING |
37. Actors smoking in the movies does not encourage
smoking among teens. 1_____ Strongly agree 2--_____ Agree 3_____
Disagree 4_____ Strongly disagree 5_____ Don't know/Not sure |
| AWARENESS OF SMOKING IN MOVIES |
38. In the past 30 days, how often did you see adults
smoking on screen when you watched movies in a movie theater or
on video, DVD, cable, or satellite? 1--_____ Almost always 2_____
Often 3_____ Sometimes 4_____ Rarely 5_____ Never 6_____I have not
seen a movie at the theater, on video or DVD or cable or satellite
in the past 30 days 7_____ Don't know/Not sure |
| |
| Demographic information |
| AGE |
39. What is your age? |
| EMPLOYMENT |
40. What is your current employment status? 1_____
Employed for wages 2_____ Self-employed 3_____ Out of work for more
than 1 year 4_____ Out of work for less than 1 year 5_____ A homemaker
6_____ A student 7_____ Retired 8_____ Unable to work 9_____ Don't
know/Not sure |
| ZIP CODE |
41. What is your zip code? _______________________
|
| COUNTY |
42. What county do you work in? ______________________________________
|
| CHILDREN IN HOUSEHOLD |
43. How many children live in your household who
are younger than 5 years old, 5 through 11years old, or 12 through
17 years old? Please write in the number. 1_____ Younger than 5
years old 2_____ 5 through 11 years old 3_____ 12 through 17 years
old 4_____ Not Applicable |
| EDUCATION |
44. What is the highest level of school you completed
or the highest degree you received? 1_____ Never attended school
or only attended kindergarten 2_____ Grades 1 through 8 (Elementary)
3_____ Grades 9 through 12 (Some high school) 4_____ Grade 12 (High
school graduate) 5_____ G.E.D 6_____ Some technical or vocational
school 7_____ Some college, no degree 8_____ AA; technical or vocational
school 9_____ AA; academic 10____ BA, BS (College graduate) 11____
At least some graduate or professional school 12____ Graduate or
professional degree |
| HISPANIC |
45. Are you Hispanic or Latino? 1_____ Yes 2_____
No 3_____ Don't know/Not sure |
| RACE |
46. Which of the following best represents your
race? 1_____ White 2_____ Black or African American 3_____ Asian
4_____ Native Hawaiian or other Pacific Islander 5_____ American
Indian, Alaska Native 6_____ Don't know/Not sure 7_____ Other [Please
specify] ___________________________ |
| INCOME |
47. What is your annual household income from all
sources? 1_____ Less than $10,000 2_____ $10,000 to less than $15,000
3_____ $15,000 to less than $20,000 4_____ $20,000 to less than
$25,000 5_____ $25,000 to less than $35,000 6_____ $35,000 to less
than $50,000 7_____ $50,000 to less than $75,000 8_____ $75,000
to less than $100,000 9_____ $100,000 or more |
| **HEALTH INSURANCE 1 |
48. Are you currently covered by any kind of health
insurance, that is, any policy or program that provides or pays
for medical care? 1_____ Yes 2_____ No PLEASE GO ON TO QUESTION
3_____ Don't know/Not sure PLEASE GO ON TO QUESTION |
| **HEALTH INSURANCE 2 |
49. What type of health care coverage do you use
to pay for most of your medical care? 1_____ Private insurance coverage
2_____ Medicare 3_____ Medicaid or Medical Assistance 4_____ Military,
CHAMPUS, TriCare, or the VA 5_____ Indian Health Service 6_____
None 7_____ Other [Please specify] ___________________________ 8_____
Don't know/Not sure |
| HEALTH CARE PROVIDER ASK |
50. During the past 12 months, did any doctor, nurse
or health professional ask if you smoke? 1_____ Yes 2_____ No 3_____
Did not see a health care professional in the past 12 months 4_____
Don't know/Not sure |
| |
| COMMUNITY PARTNER AWARENESS 1 |
51. Have you heard of the "Community Partner Name"
and its services? 1___yes 2___no |
| COMMUNITY PARTNER AWARENESS 2 |
52. From what source did you hear about them? (read
choices, check all that apply) 1___television 2___radio 3___newspaper
4___word of mouth 5 __ billboards 6___other _________________________________________
|
| REALITY CHECK AWARENESS |
53. Have you ever heard of "Reality Check", a youth-oriented
program designed to get youth actively involved in promoting anti-tobacco
issues? 1_____ Yes 2_____ No |
| SMOKELESS TOBACCO USE |
54. Do you now use any of the following tobacco
products? (read choices, circle all that apply) Smokeless tobacco
in the form of chewing tobacco, snuff, or dip such as Redman, Levi
Garrett, Beechnut, Skoal, Bandits, or Copenhagen? Yes or No Cigars,
cigrarillos or little cigars? Yes or No Pipe tobacco? Yes or No
|
| BIDI USE, KRETEK/ CLOVE USE |
55. How about...? (read choices, circle all that
apply) Bidis, which are flavored cigarettes from India? Yes or No
{If yes} Do you smoke them every day or some days? ______Every day
______Some days Kreteks or clove cigarettes? Yes or No {If yes}
Do you smoke them every day or some days? ______Every day ______Some
days |
| **ADULT TOBACCO USE 1 |
56. Have you smoked at least 100 cigarettes in your
entire life? 1_____Yes 2_____ No 3_____ Don't know/Not sure |
| **ADULT TOBACCO USE 2 |
57. Do you now smoke cigarettes everyday, some days,
or not at all? 1_____ Everyday PLEASE GO ON TO QUESTION 2_____Some
days PLEASE GO ON TO QUESTION 3_____ Not at all Thank you for taking
the time to help us study this important issue. If you want more
information on the survey contact the Community Partner Name at
(xxx) xxx-xxxx. |
| Ask the Following to Smokers
Only: (Those who answer YES to Q56 AND EVERYDAY OR SOME
DAYS to Q57 above} |
| AMOUNT SMOKED |
58. On the days that you smoke, what is the average
number of cigarettes that you smoke? ___ ___ number of cigarettes
(1 pack = 20 cigarettes) |
| ADDICTION 1 |
59. On the days that you smoke, how soon after you
wake up do you have your first cigarette? Would you say. 1_____
Within 5 minutes 2_____ 6-30 minutes 3_____ 31-60 minutes 4_____
After 60 minutes 5_____ Don't know/Not sure |
| ADDICTION 2 |
60. Would you say you are addicted to cigarettes?
1_____ Not at all true 2_____ Somewhat true 3_____ Very true 4_____
Don't know/Not sure |
| INDIAN RESERVATION PURCHASE |
61. In the past 12 months, have you or a friend
or relative purchased cigarettes for your own use at an Indian reservation
or through an Indian enterprise? 1_____ Yes 2_____ No PLEASE GO
ON TO QUESTION {If yes} How often did you purchase cigarettes here?
1_____ All the time 2_____ Sometimes 3_____ Rarely 4_____ Never
|
| INTERNET PURCHASE |
62. In the past 12 months, have you or a friend
or relative purchased cigarettes for your own use from a web site
or on the internet? 1_____ Yes 2_____ No {If yes} How often did
you purchase cigarettes here? 1_____ All the time 2_____ Sometimes
3_____ Rarely 4_____ Never |
| HEALTH PROFESSIONAL ADVISE |
63. In the past 12 months, has a doctor, nurse,
or other health professional advised you to quit smoking? 1_____
Yes 2_____ No PLEASE GO ON TO QUESTION 3_____ Did not see a health
care professional in the past 12 months PLEASE GO ON TO QUESTION
4_____ Don't know/Not sure PLEASE GO ON TO QUESTION |
| HEALTH PROFESSIONAL ASSIST |
64. When a doctor, nurse, or other health professional
advised you to quit smoking, did he/she do any of the following?
[Check all that apply] 1_____ Prescribe or recommend a nicotine
patch, nicotine, gum, nasal spray, an inhaler, or pills such as
Zyban? 2_____ Suggest that you set a specific date to stop smoking?
3_____ Suggest that you use a smoking cessation class, program,
or counseling? 4_____ Suggest you call a telephone quit line? 5_____
Provide you with booklets, videos, or other materials to help you
quit smoking on your own? 6_____ Schedule a follow-up visit to discuss
your progress? |
| AWARENESS OF CESSATION SERVICES 1 |
65. Are you aware of cessation services in the county?
1 __ Yes Thank you for taking the time to help us study this important
issue. If you want more information on the survey contact the Tompkins
County Health Department at 274-6712 or the Cortland County Health
Department at 757-5501. 2 __ No 3 __ Not sure/Don't know |
| AVAILABILITY OF CESSATION SERVICES 2 |
66. Would you be interested in learning about available
cessation services? 1 __ Yes Provide community partner contact information
or NYS Quit Line 1-866-NY-QUITS 2 __ No |
