Hello, this is __________ calling on behalf of the Department of Health. We are conducting an important research study about factors that affect adults’ health status and their beliefs about health conditions. I would like to speak to a member of the household who is age 18 or older. Your help is voluntary, but important. If we come to a question you don’t want to answer, we will skip over it. You can end the interview at any time. The information you provide will be kept strictly confidential. The survey should only take about 5 minutes, can you help us out tonight? If NO-try to arrange a CALL BACK time.

Our first few questions deal with secondhand smoke exposure.

1. Do you think that breathing smoke from someone else’s cigarettes is:
Very harmful to one’s health
Somewhat harmful to one’s health
Not very harmful to one’s health
Not harmful at all to one’s health
DK/NS

2. Which statement best describes the rules about smoking in your home?
Smoking is not allowed anywhere inside the home
Smoking is allowed in some places or at some times
Smoking is allowed anywhere inside the home
There are no rules about smoking inside the home
Don’t know/Not sure

3. Which statement best describes the rules about smoking in your family vehicle or vehicles?
Smoking is never allowed in any vehicle
Smoking is allowed some times or in some vehicles
Smoking is allowed in all vehicles
Do not have a family vehicle
Don’t know/Not sure

For each of the following types of locations please tell how often you were exposed to secondhand smoke at the places.

IF YOU DID VISIT EACH OF THE TYPES OF LOCATIONS IN YOUR COUNTY IN THE PAST YEAR, how often were you exposed to secondhand smoke when visiting this location IN YOUR COUNTY? [DID NOT VISIT; All of the time; Most of the time ; Some of the time; Hardly ever; Never; Don't Know]
4. public outdoor community event such as an auto show, music festival or concert?
5. public beach?
6. public park?
7. public playground?
8. area around building entryways?
9. on the grounds of a hospital or medical facility (including parking garages, parking lots, and outdoor employee break areas)

For each of the following places please tell me if you think smoking should be allowed anywhere; be restricted to certain areas; or not be allowed at all. [Allowed anywhere; Restricted to certain areas; Not allowed at all; Not sure /Refused]
10. public outdoor community event such as an auto show, music festival or concert
11. public beach?
12. public park?
13. public playground?
14. area around building entryways?
15. on the grounds of a hospital or medical facility

16. How often did you go to a bar in your community in the past month? ________ times

17. When you last went to a bar in your community in the past month, how often did you see people smoking? Nearly every time
Sometimes
Rarely
Never
Don’t know/Not sure
Didn’t go to a bar in the past month

18. Are you currently employed?
Yes (go to #19)
No (go to #21)

19. While working at your job, are you indoors most of the time?
Yes; No; Don't Know /Not Sure

20. In the past seven days, has anyone smoked in your work area or work vehicle?
Yes; No; DK/NS

21. Do you rent or own your home?
Rent; Own; Neither

22. (If RENT) Is there a policy that prohibits indoor smoking in your building? Yes; No; DK/NS

23. (If RENT) Would you like to see a policy that prohibits indoor smoking in your building?
1____Yes 2___ No 3___DK/NS

24. In the past seven days, have you seen anyone smoking in your community inside public places other than bars? Yes; No; DK/NS
25. {If yes} What type of location? ___________________________________________

Our next few questions deal with awareness of advertising or information about the dangers of tobacco or quitting smoking….

During the past 7 days on average, how many hours a day did you: [PLEASE ENTER THE TIME TO NEAREST HALF HOUR]:
27. Watch television?
28. Listen to the radio?

29. In the past 30 days how often have you read a newspaper?
Every day; 2-3 times per week; Once per week; Less than once per week; Never or rarely; DK/NS

30. In the past 30 days how often have you read a penny saver or shopper?
Every issue; 2-3 times per month; Once per month; Less than once per month; Never or rarely; DK/NS

In the past 30 days, have you noticed advertising or information about the dangers of tobacco or quitting smoking.… [Every Day; 2-3 times per week; Once per week; Less than once per week; Never; NO/DK/NA]
31. on television?
32. on radio?
33. in newspapers?

34. Had you heard of “Tobacco Free Tompkins” and its services before this survey? Yes; No; DK/NS

35. From what source did you hear about them? (read choices, check all that apply)
television; radio; newspaper; word of mouth; billboards; other

36. Have you ever heard of “Reality Check”, a youth-oriented program designed to get youth actively involved in promoting anti-tobacco issues? Yes; No; DK/NS

37. Have you recently seen advertising or information about the dangers of tobacco or quitting smoking that was sponsored by ”community partner”? (refer to the specific county ads on the NOTE SHEET here)
Yes; No; DK/NS

38. 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?
Positively; Negatively; Neither positively or negatively; Both negative and positive; No opinion/Don’t know/Not applicable

Please tell me how much you agree or disagree with the following statement about reduced harm of tobacco.

39. “Smoking light cigarettes is safer than smoking regular cigarettes.”
Strongly Agree; Agree; Disagree; Strongly Disagree; Don’t Know/Not Sure

40. “Using smokeless tobacco, (chewing tobacco, snuff, dip, etc.), is safer than smoking regular cigarettes.”
Strongly Agree; Agree; Disagree; Strongly Disagree; Don’t Know/Not Sure

41. During the past 12 months, did any doctor, nurse or health professional ask if you smoke? (ASK CAREFULLY!!!)
Yes; No; Did not see a health care professional in the past 12 months ; DK/NS

42. Have you ever heard of the New York State Smokers’ Quitline? Yes; No; DK/NS
Quit Line: 1-866-NY-QUITS 1-866-697-8487

43. {If yes to #42} Where did you hear about the New York State Smokers’ Quitline? (If multiple, ask which first, record only one)
Television; Radio; Posters/billboards; Movies; Newspapers/magazines; Internet; Other; Don’t know/Not sure

44. Have you ever called the New York St. Smokers’ Quitline? Yes; No; DK/NS

45. Did you call for yourself, or for a friend or family member?
Called for self; Called for someone else; Other [Please Specify]

The next set of questions involves exposure to tobacco advertising….

In the past 30 days, how often have you noticed cigarettes or tobacco products being advertised or promoted at any of the following… circle each that applies: [Every Day; 2-3 times per week; Once per week; Less than once per week; Never; NO/DK/NA]
46. on posters or billboards?
47. in newspapers or magazines
48. on shop windows or inside shops where tobacco is sold?
49. at sports events?
50. at cultural events?

51. 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?
All of the time; Most of the time; Some of the time; Hardly ever; Never; I never go to these places.

52. Do you think advertising of tobacco products should be: always allowed, allowed under some conditions, or not allowed at all?
Always allowed; Allowed under some conditions; Not allowed at all; No opinion/Don’t know

Our next two questions deal with tobacco in the movies.

53. Please tell me how much you agree or disagree with the following statement about tobacco use in movies.
“Movies rated G, PG, and PG-13 should not show actors smoking.”
Strongly Agree; Agree; Disagree; Strongly Disagree; Don’t Know/Not Sure

54. 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?
Almost always
Often
Sometimes
Rarely
Never
I not seen a movie in the past 30 days
DK/NS.

Our last section of questions deals with tobacco use.

Do you now use any of the following products? [YES, every day; YES, some days; No, don’t use]
55. Smokeless Tobacco (ie chewing tobacco, snuff, dip, like Skoal, Redman, etc.)
56. Cigars, cigarillos, or little cigars
57. Pipe tobacco
58. Bidis, (beedees) which are flavored cigarettes from India
59. Kreteks (kreetecks)or clove cigarettes

60. Have you smoked at least 100 cigarettes in your entire life? Yes; No; DK/NS

61. Do you now smoke cigarettes everyday, some days, or not at all? ED; SD; Not at All

Next Questions ONLY FOR FORMER SMOKERS: (YES to Q60 and NOT AT ALL to Q61)

62. How long ago did you quit? (indicate whether weeks or months or years)

63. If Q62<3 years, then ask:

64. Has the New York State law prohibiting smoking in all workplaces, including bars and restaurants, had an effect on your tobacco use? Which of the following best describes the effect?
No effect on my tobacco use (law did not cause me to quit)
Law enacted has caused me to quit
Refused.

When you quit smoking, did you use any of the following methods or strategies to quit? [Yes; No]
65. Stopping by gradually cutting back on cigarettes
66. Switching to chewing tobacco, cigars, or pipes.
67. Switching to “lights” in order to quit.
68. Giving up cigarettes all at once.
69. Quit with a friend, relative, or acquaintance.
70. The nicotine patch, nicotine gum, and/or other medication.
71. OTHER(specify):_______________________________

GO TO DEMOGRAPHICS (#99) AFTER THIS QUESTION.

Next Questions ONLY FOR CURRENT SMOKERS: (YES to Q60 AND ED or SD to Q61)

72. On the days that you smoke, what is the average number of cigarettes that you smoke?
number of cigarettes/day (1 pack = 20 cigarettes)

73. In the past 12 months, has a doctor, nurse, or other health professional advised you to quit smoking?
Yes; No; Did not see a health care professional in the past 12 months; DK/NS

When a doctor, nurse, or other health professional advised you to quit smoking, did he/she do any of the following? [Yes; No] — ask all 6 of these
74. Prescribe or recommend a nicotine patch, nicotine, gum, nasal spray, an inhaler, or pills such as Zyban?
75. Suggest that you set a specific date to stop smoking?
76. Suggest that you use a smoking cessation class, program, or counseling?
77. Suggest you call a telephone quit line?
78. Provide you with booklets, videos, or other materials to help you quit smoking on your own?
79. Schedule a follow-up visit to discuss your progress?

80. During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking? Yes; No; DK/NS; Refused

81. If YES, how long did you remain tobacco free? _______ Days or Weeks or Months?

82. How many times have you attempted to quit smoking in the past three years?

If Q82>0: The last time you tried to quit smoking, did you use any of the following methods or strategies to quit? [Yes; No]
83. Stopping by gradually cutting back on cigarettes
84. Switching to chewing tobacco, cigars, or pipes.
85. Switching to “lights” in order to quit.
86. Giving up cigarettes all at once.
87. Quit with a friend, relative, or acquaintance.
88. The nicotine patch, nicotine gum, and/or other medication.
89. OTHER (specify)

90. Did you ever use or switch to a low tar or nicotine cigarette to reduce your health risk?
Yes; No; DK/NS; Refused

91. 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? Yes; No;

92. How often did you or they purchase cigarettes there?
All of the time
Sometimes
Rarely
Never
DK/NS

93. In the past 12 months, have you or a friend or relative purchased cigarettes for your own use from a website or on the internet? Yes; No

94. How often did you or they purchase cigarettes there?
All of the time
Sometimes
Rarely
Never
DK/NS

95. Has the New York State law prohibiting smoking in all workplaces, including bars and restaurants, had an effect on your tobacco use? Which of the following best describe the effects? (CHOOSE ALL THAT APPLY)
Law enacted has caused me to plan (or consider more strongly) to quit
Law enacted has caused me to reduce the # of cigarettes that I smoke
No effect on my tobacco use (still smoking and law did not caused me to consider quitting)
Refused.

96. Would you like to quit smoking now? Yes; No; DK/NS; Refused

97. Are you aware of cessation services in the county? Yes; No; DK/NS; Refused

98. Would you be interested in learning about available cessation services? Yes; No

Quit Line: 1-866-NY-QUITS 1-866-697-8487

Finally, to better understand the many factors that may be related to your health, we have a few demographic questions for you.

99. What is your age (read intervals,…)?
18-24
25-34
35-44
45-54
55-64
65-74
75-84
85+
9_____Refused

100. What is your current employment status? (check all that apply)
Employed for wages 5_____
Self-employed 6_____
Out of work for more than 1 year 7_____
Out of work for less than 1 year
A homemaker
A student
Retired
Unable to work
DK/NS

101. What county do you work in?_______________________________

How many children live in your household who are:
102. Younger than 5 years old?
103. 5-11 years old?
104. 12-17 years old?

105. What is the highest level of school you completed or the highest degree you received? (open-end, choose one)
Never attended school or only attended kind.
Grades 1 through 8 (Elementary)
Grades 9 through 12 (Some high school)
Grade 12 (High school graduate)
G.E.D
Some technical or vocational school
Some college, no degree
AA; technical or vocational school
AA; academic
BA, BS (College graduate)
At least some grad or prof school
Graduate or professional degree

106. Are you Hispanic or Latino? Yes; No; DK/NS;

107. Which of the following best represents your race or ethnicity?
White
Black or African American
Hispanic or Latino
Asian
Native Hawaiian or other Pacific Islander
American Indian, Alaska Native
Don’t know/Not sure
Other [Please specify] ________________

108. What is your annual household income from all sources (stop me when I get to your interval)?
Less than $10,000
$10,000 to less than $15,000
$15,000 to less than $20,000
$20,000 to less than $25,000
$25,000 to less than $35,000
$35,000 to less than $50,000
$50,000 to less than $75,000
$75,000 to less than $100,000
$100,000 or more

109. Are you currently covered by any kind of health insurance, that is, any policy or program that provides or pays for medical care? Yes; No; Don’t Know /Not Sure;

110. What type of health care coverage do you use to pay for most of your medical care?
Private insurance coverage
Medicare
Medicaid or Medical Assistance
Military, CHAMPUS, TriCare, or the VA
Indian Health Service
None
Other [Please specify] ___________
Don’t know/Not sure

111. What is your gender 1___Male 2___Female

Thank you for taking the time to help us study this important issue. If you want more information regarding this survey contact <Community Partner Information>.