Screener for Study on Tobacco and other Nicotine Products

We are with xxxxxxx University, School of Public Health and are doing a research study
pertaining to tobacco and other nicotine products. We are hoping you might be interested in
participating in a one-time focus group on the topic that will in-turn help the public
understand viewpoints on tobacco products. To see if you qualify, please take the time to fill
out the information below. Thank you or your help on this very important project.

FOR THE FOLLOWING QUESTIONS CHECK THE BOXES THAT APPLY TO YOU.

1. What is your gender?

FEMALE
MALE

2. Is your age between 18-24?

NO
YES

3. Do you smoke cigarettes or use other tobacco products at present?

NO
YES (please continue to question Q#5)

4. Have you ever smoked cigarettes or used other tobacco products in the
past?

YES
NO
5. What types of tobacco products have you used? Please check all that apply.

Cigarettes
Traditional Cigars
Little Cigars
Chewing tobacco
Dipping tobacco
Snuff
Snus
OTHER___________

6. Have you ever tried to quit using all tobacco products?

YES
NO (continue to Q. 7)
7. You mentioned that you have not tried to quit using any tobacco
products. Do you plan to quit using them in the future?

YES
NO

8. In question #4, you said that in the past you’ve made an attempt to
quit smoking. The last time you stopped smoking during the past 12
months because you were trying to quit, how long did you stop for?

A. Less than 24 hours

B. A full 24 hours
C. About a week
D. About a month
E. Longer than a month

9. What products, if any, did you use to help yourself quit smoking?
Please check all that apply.

A. a nicotine patch
B. a nicotine gum
C. a nicotine nasal spray
D. a nicotine inhaler
E. a nicotine lozenge
F. a nicotine tablet
G. a prescription anti-
depressant (e.g. Wellbutrin)
H. a quit line
I. a website
J. hypnosis
K. a self-help guide/book
L. alternative medicine (e.g.
acupuncture or herbal
remedies

10. Are you or any member of your household currently employed or

have you ever been employed in any of the following industries?
Advertising / Public Relations / Journalism / Media TERMINATE
Radio / TV / Film TERMINATE
Financial Services
Market Research TERMINATE
Real Estate
Tobacco Industry TERMINATE
Healthcare

6. Have you ever participated in a market research discussion group?

 Yes No

IF YES: What was the topic?__________ How long ago? _________________