Attachment 2- Testing Instrument/Smokers’ Willingness to Use Tobacco Cessation Products and Services, DOH Oral Health
OMB #0920-0222; Expiration Date: 02/28/10
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Note to reviewers: This self-administered module is part of a larger survey. Sponsor has requested that questions be administered as written.
Which, if any, of the following services or products, do you think help smokers quit? (“X” all that apply)
Stop smoking clinic or class
Telephone quitline
One-on-one counseling from a health care provider
Self-help materials, books or videos
Nicotine patch, gum, lozenge, inhaler
Prescription medications (Zyban/Wellbutrin/bupropion, Chantix)
Acupuncture
Hypnosis
Internet quit site
Mobile phone/PDA
Other
None
Stop smoking products with nicotine are….? (“X” ONE)
More harmful than cigarettes
Less harmful than cigarettes
As harmful as cigarettes
Don’t know
What types of assistance did you utilize the last time when you tried to quit smoking? (“X” all that apply)
Stop smoking clinic or class
Telephone quitline
One-on-one counseling from a health care provider
Self-help materials, books or videos
Nicotine patch, gum, lozenge, inhaler
Prescription medications (Zyban/Wellbutrin/bupropion, Chantix)
Acupuncture
Hypnosis
Internet quit site
Mobile phone/PDA
Other
None
The last time you tried to quit smoking what did you do? (“X” all that apply)
Gradually reduced the number of cigarettes smoked
Switched to “light” cigarettes”
Switched to smokeless tobacco/snuff
Got help from family/friends
Other
None
How many times have you tried to quit smoking?
_______________
What best describes your intentions regarding quitting smoking? Would you say you…(“X” one)
Will quit in the next 30 days
Will quit in the next 6 months
Will quit sometime but not in the next 6 months
I do not plan to quit
What medical information could your health care provider give
you that would
increase your motivation to quit? (“X”
all that apply)
Information on…
How smoking is affecting your overall health
How smoking is affecting your current health problems
How smoking around others affects their health
Your family history of smoking-related illnesses
Other
I do not need medical information about smoking
Information from my provider won’t increase my motivation to quit
What information on quitting could your health care provider give you that would increase your motivation to quit? (“X” all that apply)
Information on…
How the quitting process works (it takes several tries to quit)
How he/she can help you develop a plan for quitting
How telephone quitlines work
How stop smoking clinics/classes work
How quitting medications work
Services that are covered by my health insurance
How to get support for quitting from your family/friends
How to deal with stress when quitting
Other
I do not need information about quitting
Information from my provider won’t increase my motivation to quit
What services would you want from your health care provider to help you quit? (“X” all that apply)
Help developing a plan for quitting
Prescription for quitting medication
Self help materials, books, or videos
Referral to stop smoking clinic/class/specialist
Referral to a telephone quitline
Information on how to quit on your own
Information for family/friends to help you quit
Other
I would not be interested in services from my provider
10. How likely are you to seek health care provider’s advice in your next quit attempt? (5= Most likely, 1=least likely)
1 2 3 4 5
11. Have you ever asked a health care provider for help in quitting smoking?
Yes
No
12. Do you think a health care provider should help you quit smoking?
Yes
No
13. If the following services/treatments were free, which would you use in your next quit attempt? (“X” all that apply)
Stop smoking clinic or class
Telephone quitline
One-on-one counseling from a health care provider
Self-help materials, books or videos
Nicotine patch, gum, lozenge, inhaler
Prescription medications (Zyban/Wellbutrin/bupropion, Chantix)
Acupuncture
Hypnosis
Internet quit site
Mobile phone/PDA
Other
I would not use any services/treatments
14. What services would you want from a free telephone quitline to help you quit? (“X” all that apply)
Help developing a quit plan
Information on quitting medications
Self help materials, books, or videos
Referral to stop smoking clinic/class/local specialist
Information on how quit on your own
Information for family/friends to help you quit
Information on healthy eating/increasing exercise
Unlimited calls
Access to internet services
Free quitting medications
Prizes for Quitting
Other
I would not be interested in quitline services
15. What are the important factors to you in choosing the product you selected? Please, rank them (1 to 4) in order.
[ ] Costs of the therapy
[ ] Convenience of the therapy
[ ] Availability (prescription or nonprescription)
[ ] More helpful in quitting
17. If you were purchasing the medication to quit smoking, would you be willing to pay maximum amount of $450 out of your pocket for the medication that may help you quit smoking?
Yes (skip to 21)
No
18. If no, would you be willing to pay $300 out of your pocket for the medication?
Yes (skip to 21)
No
19. If no, would you be willing to pay $150 out of your pocket for the medication?
Yes (skip to 21)
No
20. If no, would you be willing to pay $100 out of your pocket for the medication?
Yes
No
21. Now thinking about your household income and other expenses, how confident are you in your previous answers on willingness to pay for the quit medication. (“X” that apply)
Very confident
Somewhat confident
Not too confident
Not at all Confident
Division of Oral Health (DOH) Question
Note to reviewers: This question is interviewer-administered.
22. In the past 12 months, has a dentist, dental hygienist or other dental professional spoken with you about…
22a. …quitting cigarette smoking or stopping using tobacco to improve your dental health?
Yes
No
22b. …having your blood sugar checked to improve your dental health?
Yes
No
22c. …looking inside your mouth to check for oral cancer?
Yes
No
| File Type | application/msword |
| File Title | Attachment x- Testing Instrument/Smokers’ Willingness to Use Tobacco Cessation Products and Services, DOH Oral Health |
| Author | Karen Roberta Whitaker |
| Last Modified By | mxm3 |
| File Modified | 2009-07-09 |
| File Created | 2009-07-09 |