MDS Intake Questions July 21, 2009

Transcription

1 MDS Intake Questions July 21, 2009 Notes: The updated MDS Intake questions contain two options for assessing use of different tobacco types. The first (Option 1), which is included in the primary section of the intake questions, assesses for all types of tobacco at the same time. Option 2 is included in the Appendix and contains exactly the same questions, but in a different order. Option 2 reflects the ordering of the original MDS and asks about cigarette use first and other types of tobacco later. The two options are provided in an attempt to provide maximum flexibility for quitlines, while increasing standardization of the individual questions. IntakeQuestions_MDSImplementationGuide Page 1 of 22

2 MDS Intake Questions July 8, 2009 NAQC MDS Intake Question 1: How can I help you? Want help / information about quitting Optional Probe if selected: So, you are still using tobacco right now? Want help / information about staying quit Want to refer someone for help Want general information or materials about quitline service Other: 2a. Just to confirm, are you calling for yourself, or calling on behalf of or to help someone else? : Calling for yourself (SKIP TO Q3) Calling on behalf of or to help someone else (CONTINUE TO Q2b) Optional: 2b. Are you: A health professional A friend or family member A community organization, worksite, insurance Other: IntakeQuestions_MDSImplementationGuide Page 2 of 22

3 NAQC MDS Intake Question 3: How did you hear about the quitline? (; CHECK ALL RESPONSES) MEDIA Newspaper Radio Television Internet/web Other: Other selections can be added by quitline OTHER ADVERTISING Phone directory Flyers, brochures Other: Other selections can be added by quitline REFERRAL Health professional (doctor, dentist, etc.) Family / friends Workplace Health insurance Community organization Other: Other selections can be added by quitline NAQC MDS Intake Question 4: Is this your first call to the quitline in the past year? Yes No Optional: How many times did you call the quitline in the past year? (# of times) IntakeQuestions_MDSImplementationGuide Page 3 of 22

4 ASSESSMENT FOR TYPES OF TOBACCO USE OPTION 1 (for Option 2, see Appendix A) MDS INTAKE QUESTION 5: What types of tobacco do you use now or in the past 30 days? Cigarettes? (record response) Cigars? (record response) A pipe? (record response) Chewing tobacco, snuff, or dip? (record response) Any other type of tobacco? (record response) Cigarettes Yes No Cigars Yes No Pipe Yes No Chewing tobacco, snuff, or dip Yes No Other (optional) Yes Optional (specify): No None (note: no to all above equals none) IntakeQuestions_MDSImplementationGuide Page 4 of 22

5 NAQC MDS Intake Question 5a: Read 5a if caller responded yes to cigarettes above. 5a. Do you currently smoke cigarettes every day, some days, or not at all? [CANADA ONLY: Do you currently smoke cigarettes daily, occasionally, or not at all?] [NOTE: currently refers to right now, today.] (CHECK ONE) Everyday [CANADA ONLY: Daily] Some days [CANADA ONLY: Occasionally] (if less than 7 days per week) Optional if respond Some Days/Occasionally : How many days did you smoke in the last 30 days? Not at all (skip to 5a(2)) NAQC MDS Intake Question 5a(1) If this item is assessed through conversation with the caller, the number should be confirmed. Example: You said that you smoke 10 cigarettes per day on the days that you smoke. Is that correct? 5a(1). How many cigarettes do you smoke per day on the days that you smoke (cigarettes per day)? (If caller says over 100, confirm. 100 cpd = 5 packs per day) If caller cannot identify a specific number, probe: Give me your best guess it is OK if it is not perfect. EVERY DAY/DAILY CIGARETTE SMOKERS SKIP TO 5b, c, d, or e as indicated by the type of tobacco use question above. NAQC MDS Intake Question 5a(2) 5a(2) When was the last time you smoked a cigarette, even a puff (dd/mm/yyyy)? If caller cannot identify a specific date, use one or more of the following probes: Can you be more specific? Is there a date that stands out, in particular, such as a holiday or special occasion? Do you remember what month or season? Was it closer to the beginning, middle, or end of the month? Do you remember if it was during the week or on a weekend? Do you remember if it was closer to the beginning, middle, or end of the week? IntakeQuestions_MDSImplementationGuide Page 5 of 22

6 NAQC MDS Intake Question 5b: Read 5b if caller responded yes to cigars above. 5b. Do you currently smoke CIGARS every day, some days, or not at all? [CANADA ONLY: Do you currently smoke CIGARS daily, occasionally, or not at all?] [NOTE: currently refers to right now, today.] (CHECK ONE) Everyday [CANADA ONLY: Daily] Some days [CANADA ONLY: Occasionally] (if less than 7 days per week) Optional if respond Some Days/Occasionally : How many days did you smoke in the last 30 days? Not at all (skip to 5b(2)) NAQC MDS Intake Question 5b(1) If this item is assessed through conversation with the caller, counsellors or other quitline staff should confirm the number. For example, You said that you smoke 10 cigars per week during the weeks that you smoke. Is that correct? 5b(1). How many CIGARS do you smoke per week during the weeks that you smoke? (cigars per week) If caller cannot identify a specific number, probe: Give me your best guess it is OK if it is not perfect. EVERY DAY/DAILY CIGAR SMOKERS SKIP TO 5c, d, or e as indicated by the type of tobacco use question above. NAQC MDS Intake Question 5b(2) 5b(2) When was the last time you smoked a cigar, even a puff (dd/mm/yyyy)? If caller cannot identify a specific date, use one or more of the following probes: Can you be more specific? Is there a date that stands out, in particular, such as a holiday or special occasion? Do you remember what month or season? Was it closer to the beginning, middle, or end of the month? Do you remember if it was during the week or on a weekend? Do you remember if it was closer to the beginning, middle, or end of the week? IntakeQuestions_MDSImplementationGuide Page 6 of 22

7 NAQC MDS Intake Question 5c Read 5c if caller responded yes to a pipe above. 5c. Do you currently smoke A PIPE every day, some days, or not at all? [CANADA ONLY: Do you currently smoke A PIPE daily, occasionally, or not at all?] [NOTE: currently refers to right now, today.] (CHECK ONE) Everyday [CANADA ONLY: Daily] Some days [CANADA ONLY: Occasionally] (if less than 7 days per week) Optional if respond Some Days/Occasionally : How many days did you smoke in the last 30 days? Not at all (skip to 5c(2)) NAQC MDS Intake Question 5c(1) If this item is assessed through conversation with the caller, counsellors or other quitline staff should confirm the number. For example, You said that you smoke 10 pipes per week during the weeks that you smoke. Is that correct? 5c(1). How many PIPES do you smoke per week during the weeks that you smoke? (pipes per week) If caller cannot identify a specific number, probe: Give me your best guess it is OK if it is not perfect. EVERY DAY/DAILY PIPE SMOKERS SKIP TO 5d, or e as indicated by the type of tobacco use question above. NAQC MDS Intake Question 5c(2) 5c(2) When was the last time you smoked a pipe, even a puff (dd/mm/yyyy)? If caller cannot identify a specific date, use one or more of the following probes: Can you be more specific? Is there a date that stands out, in particular, such as a holiday or special occasion? Do you remember what month or season? Was it closer to the beginning, middle, or end of the month? Do you remember if it was during the week or on a weekend? Do you remember if it was closer to the beginning, middle, or end of the week? NAQC MDS Intake Question 5d Read 5d if caller responded yes to chewing tobacco, snuff, or dip above. IntakeQuestions_MDSImplementationGuide Page 7 of 22

8 5d. Do you currently use CHEWING TOBACCO, SNUFF, OR DIP every day, some days, or not at all? [CANADA ONLY: Do you currently smoke CHEWING TOBACCO, SNUFF, OR DIP daily, occasionally, or not at all?] [NOTE: currently refers to right now, today.] (CHECK ONE) Everyday [CANADA ONLY: Daily] Some days [CANADA ONLY: Occasionally] (if less than 7 days per week) Optional if respond Some Days/Occasionally : How many days did you chew in the last 30 days? Not at all (skip to 5d(2)) NAQC MDS Intake Question 5d(1) If this item is assessed through conversation with the caller, counsellors or other quitline staff should confirm the number. For example, You said that you use 2 tins per week during the weeks that you chew. Is that correct? 5d(1). How many POUCHES OR TINS do you use per week during the weeks that you use tobacco? (pouches/tins per week) If caller cannot identify a specific number, probe: Give me your best guess it is OK if it is not perfect. EVERY DAY/DAILY CHEW/SNUFF USERS SKIP TO 5e if indicated by the type of tobacco use question above. NAQC MDS Intake Question 5d(2) 5d(2) When was the last time you used chewing tobacco, snuff, or dip, even a pinch (dd/mm/yyyy)? If caller cannot identify a specific date, use one or more of the following probes: Can you be more specific? Is there a date that stands out, in particular, such as a holiday or special occasion? Do you remember what month or season? Was it closer to the beginning, middle, or end of the month? Do you remember if it was during the week or on a weekend? Do you remember if it was closer to the beginning, middle, or end of the week? NAQC MDS Intake question 5e Read 5e if caller responded yes to other types of tobacco above. IntakeQuestions_MDSImplementationGuide Page 8 of 22

9 5e. Do you currently use OTHER TYPES OF TOBACCO every day, some days, or not at all? [CANADA ONLY: Do you currently use OTHER TYPES OF TOBACCO daily, occasionally, or not at all?] [NOTE: currently refers to right now, today.] (CHECK ONE) Everyday [CANADA ONLY: Daily] Some days [CANADA ONLY: Occasionally] (if less than 7 days per week) Optional if respond Some Days/Occasionally : How many days did you use other types of tobacco in the last 30 days? Not at all (skip to 5e(2)) NAQC MDS Intake Question 5e(1) If this item is assessed through conversation with the caller, counsellors or other quitline staff should confirm the number. For example, You said that you smoke 10 bidis per week during the weeks that you smoke. Is that correct? 5e(1). How much OTHER TOBACCO do you use per week during the weeks that you smoke? (other tobacco per week) If caller cannot identify a specific number, probe: Give me your best guess it is OK if it is not perfect. EVERY DAY/DAILY OTHER TOBACCO PRODUCT USERS SKIP TO MDS INTAKE Q6 NAQC MDS Intake Question 5e(2) 5e(2) When was the last time you used other types of tobacco, even a puff or pinch (dd/mm/yyyy)? If caller cannot identify a specific date, use one or more of the following probes: Can you be more specific? Is there a date that stands out, in particular, such as a holiday or special occasion? Do you remember what month or season? Was it closer to the beginning, middle, or end of the month? Do you remember if it was during the week or on a weekend? Do you remember if it was closer to the beginning, middle, or end of the week? NAQC MDS Intake Question 6 Cigarette smokers only: How soon after you wake up do you smoke your first cigarette? () IntakeQuestions_MDSImplementationGuide Page 9 of 22

10 Within five minutes 6 to 30 minutes 31 to 60 minutes More than 60 minutes TIME TO FIRST TOBACCO USE (OTHER THAN CIGARETTES) NAQC MDS Intake Optional Question 7: How soon after you wake up do you use tobacco (other than cigarettes)? () Within five minutes 6 to 30 minutes 31 to 60 minutes More than 60 minutes NAQC MDS Intake Question 8: Do you intend to quit within the next 30 days? () Yes No NAQC MDS Intake Optional Question 9: Optional 9a: At what age did you start smoking cigarettes regularly? (age in years) Optional 9b: At what age did you start smoking cigars regularly? (age in years) Optional 9c: At what age did you start smoking a pipe regularly? (age in years) Optional 9d: At what age did you start using chewing tobacco, snuff, or dip regularly? (age in years) Optional 9e: At what age did you start using other tobacco products regularly? (age in years) IntakeQuestions_MDSImplementationGuide Page 10 of 22

11 C. CALLER CHARACTERISTICS (Ask of all eligible* callers) (*eligible is defined by each quitline and should be clearly described. For example, if a quitline provides services of any kind to proxy callers, then proxy callers should be asked this question.) Optional Scripting: Before we finish, I'd like to ask you some additional questions about yourself. Several communities have been targeted by the tobacco industry or have higher smoking rates. We have some special materials for people in these communities, and your answers can help us understand whether we are serving all tobacco users well. Please remember that participation is voluntary and your answers will remain confidential. This should only take a few minutes. May I ask you these additional questions? NAQC MDS Intake Question 10: First I need to verify are you male or female? Male Female NAQC MDS Intake Question 11: What year were you born? It is acceptable to assess this information through conversation with the caller, although the specific year of birth should be confirmed. (E.g., you just said you are 52 years old. Does that mean you were born in 1957? ) Optional 11a: What is your date of birth? / (mm/yyyy) NAQC MDS Intake Question 12: What is your zip code? (Canada: What is your postal code?) NAQC MDS Intake Optional Question 13 Optional (USA only): Do you have any health insurance, including pre-paid or government programs? Yes GO TO OPTIONAL QUESTION 14 No SKIP TO QUESTION 15 IntakeQuestions_MDSImplementationGuide Page 11 of 22

12 NAQC MDS Intake Optional Question 14 Optional (USA only): What type of health insurance do you have? Suggested prompt: Please take out your health insurance card and read off the name of the health plan on the card. Quitlines are to provide response categories that meet the needs of the individual state, province, or territory, but responses should be able to be rolled up to: Private Insurance, Government-sponsored insurance (including Medicaid, Medicare, military insurance, etc.), or no insurance. NAQC MDS Intake Question 15: What is the highest level of education you have completed? () USA: Less than grade 9 Grade 9 to 11, no degree GED High school degree Some college or university College or university degree CANADA: Less than high school High school diploma Some college, Technical or trade school (includes any post-high school education, including technical or trade school, but not a degree.) College or university degree (includes AA, BA, Masters, Ph.D.) IntakeQuestions_MDSImplementationGuide Page 12 of 22

13 NAQC MDS Intake Question 16: USA only: Are you of Hispanic, Latino, or Spanish origin? No (Not of Hispanic, Latino, or Spanish origin) Yes (of Hispanic, Latino, or Spanish origin) NAQC MDS Intake question 17 USA: What is your race? Which one or more of these groups would you say best describes you? (select one or more) White Black, African Am., or Negro American Indian or Alaska Native Optional: Specify name of enrolled or principal tribe Asian Optional if respond Asian : Which specific ethnicity or race do you identify with the most? (Do not read responses; code answer) Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian (e.g., Hmong, Lao, Thai, Pakistani, Cambodian, etc.) Optional: Specify Native Hawaiian or other Pacific Islander Optional if respond Native Hawaiian or other pacific islander : Which specific ethnicity or race do you identify with the most? (Do not read responses; code answer) Guamanian or Chamorro Samoan Other Pacific Islander (e.g., Fijian, Tongan, etc.) Optional: Specify Some other race Optional: Specify Not Asked IntakeQuestions_MDSImplementationGuide Page 13 of 22

14 MDS Intake Question 17a-c: CANADA: 17a: People living in Canada come from many different cultural and racial backgrounds. Are you (select all that apply): (Note: This information is collected to support programs that promote equal opportunity for everyone to share in the social, cultural, and economic life of Canada.) White Asian Optional if respond Asian : Which specific ethnicity or race do you identify with the most? (Do not read responses; code answer) Chinese Filipino Korean Japanese South Asian (e.g., East Indian, Pakistani, Sri Lankan, etc.) Southeast Asian (e.g., Vietnamese, Cambodian, Malaysian, Laotian, etc.) West Asian (e.g., Iranian, Afghan, etc.) Black Latin American Arab Aboriginal ( North American Indian, Métis, or Inuit (Eskimo))? Other Specify 17b: Optional: Are you a member of an Indian Band/First Nation? No Yes, member of an Indian Band/First Nation Specify Indian Band/First Nation (for example, Musqueam) 17c: Optional: To which of the following ethnic or cultural groups did your ancestors belong? (ancestor = great grandparents or further back) (READ; CAN CHECK MORE THAN ONE) Canadian (English or French Canadian) Aboriginal (Native Indian, Métis, Inuit) British (English, Irish, Scottish, Welsh) European (specify country): Asian (specify country): Other (specify): (DON T READ) None of the above (DON T READ) (DON T READ) (DON T READ) IntakeQuestions_MDSImplementationGuide Page 14 of 22

15 NAQC MDS Intake Optional Question 18: Recommended question and scripting: Do you consider yourself to be one or more of the following: [say the letter and the response option so that they can respond by either one] a) Straight b) Gay or Lesbian c) Bisexual d) Transgender [If pause or refusal/none of above, also say: You can name a different category if that fits you better: ] e) Other i. queer ii. genderqueer iii. dyke iv. other These are not read aloud, but are pre-coded as they were the most frequently chosen in the testing phase. NAQC MDS INTAKE ADMINISTRATIVE DATA Counselor ID (Optional) Caller ID Date of first contact with quitline (dd/mm/yyyy): / / Services provided to caller (or that the caller registered for) (Check all that apply): Basic information (no materials sent) Literature and/or self-help materials Reactive counseling (one counseling session) Proactive counseling (more than one counseling session) Medications (FDA approved) (Optional: type of medication) Referral to another service (for tobacco cessation or other services) Other Mode of entry to the quitline (e.g., direct call to the number, fax referral, internet advertising, solicitation/click-through, etc.) IntakeQuestions_MDSImplementationGuide Page 15 of 22

16 APPENDIX A ASSESSMENT FOR TYPES OF TOBACCO USE OPTION 2 (cigarettes first, then other tobacco products) MDS INTAKE QUESTION 5 (option 2): Do you use cigarettes now or in the past 30 days? Cigarettes Yes No SKIP TO MDS INTAKE QUESTION 6a Read 5a if caller responded yes to cigarettes above. 5a. Do you currently smoke cigarettes every day, some days, or not at all? [CANADA ONLY: Do you currently smoke cigarettes daily, occasionally, or not at all?] [NOTE: currently refers to right now, today.] (CHECK ONE) Everyday [CANADA ONLY: Daily] Some days [CANADA ONLY: Occasionally] (if less than 7 days per week) Optional if respond Some Days/Occasionally : How many days did you smoke in the last 30 days? Not at all (skip to 5a(2)) NAQC MDS Intake Question 5a(1) If this item is assessed through conversation with the caller, counsellors or other quitline staff should confirm the number. For example, You said that you smoke 10 cigarettes per day on the days that you smoke. Is that correct? 5a(1). How many cigarettes do you smoke per day on the days that you smoke (cigarettes per day)? (If caller says over 100, confirm. 100 cpd = 5 packs per day; If caller says less than one per day, code as Some Days) If caller cannot identify a specific number, probe: Give me your best guess it is OK if it is not perfect. EVERY DAY/DAILY CIGARETTE SMOKERS SKIP TO 6. IntakeQuestions_MDSImplementationGuide Page 16 of 22

17 MDS Intake 5a(2) 5a(2) When was the last time you smoked a cigarette, even a puff (dd/mm/yyyy)? If caller cannot identify a specific date, use one or more of the following probes: Can you be more specific? Is there a date that stands out, in particular, such as a holiday or special occasion? Do you remember what month or season? Was it closer to the beginning, middle, or end of the month? Do you remember if it was during the week or on a weekend? Do you remember if it was closer to the beginning, middle, or end of the week? NAQC MDS Intake Question 6 Cigarette smokers only: How soon after you wake up do you smoke your first cigarette? () Within five minutes 6 to 30 minutes 31 to 60 minutes More than 60 minutes IntakeQuestions_MDSImplementationGuide Page 17 of 22

18 MDS INTAKE QUESTION 6a: What other types of tobacco do you use now or in the past 30 days? Cigars? (record response) A pipe? (record response) Chewing tobacco, snuff, or dip? (record response) Any other type of tobacco? (record response) Cigars Yes No Pipe Yes No Chewing tobacco or Snuff Yes No Other (optional) Yes Optional (specify): No None (note: no to all above equals none) IntakeQuestions_MDSImplementationGuide Page 18 of 22

19 NAQC MDS Intake Question 5b Read 5b if caller responded yes to cigars above. 5b. Do you currently smoke CIGARS every day, some days, or not at all? [CANADA ONLY: Do you currently smoke CIGARS daily, occasionally, or not at all?] [NOTE: currently refers to right now, today.] (CHECK ONE) Everyday [CANADA ONLY: Daily] Some days [CANADA ONLY: Occasionally] (if less than 7 days per week) Optional if respond Some Days/Occasionally : How many days did you smoke in the last 30 days? Not at all (skip to 5b(2)) NAQC MDS Intake Question 5b(1) If this item is assessed through conversation with the caller, counsellors or other quitline staff should confirm the number. For example, You said that you smoke 10 cigars per week during the weeks that you smoke. Is that correct? 5b(1). How many CIGARS do you smoke per week during the weeks that you smoke? (cigars per week) If caller cannot identify a specific number, probe: Give me your best guess it is OK if it is not perfect. EVERY DAY/DAILY CIGAR SMOKERS SKIP TO 5c, d, or e as indicated by the type of tobacco use question above. NAQC MDS Intake Question 5b(2) 5b(2) When was the last time you smoked a cigar, even a puff (dd/mm/yyyy)? If caller cannot identify a specific date, use one or more of the following probes: Can you be more specific? Is there a date that stands out, in particular, such as a holiday or special occasion? Do you remember what month or season? Was it closer to the beginning, middle, or end of the month? Do you remember if it was during the week or on a weekend? Do you remember if it was closer to the beginning, middle, or end of the week? IntakeQuestions_MDSImplementationGuide Page 19 of 22

20 NAQC MDS Intake Question 5c Read 5c if caller responded yes to a pipe above. 5c. Do you currently smoke A PIPE every day, some days, or not at all? [CANADA ONLY: Do you currently smoke A PIPE daily, occasionally, or not at all?] [NOTE: currently refers to right now, today.] (CHECK ONE) Everyday [CANADA ONLY: Daily] Some days [CANADA ONLY: Occasionally] (if less than 7 days per week) Optional if respond Some Days/Occasionally : How many days did you smoke in the last 30 days? Not at all (skip to 5c(2)) NAQC MDS Intake Question 5c(1) If this item is assessed through conversation with the caller, counsellors or other quitline staff should confirm the number. For example, You said that you smoke 10 pipes per week during the weeks that you smoke. Is that correct? 5c(1). How many PIPES do you smoke per week during the weeks that you smoke? (cigars per week) If caller cannot identify a specific number, probe: Give me your best guess it is OK if it is not perfect. EVERY DAY/DAILY PIPE SMOKERS SKIP TO 5d, or e as indicated by the type of tobacco use question above. NAQC MDS Intake Question 5c(2) 5c(2) When was the last time you smoked a pipe, even a puff (dd/mm/yyyy)? If caller cannot identify a specific date, use one or more of the following probes: Can you be more specific? Is there a date that stands out, in particular, such as a holiday or special occasion? Do you remember what month or season? Was it closer to the beginning, middle, or end of the month? Do you remember if it was during the week or on a weekend? Do you remember if it was closer to the beginning, middle, or end of the week? IntakeQuestions_MDSImplementationGuide Page 20 of 22

21 NAQC MDS Intake Question 5d Read 5d if caller responded yes to chewing tobacco, snuff, or dip above. 5d. Do you currently use CHEWING TOBACCO, SNUFF, OR DIP every day, some days, or not at all? [CANADA ONLY: Do you currently smoke CHEWING TOBACCO, SNUFF, OR DIP daily, occasionally, or not at all?] [NOTE: currently refers to right now, today.] (CHECK ONE) Everyday [CANADA ONLY: Daily] Some days [CANADA ONLY: Occasionally] (if less than 7 days per week) Optional if respond Some Days/Occasionally : How many days did you chew in the last 30 days? Not at all (skip to 5d(2)) NAQC MDS Intake Question 5d(1) If this item is assessed through conversation with the caller, counsellors or other quitline staff should confirm the number. For example, You said that you use 2 tins per week during the weeks that you chew. Is that correct? 5d(1). How many POUCHES OR TINS do you use per week during the weeks that you use tobacco? (pouches/tins per week) If caller cannot identify a specific number, probe: Give me your best guess it is OK if it is not perfect. EVERY DAY/DAILY CHEW/SNUFF USERS SKIP TO 5e if indicated by the type of tobacco use question above. NAQC MDS Intake Question 5d(2) 5d(2) When was the last time you used chewing tobacco, snuff, or dip, even a pinch (dd/mm/yyyy)? If caller cannot identify a specific date, use one or more of the following probes: Can you be more specific? Is there a date that stands out, in particular, such as a holiday or special occasion? Do you remember what month or season? Was it closer to the beginning, middle, or end of the month? Do you remember if it was during the week or on a weekend? Do you remember if it was closer to the beginning, middle, or end of the week? IntakeQuestions_MDSImplementationGuide Page 21 of 22

22 NAQC MDS Intake Question 5e Read 5e if caller responded yes to other types of tobacco above. 5e. Do you currently use OTHER TYPES OF TOBACCO every day, some days, or not at all? [CANADA ONLY: Do you currently use OTHER TYPES OF TOBACCO daily, occasionally, or not at all?] [NOTE: currently refers to right now, today.] (CHECK ONE) Everyday [CANADA ONLY: Daily] Some days [CANADA ONLY: Occasionally] (if less than 7 days per week) Optional if respond Some Days/Occasionally : How many days did you use other types of tobacco in the last 30 days? Not at all (skip to 5e(2)) NAQC MDS Intake Question 5e(1) If this item is assessed through conversation with the caller, counsellors or other quitline staff should confirm the number. For example, You said that you smoke 10 bidis per week during the weeks that you smoke. Is that correct? 5e(1). How much OTHER TOBACCO do you use per week during the weeks that you smoke? (other tobacco per week) () If caller cannot identify a specific number, probe: Give me your best guess it is OK if it is not perfect. EVERY DAY/DAILY OTHER TOBACCO PRODUCT USERS SKIP TO MDS INTAKE Q6 NAQC MDS Intake Question 5e(2) 5e(2) When was the last time you used other types of tobacco, even a puff or pinch (dd/mm/yyyy)? If caller cannot identify a specific date, use one or more of the following probes: Can you be more specific? Is there a date that stands out, in particular, such as a holiday or special occasion? Do you remember what month or season? Was it closer to the beginning, middle, or end of the month? Do you remember if it was during the week or on a weekend? Do you remember if it was closer to the beginning, middle, or end of the week? IntakeQuestions_MDSImplementationGuide Page 22 of 22