OMB
No. XXXX-xxxx
Exp. Date xx/xx/xxxx
Evaluation of the Public Education Campaign on Teen Tobacco-Media Tracking (ExPECTT-MT)
Subjects for Questionnaire:
Study Screener
Section A: Media Use and Awareness
Section B: Tobacco Use Behavior, Attitudes & Beliefs
Section
C: Demographic Items
Study Screener (Email invitation to pre-selected parents from existing panel)
Greetings!
We have a new survey and your participation is requested. The survey is meant for children (males/females) ages 13-17. If [he/she] qualifies and completes, your Global Test Market account will be credited with the Market Points stated in the invitation.
Best Regards –
Global Test Market Team
Study Introduction
Thank you for agreeing to take part in this survey. The survey will take approximately 30 minutes to complete. You will be asked various questions about your experiences with tobacco products, media use, as well as some questions about your background. Even if you do not use tobacco products, the information you provide will still be very important.
Your responses will be kept strictly confidential, and neither your name nor other personal information will be associated with your responses. The data collected for this study will be combined with that of all participants before it is analyzed.
S1. How old are you?
1 11 years old or younger (GO TO CLOSING TEXT)
2 12 years old (GO TO CLOSING TEXT)
3 13 years old (GO TO A1)
4 14 years old (GO TO A1)
5 15 years old (GO TO A1)
6 16 years old (GO TO A1)
7 17 years old (GO TO A1)
8 18 years old or older (GO TO CLOSING TEXT)
9 Prefer not to answer (GO TO CLOSING TEXT)
CLOSING TEXT “You do not qualify for this survey, which is for children ages 13 to 17. Thank you very much for your response.“
Section A: Media Use and Awareness
[INSERT STUDY CONSENT LANGUAGE HERE]
First, we’d like to ask you about your use of TV and other media.
A1. Thinking only about yesterday, about how much time did you spend watching TV shows or movies on any of the following?
|
|
At least one minute, but less than 1 hour |
1 hour or more, but less than 2 hours |
2 hours or more, but less than 3 hours |
|
|
A1_1. A TV set? Include time spent watching DVDs, streaming video like Netflix, shows that you recorded earlier, or shows “On Demand” |
1 |
2 |
3 |
4 |
5 |
9 |
A1_2. A computer, laptop, or tablet? Include streaming video like Netflix, DVDs, Hulu, etc.? |
1 |
2 |
3 |
4 |
5 |
9 |
A1_3. A cell phone/smartphone? |
1 |
2 |
3 |
4 |
5 |
9 |
A1_4. An iPod or other MP3 player? |
1 |
2 |
3 |
4 |
5 |
9 |
A2. Thinking only about yesterday, about how much time did you spend doing the following activities? You may be doing some of these activities while you are doing another (for example, listening to music while you instant messaging).
|
|
At least one minute, but less than 1 hour |
1 hour or more, but less than 2 hours |
2 hours or more, but less than 3 hours |
|
|
Listening to Music |
|
|
|
|
|
|
A2_1. Listening to music across all devices including Ipods, MP3 players, cell phones, computer, laptop, tablet, Internet radio like Pandora, CD players, and car radios. |
1 |
2 |
3 |
4 |
5 |
9 |
Using a Computer, Laptop, or Tablet |
|
|
|
|
|
|
A2_2. Watching or uploading videos such as YouTube on a computer, laptop, or tablet |
1 |
2 |
3 |
4 |
5 |
9 |
A2_3. Using social networking sites like Facebook or twitter on a computer, laptop, or tablet |
1 |
2 |
3 |
4 |
5 |
9 |
A2_4. Browsing any other type of website for anything besides schoolwork on a computer, laptop, or tablet, like news or entertainment. |
1 |
2 |
3 |
4 |
5 |
9 |
A2_5. Instant messaging or Video chatting (on Skype, Googletalk, iChat, etc.) on a computer, laptop, or tablet |
1 |
2 |
3 |
4 |
5 |
9 |
Using a Cell Phone/Smartphone |
|
|
|
|
|
|
A2_6. Text messaging on a cell phone/smartphone |
1 |
2 |
3 |
4 |
5 |
9 |
A2_7. Watching or uploading videos such as YouTube on a cell phone/smartphone |
1 |
2 |
3 |
4 |
5 |
9 |
A2_8. Going to social networking sites like Facebook or twitter on a cell phone/smartphone |
1 |
2 |
3 |
4 |
5 |
9 |
A2_9. Browsing any other type of website on a cell phone/smartphone like news or entertainment. Include smartphone apps. |
1 |
2 |
3 |
4 |
5 |
9 |
Playing Games and Reading |
|
|
|
|
|
|
A2_10. Playing games on all electronic devices. Include cell phones/smartphones, computers, laptops, tablets, game players hooked up to a TV/computer (Xbox, Wii, PSP) and handheld players (Nintendo DS, Sony PSP, iPod) |
1 |
2 |
3 |
4 |
5 |
9 |
A2_11. Reading a book that was for your own enjoyment (not a homework assignment). Include e-book or e-readers. |
1 |
2 |
3 |
4 |
5 |
9 |
A2_12. Looking at or reading any magazines? Do not include time spent reading magazines on a computer, laptop, or tablet. |
1 |
2 |
3 |
4 |
5 |
9 |
A2_13. How often do you go to the movies at a movie theater?
1 Once a week or more often
2 One or two times a month
3 Once every two or three months
4 One or two times a year
5 I do not see movies at a movie theater
9 Prefer not to answer
A3. We want to ask you about some slogans or themes that might or might not have appeared in the media around here, as part of ads about tobacco.
A3_1. In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme?
Healthy Teen
1___ Yes
2___ No
3___ Not Sure
A3_2. In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme?
Rebellion
1___ Yes
2___ No
3___ Not Sure
A3_3. In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme?
Digital Youth Against Tobacco (DYAT)
1___ Yes
2___ No
3___ Not Sure
A3_4. In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme?
The Real Cost
1___ Yes
2___ No
3___ Not Sure
A3_5. In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme?
Drop the Ash
1___ Yes
2___ No
3___ Not Sure
A4. In the past [FILL MONTHS], that is since [FILL DATE], have you seen or heard of any ads on television or radio with the following themes or slogans?
[RANDOMIZE ORDER] 1 2
Yes No
1 FDA CTP CAMPAIGN: campaign name or theme 1
2 FDA CTP CAMPAIGN: campaign name or theme 2
3 FDA CTP CAMPAIGN: campaign name or theme 3
4 FDA CTP CAMPAIGN: campaign name or theme 4
5 FDA CTP CAMPAIGN: campaign name or theme 5
6 FDA CTP CAMPAIGN: campaign name or theme 6
7 Tips from Former Smokers (Tips) [INSERT PHOTO]
8 truth campaign [INSERT PHOTO]
9 pharmaceutical cessation aid advertisements [INSERT PHOTO]
10 State or local advertising advertisement 1[INSERT PHOTO]
17 State or local advertising advertisement 2[INSERT PHOTO]
[If A4=1-6 ASK A5]
A5. Where have you seen or heard about [INSERT CAMPAIGN NAME]?
1 2
Yes No
[RANDOMIZE]
A5_1. On TV
A5_2. On the radio
A5_3. In newspapers or magazines
A5_4. On the Internet
A5_5. Billboards or other outdoor ads
A6. The [INSERT CAMPAIGN NAME] is on social networking sites. Have you ever seen [INSERT CAMPAIGN NAME] on the following sites?
1 2
Yes No
A6_1. Facebook?
A6_2. Twitter?
A6_3. [INSERT SOCIAL MEDIA SITE A]
A6_4. [INSERT SOCIAL MEDIA SITE B]
A7_x. Now we would like to show you some screen shots from a television advertisement that has been shown in the U.S. Once you have viewed the images displayed below, please click on the forward arrow below to continue with the survey.
[DISPLAY STORYBOARD IMAGES FOR AD_x]
A8_x. Have you seen this ad on television in the past [FILL MONTHS], [FILL DATE]?
1 Yes
2 No
9 Prefer not to answer
[IF A8x=1, ASK A8a_x]
A8a_x. In the past [FILL MONTHS], how frequently have you seen this ad on television?
1 Rarely
2 Sometimes
3 Often
4 Very Often
9 Prefer not to answer
A9_x. Have you seen this ad online in the past [FILL MONTHS], months, since [FILL DATE]? (For example, a video ad that played before you watched the video you wanted to see online.)
1 Yes
2 No
9 Prefer not to answer
[IF A9_x = 1, ASK A9a_x]
A9a_x. In the past [FILL MONTHS], how frequently have you seen this ad online?
1 Rarely
2 Sometimes
3 Often
4 Very Often
9 Prefer not to answer
[IF A8_x or F9_x =1 OR 2, GO TO GO TO A10_x; OTHERWISE GO TO B1.]
A10_x. How would you describe this advertisement?
A10_1. |
Bad |
-3 |
-2 |
-1 |
0 |
+1 |
+2 |
+3 |
Good |
A10_2. |
Unenjoyable |
-3 |
-2 |
-1 |
0 |
+1 |
+2 |
+3 |
Enjoyable |
A11_x. Please tell us if you strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree with the following statements.
|
|
1 |
2 |
3 |
4 |
5 |
9 |
A11_1 |
This ad is worth remembering |
1 |
2 |
3 |
4 |
5 |
9 |
A11_2 |
This ad grabbed my attention |
1 |
2 |
3 |
4 |
5 |
9 |
A11_3 |
This ad is powerful |
1 |
2 |
3 |
4 |
5 |
9 |
A11_4 |
This ad is informative |
1 |
2 |
3 |
4 |
5 |
9 |
A11_5 |
This ad is meaningful to me |
1 |
2 |
3 |
4 |
5 |
9 |
A11_6 |
This ad is convincing |
1 |
2 |
3 |
4 |
5 |
9 |
A11_7 |
This ad is terrible |
1 |
2 |
3 |
4 |
5 |
9 |
A11_8 |
This ad is ridiculous |
1 |
2 |
3 |
4 |
5 |
9 |
A11_9 |
I trust the information in this ad |
1 |
2 |
3 |
4 |
5 |
9 |
A11_10 |
This ad told me things I never knew before about tobacco |
1 |
2 |
3 |
4 |
5 |
9 |
|
|
|
|
|
|
|
|
A11_12 |
The person/people in this ad are like me |
1 |
2 |
3 |
4 |
5 |
9 |
A11_13 |
This ad gave me good reasons not to use tobacco |
1 |
2 |
3 |
4 |
5 |
9 |
A12_x. On a scale of 1 to 5, indicate whether the ad made [INSERT TOBACCO PRODUCT] look like something you would or wouldn’t want to do.
1. The ad makes me want to USE [INSERT TOBACCO PRODUCT]
2
3
4
5. The ad makes me want to not USE made [INSERT TOBACCO PRODUCT]
A13_x. On scale of 1 to 5, where 1 means “not at all” and 5 means “very”, please indicate how much this ad made you feel…
1 2 3 4 5
[RANDOMIZE ORDER] Not at all Very
A13a_x. Sad
A13b_x. Afraid
A13c_x. Irritated
A13d_x. Angry
A13e_x. [INSERT EMOTION]
A14. Did you talk to anyone about any of these ads?
1 Yes
2 No
9 Prefer not to answer
[IF A14=1, ASK A15]
A15. When you talked about the ads, did you talk about any of the following topics?
1 2
Yes No
[RANDOMIZE]
A15_1. These ads were good
A15_2. These ads were NOT good
A15_3. I should not smoke
A15_4. The person I was talking to or someone else I know should not smoke
A15_5. Other, specify________________________
[REPEAT A7_x. FOR OTHER ADS]
A16. Do your parents have rules about how much time you can spend using media, such as TV, computer, video games, cell phones, and music?
1 Yes, my parents have lots of rules about it.
2 Yes, my parents have a few rules about it.
3 No, my parents don’t have any rules about it.
9 Prefer not to answer
A17. Do your parents have rules about what you are allowed to do on the computer, which video games you are allowed to play, or what music you’re allowed to listen to?
1 Yes, my parents have lots of rules about it.
2 Yes, my parents have a few rules about it.
3 No, my parents don’t have any rules about it.
9 Prefer not to answer
A18. In general, how often do your parents make sure you follow the rules they have about using media, such as TV, computers, video games, and music?
1 Most of the time
2 Some of the time
3 A little of the time
4 Never
5 My parents don’t have rules about using media
9 Prefer not to answer
A19. How often do your parents let you watch movies or videos that are rated R?
1 Never
2 Once in awhile
3 Sometimes
4 All the time
9 Prefer not to answer
Section B: Tobacco Use Behavior, Attitudes & Beliefs
Cigarette Use
B1. Have you ever tried cigarette smoking, even one or two puffs?
1 Yes
2 No
9 Prefer not to answer
[IF B1=1 or 9, GO TO B2. IF B1=2, GO TO B5]
B2. During the past 30 days, on how many days did you smoke cigarettes?
1 0 days
2 1 or 2 days
3 3 to 5 days
4 6 to 9 days
5 10 to 19 days
6 20 to 29 days
7 All 30 days
9 Prefer not to answer
[IF B2=1, GO TO B5, otherwise GO TO B3]
B3 During the past 30 days, were the cigarettes that you usually smoked menthol?
1 Yes
2 No
9 Prefer not to answer
B4. About how many cigarettes have you smoked in your entire life? Your best guess is fine.
1 0 cigarettes
2 1 or more puffs but never a whole cigarette
3 1 cigarette
4 2 to 5 cigarettes
5 6 to 15 cigarettes (about 1/2 a pack total)
6 16 to 25 cigarettes (about 1 pack total)
7 26 to 99 cigarettes (more than 1 pack, but less than 5 packs)
8 100 or more cigarettes (5 or more packs)
9 Prefer not to answer
B5. Do you consider yourself a smoker?
1 Yes
2 No
9 Prefer not to answer
[IF B2=2-9 GO TO B5; OTHERWISE GO TO B6]
B6. I plan to stop smoking cigarettes for good within the next… (PLEASE CHOOSE THE FIRST ANSWER THAT FITS)
1 7 days
2 30 days
3 6 months
4 1 year
5 I do not plan to stop smoking cigarettes within the next year
9 Prefer not to answer
Other Tobacco Use
B7. Have you ever used smokeless tobacco, such as chewing tobacco, snuff, snus (rhymes with goose) or dip, such as Copenhagen, Skoal, Grizzly, Kodiak, and Red Seal even just a small amount?
1 Yes
2 No
9 Prefer not to answer
[IF C6=1, GO TO C7; OTHERWISE GO TO C8]
B8. During the past 30 days, on how many days did you use chewing tobacco, snuff or dip?
1 0 days
2 1 or 2 days
3 3 to 5 days
4 6 to 9 days
5 10 to 19 days
6 20 to 29 days or
7 All 30 days
9 Prefer not to answer
[IF B7=2-9 GO TO B8; OTHERWISE GO TO B9]
B9. I plan to stop using smokeless tobacco such as chewing tobacco, snuff, or dip for good within the next… (PLEASE CHOOSE THE FIRST ANSWER THAT FITS)
1 7 days
2 30 days
3 6 months
4 1 year
5 I do not plan to stop using smokeless tobacco within the next year
9 Prefer not to answer
[IF B2=1 OR B7=1 GO TO B9; OTHERWISE GO TO B10]
B10. Thinking about the future…
|
|
1 |
2 |
3 |
4 |
9 |
B10_1 |
Do you think that you will try a cigarette soon? |
1 |
2 |
3 |
4 |
9 |
B10_2 |
Do you think you will smoke a cigarette at any time in the next year? |
1 |
2 |
3 |
4 |
9 |
B10_3 |
If one of your best friends were to offer you a cigarette, would you smoke it? |
1 |
2 |
3 |
4 |
9 |
B10_4 |
Do you think that you will try smokeless tobacco such as chewing tobacco, snuff or dip soon? |
1 |
2 |
3 |
4 |
9 |
B10_5 |
Do you think you will use smokeless tobacco such as chewing tobacco, snuff or dip at any time in the next year? |
1 |
2 |
3 |
4 |
9 |
B10_6 |
If one of your best friends were to offer you smokeless tobacco such as chewing tobacco, snuff or dip, would you use it? |
1 |
2 |
3 |
4 |
9 |
B11. Smoking cigarettes is…
B11_1 |
Bad |
-3 |
-2 |
-1 |
0 |
+1 |
+2 |
+3 |
Good |
B11_2 |
Unenjoyable |
-3 |
-2 |
-1 |
0 |
+1 |
+2 |
+3 |
Enjoyable |
B12. Using smokeless tobacco, such as chewing tobacco, snuff, or dip is…
B12_1 |
Bad |
-3 |
-2 |
-1 |
0 |
+1 |
+2 |
+3 |
Good |
B12_2 |
Unenjoyable |
-3 |
-2 |
-1 |
0 |
+1 |
+2 |
+3 |
Enjoyable |
B13. How much do you agree or disagree with the following statements? If I smoke I will…
|
|
1 |
2 |
3 |
4 |
5 |
9 |
B13_1. |
Damage my body |
1 |
2 |
3 |
4 |
5 |
9 |
B13_2. |
Be controlled by smoking |
1 |
2 |
3 |
4 |
5 |
9 |
B13_3. |
Be unattractive |
1 |
2 |
3 |
4 |
5 |
9 |
B13_4. |
Inhale poisons |
1 |
2 |
3 |
4 |
5 |
9 |
B13_5. |
Develop cancer of the lip, mouth, tongue or throat |
1 |
2 |
3 |
4 |
5 |
9 |
B13_6. |
Develop sexual and/or fertility problems |
1 |
2 |
3 |
4 |
5 |
9 |
B13_7. |
Lose my taste buds |
1 |
2 |
3 |
4 |
5 |
9 |
B13_8. |
Be unable to stop when I want to |
1 |
2 |
3 |
4 |
5 |
9 |
B13_9. |
Get wrinkles |
1 |
2 |
3 |
4 |
5 |
9 |
B13_10. |
Develop skin problems |
1 |
2 |
3 |
4 |
5 |
9 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
B13_11 |
Have problems with my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
B13_12. |
Lose my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
B13_13. |
Have trouble breathing |
1 |
2 |
3 |
4 |
5 |
9 |
B13_14 |
Shorten my life |
1 |
2 |
3 |
4 |
5 |
9 |
B13_15. |
Develop a smoking-related disease |
1 |
2 |
3 |
4 |
5 |
9 |
B13_16. |
Have bad breath |
1 |
2 |
3 |
4 |
5 |
9 |
B13_17 |
Get sick more often |
1 |
2 |
3 |
4 |
5 |
9 |
B13_18. |
Decrease my sports performance |
1 |
2 |
3 |
4 |
5 |
9 |
B13_19. |
End up wasting money on cigarettes |
1 |
2 |
3 |
4 |
5 |
9 |
B13_20. |
Become addicted |
1 |
2 |
3 |
4 |
5 |
9 |
B13_21. |
Harm others with second-hand smoke |
1 |
2 |
3 |
4 |
5 |
9 |
B13_22. |
Be a bad influence on others |
1 |
2 |
3 |
4 |
5 |
9 |
B14. How much do you agree or disagree with the following statements? If I use smokeless tobacco, snuff or dip, I will…
|
|
1 |
2 |
3 |
4 |
5 |
9 |
B14_1. |
Damage my body |
1 |
2 |
3 |
4 |
5 |
9 |
B14_2. |
Be controlled by smokeless tobacco |
1 |
2 |
3 |
4 |
5 |
9 |
B14_3. |
Be unattractive |
1 |
2 |
3 |
4 |
5 |
9 |
B14_4. |
Ingest poisons |
1 |
2 |
3 |
4 |
5 |
9 |
B14_5. |
Develop cancer of the lip, mouth, tongue or throat |
1 |
2 |
3 |
4 |
5 |
9 |
B14_6. |
Develop sexual and/or fertility problems |
1 |
2 |
3 |
4 |
5 |
9 |
B14_7. |
Lose my taste buds |
1 |
2 |
3 |
4 |
5 |
9 |
B14_8. |
Be unable to stop when I want to |
1 |
2 |
3 |
4 |
5 |
9 |
B14_9. |
Get wrinkles |
1 |
2 |
3 |
4 |
5 |
9 |
B14_10. |
Develop skin problems |
1 |
2 |
3 |
4 |
5 |
9 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
B14_11 |
Have problems with my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
B14_12. |
Lose my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
B14_13. |
Shorten my life |
1 |
2 |
3 |
4 |
5 |
9 |
B14_14. |
Develop a tobacco-related disease |
1 |
2 |
3 |
4 |
5 |
9 |
B14_15. |
Have bad breath |
1 |
2 |
3 |
4 |
5 |
9 |
B14_16 |
Get sick more often |
1 |
2 |
3 |
4 |
5 |
9 |
B14_17. |
Decrease my sports performance |
1 |
2 |
3 |
4 |
5 |
9 |
B14_18. |
End up wasting money on cigarettes |
1 |
2 |
3 |
4 |
5 |
9 |
B14_19. |
Become addicted |
1 |
2 |
3 |
4 |
5 |
9 |
B14_20. |
Be a bad influence on others |
1 |
2 |
3 |
4 |
5 |
9 |
B15. How much do you agree or disagree with the following statements about smoking cigarettes?
|
|
1 |
2 |
3 |
4 |
5 |
9 |
B15_1. |
Smoking can cause immediate damage to my body. |
1 |
2 |
3 |
4 |
5 |
9 |
B15_2. |
It is safe for me to smoke for only a year or two, as long as I quit after that. |
1 |
2 |
3 |
4 |
5 |
9 |
B15_3. |
If I started to smoke occasionally I would not become addicted. |
1 |
2 |
3 |
4 |
5 |
9 |
B15_4. |
Smoking cigarettes helps people relieve stress. |
1 |
2 |
3 |
4 |
5 |
9 |
B15_5. |
Cigarette ingredients are disgusting. |
1 |
2 |
3 |
4 |
5 |
9 |
B15_6. |
Cigarette ingredients are dangerous. |
1 |
2 |
3 |
4 |
5 |
9 |
B15_7. |
Smoking is a way to show others you’re not afraid to take risks |
1 |
2 |
3 |
4 |
5 |
9 |
B15_8. |
Smoking cigarettes can help keep your weight down |
1 |
2 |
3 |
4 |
5 |
9 |
B16. How much do you agree or disagree with the following statements about using smokeless tobacco such as chewing tobacco, snuff, or dip?
|
|
1 |
2 |
3 |
4 |
5 |
9 |
B16_1. |
Using smokeless tobacco can cause immediate damage to my body. |
1 |
2 |
3 |
4 |
5 |
9 |
B16_2. |
It is safe for me to use smokeless tobacco for only a year or two, as long as I quit after that. |
1 |
2 |
3 |
4 |
5 |
9 |
B16_3. |
If I started to use smokeless tobacco occasionally I would not become addicted. |
1 |
2 |
3 |
4 |
5 |
9 |
B16_4. |
Using smokeless tobacco helps people relieve stress. |
1 |
2 |
3 |
4 |
5 |
9 |
B16_5. |
Smokeless tobacco is disgusting. |
1 |
2 |
3 |
4 |
5 |
9 |
B16_6. |
Smokeless tobacco is dangerous. |
1 |
2 |
3 |
4 |
5 |
9 |
B16_7. |
Using smokeless tobacco is a way to show others you’re not afraid to take risks |
1 |
2 |
3 |
4 |
5 |
9 |
B16_8. |
Smokeless tobacco, such as chewing tobacco, snuff, or dip, is safer to use than cigarettes |
1 |
2 |
3 |
4 |
5 |
9 |
B17. Do you believe cigarette smoking is related to…
|
|
1 |
2 |
3 |
4 |
Don’t Know |
9 |
B17_1 |
Lung Cancer? |
1 |
2 |
3 |
4 |
5 |
9 |
B17_2 |
Cancer of the lip, mouth, tongue or throat? |
1 |
2 |
3 |
4 |
5 |
9 |
B17_3 |
Heart Disease? |
1 |
2 |
3 |
4 |
5 |
9 |
B17_4 |
Diabetes? |
1 |
2 |
3 |
4 |
5 |
9 |
B17_5 |
Emphysema? |
1 |
2 |
3 |
4 |
5 |
9 |
B17_6 |
Stroke? |
1 |
2 |
3 |
4 |
5 |
9 |
B17_7 |
Hole in throat (stoma or tracheotomy)? |
1 |
2 |
3 |
4 |
5 |
9 |
B17_8 |
Buerger’s Disease? |
1 |
2 |
3 |
4 |
5 |
9 |
B17_9 |
Removal of limbs (amputations)? |
1 |
2 |
3 |
4 |
5 |
9 |
B17_10 |
Asthma? |
1 |
2 |
3 |
4 |
5 |
9 |
B17_11 |
Gallstones? |
1 |
2 |
3 |
4 |
5 |
9 |
B17_12 |
COPD or chronic bronchitis? |
1 |
2 |
3 |
4 |
5 |
9 |
B18. Do you believe smokeless tobacco such as chewing tobacco, snuff, or dip is related to….
|
|
1 |
2 |
3 |
4 |
Don’t Know |
9 |
B18_1 |
Oral cancer? |
1 |
2 |
3 |
4 |
5 |
9 |
B18_2 |
Esophageal cancer? |
1 |
2 |
3 |
4 |
5 |
9 |
B18_3 |
Pancreatic cancer? |
1 |
2 |
3 |
4 |
5 |
9 |
B18_4 |
Gum disease? |
1 |
2 |
3 |
4 |
5 |
9 |
B18_5 |
Tooth loss? |
1 |
2 |
3 |
4 |
5 |
9 |
B18_6 |
Red or white patches in the mouth (such as leukoplakia)? |
1 |
2 |
3 |
4 |
5 |
9 |
B19. Does cigarette smoke contain….
|
|
1 |
2 |
3 |
4 |
Don’t Know |
9 |
B19_1 |
Ammonia, a substance found in fertilizer and household cleaners? |
1 |
2 |
3 |
4 |
5 |
9 |
B19_2 |
Arsenic, a substance found in motor oil? |
1 |
2 |
3 |
4 |
5 |
9 |
B19_3 |
Benzene, a chemical found in gasoline? |
1 |
2 |
3 |
4 |
5 |
9 |
B19_4 |
Beryllium, a substance used in nuclear weapons and nuclear power reactors? |
1 |
2 |
3 |
4 |
5 |
9 |
B19_5 |
Cadmium, a substance found in batteries? |
1 |
2 |
3 |
4 |
5 |
9 |
B19_6 |
Carbon monoxide, a substance found in car exhaust? |
1 |
2 |
3 |
4 |
5 |
9 |
B19_7 |
Formaldehyde, a chemical used to preserve things? |
1 |
2 |
3 |
4 |
5 |
9 |
B19_8 |
Hydrogen cyanide, a substance used to kill insects? |
1 |
2 |
3 |
4 |
5 |
9 |
B19_9 |
Lead, a substance found in bullets? |
1 |
2 |
3 |
4 |
5 |
9 |
B19_10 |
Naphthalene, a chemical found in mothballs? |
1 |
2 |
3 |
4 |
5 |
9 |
B19_11 |
2-Nitropropane, a substance found in paint and ink? |
1 |
2 |
3 |
4 |
5 |
9 |
B19_12 |
Polonium 210, a poison? |
1 |
2 |
3 |
4 |
5 |
9 |
B19_13 |
Uranium, a substance used in nuclear weapons and nuclear power reactors? |
1 |
2 |
3 |
4 |
5 |
9 |
B20. Does smokeless tobacco such as chewing tobacco, snuff, or dip contain….
|
|
1 |
2 |
3 |
4 |
Don’t Know |
9 |
B20_1 |
Ammonia, a substance found in fertilizer and household cleaners? |
1 |
2 |
3 |
4 |
5 |
9 |
B21_2 |
Arsenic, a substance found in motor oil? |
1 |
2 |
3 |
4 |
5 |
9 |
B20_3 |
Beryllium, a substance used in nuclear weapons and nuclear power reactors? |
1 |
2 |
3 |
4 |
5 |
9 |
B20_4 |
Cadmium, a substance found in batteries? |
1 |
2 |
3 |
4 |
5 |
9 |
B20_5 |
Formaldehyde, a chemical used to preserve things? |
1 |
2 |
3 |
4 |
5 |
9 |
B20_6 |
Lead, a substance found in bullets? |
1 |
2 |
3 |
4 |
5 |
9 |
B20_7 |
Naphthalene, a chemical found in mothballs? |
1 |
2 |
3 |
4 |
5 |
9 |
B20_8 |
Polonium 210, a poison? |
1 |
2 |
3 |
4 |
5 |
9 |
BA3 20_9 |
Uranium, a substance used in nuclear weapons and nuclear power reactors? |
1 |
2 |
3 |
4 |
5 |
9 |
B21. How many of your four closest friends…
|
|
0 |
1 |
2 |
3 |
4 |
9 |
B21_1. |
Smoke cigarettes? |
0 |
1 |
2 |
3 |
4 |
9 |
B21_2. |
Use smokeless tobacco, such as chewing tobacco, snuff or dip? |
0 |
1 |
2 |
3 |
4 |
9 |
Section C: Demographic Items
C1. Are you male or female?
1 Female
2 Male
9 Prefer not to answer
C2. Are you Hispanic, Latino/a, or of Spanish origin?
1 No, not of Hispanic, Latino/a, or Spanish origin
2 Yes, Mexican American, Chicano/a
3 Yes, Puerto Rican
4 Yes, Cuban
5 Yes, another Hispanic, Latino/a, or Spanish origin
9 Prefer not to answer
C3. What race or races do you consider yourself to be? Please select 1 or more of these categories.
|
1 |
|
|
C3_1. White |
1 |
|
|
C3_2. Black or African American |
1 |
|
|
C3_3. American Indian or Alaska Native |
1 |
|
|
C3_4. Asian Indian |
1 |
|
|
C3_5. Chinese |
1 |
|
|
C3_6. Filipino |
1 |
|
|
C3_7. Japanese |
1 |
|
|
C3_8. Korean |
1 |
|
|
C3_9. Vietnamese |
1 |
|
|
C3_10. Native Hawaiian |
1 |
|
|
C3_11. Guamanian or Chamorro |
1 |
|
|
C3_12. Samoan |
1 |
|
|
C3_13. Other Asian |
1 |
|
|
C3_14. Other Pacific Islander |
1 |
|
|
|
|
|
|
[IF C2=2-9, GO TO C4, OTHERWISE GO TO C6]
C4. How much do you watch Spanish and English television? Would you say…
1 Only Spanish
2 Spanish more than English
3 Spanish and English equally
4 English more than Spanish
5 English only
9 Prefer not to answer
C5. During the past 30 days, about how much money did you have each week to spend any way you wanted to?
1 None
2 Less than $5
3 $6 to $10
4 $11 to $20
5 $21 to $35
6 $36 to $50
7 $51 to $75
8 $76 to $125
9 $126 or more
99 Prefer not to answer
C6. How often do your parents let you watch movies or videos that are rated R?
1 Never
2 Once in awhile
3 Sometimes
4 All the time
9 Prefer not to answer
C7. Other than you, has anyone who lives with you used any of the following during the past 30 days…? (You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
1 cigarettes
2 smokeless tobacco, such as chewing tobacco, snuff, snus (rhymes with goose) or dip, such as Copenhagen, Skoal, Grizzly, Kodiak, and Red Seal
3 cigars, cigarillos, or little cigars such as Swisher Sweets, Black & Mild, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s
4 tobacco out of a water pipe (also called “hookah”)
5 electronic cigarettes, such as blu, NJOY, Mistic, 21st Century Smoke
6 any other form of tobacco
7 No, no one who lives with me has used any form of tobacco during the past 30 days
9 Prefer not to answer
C8. Do you have any brother(s) and/or sister(s) who have smoked cigarettes during the past 30 days?
1 Yes
2 No
3 I don’t know
4 I don’t have any brothers or sisters
9 Prefer not to answer
Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statements.
C9. I would like to explore strange places. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree (neutral)
4 Agree
5 Strongly Agree
9 Prefer not to answer
C10. I like to do frightening things. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree (neutral)
4 Agree
5 Strongly Agree
9 Prefer not to answer
C11. I like new and exciting experiences, even if I have to break the rules. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree (neutral)
4 Agree
5 Strongly Agree
9 Prefer not to answer
C12. I prefer friends who are exciting and unpredictable. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree (neutral)
4 Agree
5 Strongly Agree
9 Prefer not to answer
C13. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
_____ Number of days
2 None
3 Don’t know
9 Prefer not to answer
Thank you for taking time to complete this survey.
OMB No: 0910-xxxx Expiration Date: xx/xx/xxxx
Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 52 minutes per response. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to PRAStaff@fda.hhs.gov
| File Type | application/msword |
| File Modified | 2013-10-29 |
| File Created | 2013-10-28 |