OMB
No. XXXX-xxxx
Exp. Date xx/xx/xxxx
Evaluation of the Public Education Campaign on Teen Tobacco (ExPECTT-B)
Subjects
for Questionnaire:
Section
A: Demographic Items
Section B: Tobacco Use Behavior
Section
C: Tobacco Use Intentions and Self-Efficacy
Section D: Cessation
(Intention, Behavior, Motivation)
Section E: Attitudes, Beliefs
& Risk Perceptions, Social Norm
Section F: Media Use and
Awareness
Section G: Environment
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.
Section A: Demographic Items
The first part of the survey asks you some general questions about yourself.
A1. How old are you?
1 11 years old
2 12 years old
3 13 years old
4 14 years old
5 15 years old
6 16 years old
7 17 years old
8 18 years old or older
9 Prefer not to answer
A2. Are you male or female?
1 Female
2 Male
9 Prefer not to answer
A3. 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
A4. What race or races do you consider yourself to be? Please select 1 or more of these categories.
|
1 |
|
|
A4_1. White |
1 |
|
|
A4_2. Black or African American |
1 |
|
|
A4_3. American Indian or Alaska Native |
1 |
|
|
A4_4. Asian Indian |
1 |
|
|
A4_5. Chinese |
1 |
|
|
A4_6. Filipino |
1 |
|
|
A4_7. Japanese |
1 |
|
|
A4_8. Korean |
1 |
|
|
A4_9. Vietnamese |
1 |
|
|
A4_10. Native Hawaiian |
1 |
|
|
A4_11. Guamanian or Chamorro |
1 |
|
|
A4_12. Samoan |
1 |
|
|
A4_13. Other Asian |
1 |
|
|
A4_14. Other Pacific Islander |
1 |
|
|
|
|
|
|
[IF A3=2-9, ASK A5, otherwise go to A7]
A5. In general, do you usually speak…
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
[IF A5=1-4, ASK A6, otherwise go to A7]
A6. When you watch TV, what type of programming do you usually watch?
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
A7. What grade are you in? If school has not started for you, what grade are you going into?
1 5th
2 6th
3 7th
4 8th
5 9th
6 10th
7 11th
8 12th
9 Ungraded or other grade
99 Prefer not to answer
A8. During the past 30 days, about how much money did you have each week to spend any way you wanted to?
1 None
2 $5 or less
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
Section B: Tobacco Use Behavior
The next section asks about your experiences with tobacco products.
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, ASK B2. IF B1=2, ASK B9]
B2. How old were you when you first tried cigarette smoking, even one or two puffs?
1 8 years old or younger
2 9 years old
3 10 years old
4 11 years old
5 12 years old
6 13 years old
7 14 years old
8 15 years old
9 16 years old
99 Prefer not to answer
B3. 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 B3=1, ASK B6, otherwise ask B4]
B4. During the past 30 days, were the cigarettes that you usually smoked menthol?
1 Yes
2 No
9 Prefer not to answer
B5. During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?
1 Less than 1 cigarette per day
2 1 cigarette per day
3 2 to 5 cigarettes per day
4 6 to 10 cigarettes per day
5 11 to 20 cigarettes per day
6 More than 20 cigarettes per day
9 Prefer not to answer
B6. 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
B7. Do you smoke:
1 Only when you are alone
2 Mainly when you are alone
3 As often alone as with others
4 Mainly when you are with others
5 Only when you are with others
9 Prefer not to answer
B8. Do you consider yourself a smoker?
1 Yes
2 No
9 Prefer not to answer
Other Substance Use
B9. 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 B9=1, ASK B10]
B10. During the past 30 days, on how many days did you use chewing tobacco, snuff, snus 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
B11. Have you ever smoked cigars, cigarillos, or little cigars such as Swisher Sweets, Black & Mild, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s, even one time?
1 Yes
2 No
9 Prefer not to answer
[IF B11=1, ASK B12]
B12. During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?
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
B13. Have you ever tried smoking tobacco out of a water pipe (also called “hookah”), even one time?
1 Yes
2 No
9 Prefer not to answer
[IF B13=1, ASK B14]
B14. During the past 30 days, on how many days did you smoke tobacco out of a water pipe (also called “hookah”)?
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
B15. Have you ever tried electronic cigarettes, such as blu, NJOY, Mistic, 21st Century Smoke, even one time?
1 Yes
2 No
9 Prefer not to answer
[IF B15=1, ASK B16]
B16. During the past 30 days, on how many days did you use electronic 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 or
7 All 30 days
9 Prefer not to answer
B17. Have you ever tried marijuana, even one time?
1 Yes
2 No
9 Prefer not to answer
[IF B17=1, ASK B18]
B18. During the past 30 days, on how many days did you use marijuana?
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
B19. During the past 30 days, on how many days did you add marijuana to a tobacco product, such as a cigar (sometimes known as a “blunt”)?
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
Section C: Tobacco Use Intentions and Self-Efficacy
C1. Thinking about the future…
|
|
1 |
2 |
3 |
4 |
9 |
C1_1. |
Do you think that you will try a cigarette soon? |
1 |
2 |
3 |
4 |
9 |
C1_2 |
Do you think you will smoke a cigarette at any time in the next year? |
1 |
2 |
3 |
4 |
9 |
C1_3 |
Do you think you will be smoking cigarettes every day one year from now? |
1 |
2 |
3 |
4 |
9 |
C1_4 |
Do you think you will be smoking cigarettes, but not every day, one year from now? |
1 |
2 |
3 |
4 |
9 |
C1_5 |
If one of your best friends were to offer you a cigarette, would you smoke it? |
1 |
2 |
3 |
4 |
9 |
C1_6 |
Do you think that you will try smokeless tobacco such as chewing tobacco, snuff, snus or dip soon? |
1 |
2 |
3 |
4 |
9 |
C1_7 |
Do you think you will use smokeless tobacco such as chewing tobacco, snuff, snus or dip at any time in the next year? |
1 |
2 |
3 |
4 |
9 |
C1_8 |
If one of your best friends were to offer you smokeless tobacco such as chewing tobacco, snuff, snus or dip, would you use it? |
1 |
2 |
3 |
4 |
9 |
C1_9 |
Do you think you will try cigars, cigarillos, or little cigars such as Swisher Sweets, Black & Mild, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s soon? |
1 |
2 |
3 |
4 |
9 |
C1_10 |
Do you think you will try cigars, cigarillos, or little cigars such as Swisher Sweets, Black & Mild, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s at any time in the next year? |
1 |
2 |
3 |
4 |
9 |
C1_11 |
If one of your best friends were to offer you a cigar, cigarillo, or little cigar, would you smoke it? |
1 |
2 |
3 |
4 |
9 |
C2. How sure are you that, if you really wanted to, you could say no to a cigarette offer if…
[RANDOMIZE C6_1-C6_3]
|
1 |
2 |
3 |
4 |
5 |
9 |
C2_1. You are at a party where most people are smoking? |
1 |
2 |
3 |
4 |
5 |
9 |
C2_2. A very close friend offers it? |
1 |
2 |
3 |
4 |
5 |
9 |
C2_3. Someone you know offers it? |
1 |
2 |
3 |
4 |
5 |
9 |
C3. How sure are you that, if you really wanted to, you could say no to a smokeless tobacco offer, such as chewing tobacco, snuff, snus or dip if…
[RANDOMIZE C3_1-C3_3]
|
1 |
2 |
3 |
4 |
5 |
9 |
C3_1. You are at a party where most people are using it? |
1 |
2 |
3 |
4 |
5 |
9 |
C3_2. A very close friend offers it? |
1 |
2 |
3 |
4 |
5 |
9 |
C3_3. Someone you know offers it? |
1 |
2 |
3 |
4 |
5 |
9 |
Section D: Cessation (Intention, Behavior, Motivation)
Cigarette Use [Ask if B3=2-9]
D1. 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
D2. During the past 3 months, did you stop smoking cigarettes for one day or longer because you were trying to quit smoking cigarettes for good?
1 Yes
2 No
9 Prefer not to answer
D3. How much do you want to quit smoking?
1 Not at all
2 A little
3 Somewhat
4 A lot
9 Prefer not to answer
Other Tobacco Use [Ask if B10=2-9]
D4. 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
D5. During the past 3 months, did you stop using smokeless tobacco such as chewing tobacco, snuff or dip for one day or longer because you were trying to quit using smokeless tobacco for good?
1 Yes
2 No
9 Prefer not to answer
D6. How much do you want to stop using smokeless tobacco such as chewing tobacco, snuff or dip?
1 Not at all
2 A little
3 Somewhat
4 A lot
9 Prefer not to answer
Section E: Attitudes, Beliefs & Risk Perceptions, Social Norm
[Ask ALL] The next set of questions asks for your opinions on cigarette use and other tobacco products.
Attitude
E1. Smoking cigarettes is… (pick one)
[RANDOMIZE E1_1-E1_4]
E1_1. |
Bad |
|
|
|
|
|
|
|
Good |
E1_2. |
Unenjoyable |
|
|
|
|
|
|
|
Enjoyable |
E2. Using smokeless tobacco, such as chewing tobacco, snuff, or dip is… (pick one)
[RANDOMIZE E2_1-E2_4]
E2_1. |
Bad |
|
|
|
|
|
|
|
Good |
E2_2. |
Unenjoyable |
|
|
|
|
|
|
|
Enjoyable |
Attitudinal Beliefs and Risk Perceptions
E3. How much do you agree or disagree with the following statements? If I smoke I will…
|
If I smoke I will… |
1 |
2 |
3 |
4 |
5 |
9 |
E3_1. |
Damage my body |
1 |
2 |
3 |
4 |
5 |
9 |
E3_2. |
Be controlled by smoking |
1 |
2 |
3 |
4 |
5 |
9 |
E3_3. |
Be unattractive |
1 |
2 |
3 |
4 |
5 |
9 |
E3_4. |
Inhale poisons |
1 |
2 |
3 |
4 |
5 |
9 |
E3_5. |
Develop cancer of the lip, mouth, tongue or throat |
1 |
2 |
3 |
4 |
5 |
9 |
E3_6. |
Develop sexual and/or fertility problems |
1 |
2 |
3 |
4 |
5 |
9 |
E3_7. |
Lose my taste buds |
1 |
2 |
3 |
4 |
5 |
9 |
E3_8. |
Be unable to stop when I want to |
1 |
2 |
3 |
4 |
5 |
9 |
E3_9. |
Get wrinkles |
1 |
2 |
3 |
4 |
5 |
9 |
E3_10. |
Develop skin problems |
1 |
2 |
3 |
4 |
5 |
9 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
E3_11 |
Have problems with my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E3_12. |
Lose my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E3_13. |
Have trouble breathing |
1 |
2 |
3 |
4 |
5 |
9 |
E3_14 |
Shorten my life |
1 |
2 |
3 |
4 |
5 |
9 |
E3_15. |
Develop a smoking-related disease |
1 |
2 |
3 |
4 |
5 |
9 |
E3_16. |
Have bad breath |
1 |
2 |
3 |
4 |
5 |
9 |
E3_17 |
Get sick more often |
1 |
2 |
3 |
4 |
5 |
9 |
E3_18. |
Decrease my sports performance |
1 |
2 |
3 |
4 |
5 |
9 |
E3_19. |
End up wasting money on cigarettes |
1 |
2 |
3 |
4 |
5 |
9 |
E3_20. |
Become addicted |
1 |
2 |
3 |
4 |
5 |
9 |
E3_21. |
Harm others with second-hand smoke |
1 |
2 |
3 |
4 |
5 |
9 |
E3_22. |
Be a bad influence on others |
1 |
2 |
3 |
4 |
5 |
9 |
E4. 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 |
E4_1. |
Damage my body |
1 |
2 |
3 |
4 |
5 |
9 |
E4_2. |
Be controlled by smokeless tobacco |
1 |
2 |
3 |
4 |
5 |
9 |
E4_3. |
Be unattractive |
1 |
2 |
3 |
4 |
5 |
9 |
E4_4. |
Ingest poisons |
1 |
2 |
3 |
4 |
5 |
9 |
E4_5. |
Develop cancer of the lip, mouth, tongue or throat |
1 |
2 |
3 |
4 |
5 |
9 |
E4_6. |
Develop sexual and/or fertility problems |
1 |
2 |
3 |
4 |
5 |
9 |
E4_7. |
Lose my taste buds |
1 |
2 |
3 |
4 |
5 |
9 |
E4_8. |
Be unable to stop when I want to |
1 |
2 |
3 |
4 |
5 |
9 |
E4_9. |
Get wrinkles |
1 |
2 |
3 |
4 |
5 |
9 |
E4_10. |
Develop skin problems |
1 |
2 |
3 |
4 |
5 |
9 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
E4_11 |
Have problems with my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E4_12. |
Lose my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E4_13 . |
Shorten my life |
1 |
2 |
3 |
4 |
5 |
9 |
E4_14. |
Develop a tobacco-related disease |
1 |
2 |
3 |
4 |
5 |
9 |
E4_15. |
Have bad breath |
1 |
2 |
3 |
4 |
5 |
9 |
E4_16 |
Get sick more often |
1 |
2 |
3 |
4 |
5 |
9 |
E4_17. |
Decrease my sports performance |
1 |
2 |
3 |
4 |
5 |
9 |
E4_18. |
End up wasting money on cigarettes |
1 |
2 |
3 |
4 |
5 |
9 |
E4_19. |
Become addicted |
1 |
2 |
3 |
4 |
5 |
9 |
E4_20. |
Be a bad influence on others |
1 |
2 |
3 |
4 |
5 |
9 |
E5. How much do you agree or disagree with the following statements about smoking cigarettes?
|
|
1 |
2 |
3 |
4 |
5 |
9 |
E5_1. |
Smoking can cause immediate damage to my body. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_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 |
E5_3. |
If I started to smoke occasionally I would not become addicted. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_4. |
Smoking cigarettes helps people relieve stress. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_5. |
Cigarette ingredients are disgusting. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_6. |
Cigarette ingredients are dangerous. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_7. |
Smoking is a way to show others you’re not afraid to take risks |
1 |
2 |
3 |
4 |
5 |
9 |
E5_8. |
Smoking cigarettes can help keep your weight down |
1 |
2 |
3 |
4 |
5 |
9 |
E6. 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 |
E6_1. |
Using smokeless tobacco can cause immediate damage to my body. |
1 |
2 |
3 |
4 |
5 |
9 |
E6_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 |
E6_3. |
If I started to use smokeless tobacco occasionally I would not become addicted. |
1 |
2 |
3 |
4 |
5 |
9 |
E6_4. |
Using smokeless tobacco helps people relieve stress. |
1 |
2 |
3 |
4 |
5 |
9 |
E6_5. |
Smokeless tobacco is disgusting. |
1 |
2 |
3 |
4 |
5 |
9 |
E6_6. |
Smokeless tobacco is dangerous. |
1 |
2 |
3 |
4 |
5 |
9 |
E6_7. |
Using smokeless tobacco is a way to show others you’re not afraid to take risks |
1 |
2 |
3 |
4 |
5 |
9 |
E6_8. |
Smokeless tobacco, such as chewing tobacco, snuff, or dip, is safer to use than cigarettes |
1 |
2 |
3 |
4 |
5 |
9 |
E7. Do you believe cigarette smoking is related to…
|
|
1 |
2 |
3 |
4 |
Don’t Know |
9 |
E7_1 |
Lung Cancer? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_2 |
Cancer of the lip, mouth, tongue or throat? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_3 |
Heart Disease? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_4 |
Diabetes? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_5 |
Emphysema? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_6 |
Stroke? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_7 |
Hole in throat (stoma or tracheotomy)? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_8 |
Buerger’s Disease? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_9 |
Removal of limbs (amputations)? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_10 |
Asthma? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_11 |
Gallstones? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_12 |
COPD or chronic bronchitis |
1 |
2 |
3 |
4 |
5 |
9 |
E8. Do you believe smokeless tobacco such as chewing tobacco, snuff, or dip is related to….
|
|
1 |
2 |
3 |
4 |
Don’t Know |
9 |
E8_1 |
Oral cancer? |
1 |
2 |
3 |
4 |
5 |
9 |
E8_2 |
Esophageal cancer? |
1 |
2 |
3 |
4 |
5 |
9 |
E8_3 |
Pancreatic cancer? |
1 |
2 |
3 |
4 |
5 |
9 |
E8_4 |
Gum disease? |
1 |
2 |
3 |
4 |
5 |
9 |
E8_5 |
Tooth loss? |
1 |
2 |
3 |
4 |
5 |
9 |
E8_6 |
Red or white patches in the mouth (such as leukoplakia)? |
1 |
2 |
3 |
4 |
5 |
9 |
E9. Does cigarette smoke contain….
|
|
1 |
2 |
3 |
4 |
Don’t Know |
9 |
E9_1 |
Ammonia, a substance found in fertilizer and household cleaners? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_2 |
Arsenic, a substance found in motor oil? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_3 |
Benzene, a chemical found in gasoline? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_4 |
Beryllium, a substance used in nuclear weapons and nuclear power reactors? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_5 |
Cadmium, a substance found in batteries? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_6 |
Carbon monoxide, a substance found in car exhaust? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_7 |
Formaldehyde, a chemical used to preserve dead animals? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_8 |
Hydrogen cyanide, a substance used to kill insects? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_9 |
Lead, a substance found in bullets? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_10 |
Naphthalene, a chemical found in mothballs? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_11 |
2-Nitropropane, a substance found in paint and ink? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_12 |
Polonium 210, a poison? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_13 |
Uranium, a substance used in nuclear weapons and nuclear power reactors? |
1 |
2 |
3 |
4 |
5 |
9 |
E10. Does smokeless tobacco such as chewing tobacco, snuff, or dip contain….
|
|
1 |
2 |
3 |
4 |
Don’t Know |
9 |
E10_1 |
Ammonia, a substance found in fertilizer and household cleaners? |
1 |
2 |
3 |
4 |
5 |
9 |
E10_2 |
Arsenic, a substance found in motor oil? |
1 |
2 |
3 |
4 |
5 |
9 |
E10_3 |
Beryllium, a substance used in nuclear weapons and nuclear power reactors? |
1 |
2 |
3 |
4 |
5 |
9 |
E10_4 |
Cadmium, a substance found in batteries? |
1 |
2 |
3 |
4 |
5 |
9 |
E10_5 |
Formaldehyde, a chemical used to preserve dead animals? |
1 |
2 |
3 |
4 |
5 |
9 |
E10_6 |
Lead, a substance found in bullets? |
1 |
2 |
3 |
4 |
5 |
9 |
E10_7 |
Naphthalene, a chemical found in mothballs? |
1 |
2 |
3 |
4 |
5 |
9 |
E10_8 |
Polonium 210, a poison? |
1 |
2 |
3 |
4 |
5 |
9 |
E10_9 |
Uranium, a substance used in nuclear weapons and nuclear power reactors? |
1 |
2 |
3 |
4 |
5 |
9 |
Social Norms
E11. How many of your four closest friends…
|
|
0 |
1 |
2 |
3 |
4 |
9 |
E11_1. |
Smoke cigarettes? |
0 |
1 |
2 |
3 |
4 |
9 |
E11_2. |
Smoke menthol cigarettes? |
0 |
1 |
2 |
3 |
4 |
9 |
E11_3. |
Use smokeless tobacco, such as chewing tobacco, snuff, snus or dip? |
0 |
1 |
2 |
3 |
4 |
9 |
E12. How many others your age…
|
|
0 |
1 |
2 |
3 |
4 |
9 |
E12_1. |
Smoke cigarettes every day? |
0 |
1 |
2 |
3 |
4 |
9 |
E12_2. |
Smoke menthol cigarettes every day?? |
0 |
1 |
2 |
3 |
4 |
9 |
E12_3. |
Use smokeless tobacco, such as chewing tobacco, snuff, or dip every day? |
|
|
|
|
|
|
E12_4. |
Smoke cigarettes, but not every day? |
0 |
1 |
2 |
3 |
4 |
9 |
E12_5. |
Smoke menthol cigarettes, but not every day?? |
0 |
1 |
2 |
3 |
4 |
9 |
E12_6. |
Use smokeless tobacco, such as chewing tobacco, snuff, or dip, but not every day? |
0 |
1 |
2 |
3 |
4 |
9 |
Section F: Media Use and Awareness
Next, we’d like to ask you about your use of TV and other media.
F1. 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 |
|
|
F1_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 |
F1_2. A computer, laptop, or tablet? Include streaming video like Netflix, DVDs, Hulu, etc.? |
1 |
2 |
3 |
4 |
5 |
9 |
F1_3. A cell phone/smartphone? |
1 |
2 |
3 |
4 |
5 |
9 |
F1_4. An iPod or other MP3 player? |
1 |
2 |
3 |
4 |
5 |
9 |
F2. 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 |
|
|
|
|
|
|
F2_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 |
|
|
|
|
|
|
F2_2. Watching or uploading videos such as YouTube on a computer, laptop, or tablet |
1 |
2 |
3 |
4 |
5 |
9 |
F2_3. Using social networking sites like Facebook or twitter on a computer, laptop, or tablet |
1 |
2 |
3 |
4 |
5 |
9 |
F2_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 |
F2_5. Instant messaging or Video chatting (on Skype, Googletalk, iChat, etc.) on a computer, laptop, or tablet |
1 |
2 |
3 |
4 |
5 |
9 |
|
|
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 |
|
|
Using a Cell Phone/Smartphone |
|
|
|
|
|
|
F2_6. Text messaging on a cell phone/smartphone |
1 |
2 |
3 |
4 |
5 |
9 |
F2_7. Watching or uploading videos such as YouTube on a cell phone/smartphone |
1 |
2 |
3 |
4 |
5 |
9 |
F2_8. Going to social networking sites like Facebook or twitter on a cell phone/smartphone |
1 |
2 |
3 |
4 |
5 |
9 |
F2_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 |
|
|
|
|
|
|
F2_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 |
F2_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 |
F2_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 |
F2_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
F3. 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.
F3_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
F3_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
F3_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
F3_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
F3_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
F4. 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 F4=1-6 ASK F5]
F5. Where have you seen or heard about [INSERT CAMPAIGN NAME]?
1 2
Yes No
[RANDOMIZE]
F5_1. On TV
F5_2. On the radio
F5_3. In newspapers or magazines
F5_4. On the Internet
F5_5. Billboards or other outdoor ads
F6. The [INSERT CAMPAIGN NAME] is on social networking sites. Have you ever seen [INSERT CAMPAIGN NAME] on the following sites?
1 2
Yes No
F6_1. Facebook?
F6_2. Twitter?
F6_3. [INSERT SOCIAL MEDIA SITE A]
F6_4. [INSERT SOCIAL MEDIA SITE B]
F7_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]
F8_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 F8x=1, ASK F8a_x]
F8a_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
F9_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 F9_x = 1, ASK F9a_x]
F9a_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 F8_x or F9_x =1 OR 2, GO TO GO TO F10_x; OTHERWISE GO TO G1.]
F10_x. How would you describe this advertisement?
F10_1. |
Bad |
-3 |
-2 |
-1 |
0 |
+1 |
+2 |
+3 |
Good |
F10_2. |
Unenjoyable |
-3 |
-2 |
-1 |
0 |
+1 |
+2 |
+3 |
Enjoyable |
F11_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 |
F11_1. |
This ad is worth remembering |
1 |
2 |
3 |
4 |
5 |
9 |
F11_2. |
This ad grabbed my attention |
1 |
2 |
3 |
4 |
5 |
9 |
F11_3. |
This ad is powerful |
1 |
2 |
3 |
4 |
5 |
9 |
F11_4. |
This ad is informative |
1 |
2 |
3 |
4 |
5 |
9 |
F11_5. |
This ad is meaningful to me |
1 |
2 |
3 |
4 |
5 |
9 |
F11_6. |
This ad is convincing |
1 |
2 |
3 |
4 |
5 |
9 |
F11_7. |
This ad is terrible |
1 |
2 |
3 |
4 |
5 |
9 |
F11_8. |
This ad is ridiculous |
1 |
2 |
3 |
4 |
5 |
9 |
F11_9. |
I trust the information in this ad |
1 |
2 |
3 |
4 |
5 |
9 |
F11_10. |
This ad told me things I never knew before about tobacco |
1 |
2 |
3 |
4 |
5 |
9 |
|
|
|
|
|
|
|
|
F11_11. |
The person/people in this ad are like me |
1 |
2 |
3 |
4 |
5 |
9 |
F11_12. |
This ad gave me good reasons not to use tobacco |
1 |
2 |
3 |
4 |
5 |
9 |
F12_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]
F13_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
F13a_x. Sad
F13b_x. Afraid
F13c_x. Irritated
F13d_x. Angry
F13e_x. [INSERT EMOTION]
[REPEAT F7_x - F13x FOR OTHER ADS]
F14. Did you talk to anyone about any of these ads?
1 Yes
2 No
9 Prefer not to answer
[IF F14=1, ASK F15]
F15. When you talked about the ads, did you talk about any of the following topics?
1 2
Yes No
[RANDOMIZE]
F15_1. These ads were good
F15_2. These ads were NOT good
F15_3. I should not smoke
F15_4. The person I was talking to or someone else I know should not smoke
F15_5. Other, specify________________________
F16. 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
F17. 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
F18. 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
F19. 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 G: Environment
The next section asks some questions about your household and peers.
G1. 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
G2. 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
G3. Which statement best describes the rules about smoking in your home? Would you say…
1 Smoking is not allowed anywhere inside your home
2 Smoking is allowed in some places or at some times
3 Smoking is allowed anywhere inside the home
4 There are no rules about smoking inside the home
9 Prefer not to answer
G4. How well would you say you have done in school? Would you say…
1 Much better than average
2 Better than average
3 Average
4 Below average
5 Much worse than average
9 Prefer not to answer
G5. I feel close to people at my school. 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
G6. I am happy to be at my school. 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
G7. I feel like I am a part of my school. 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
G8. How far do you think you will go in school?
1 I don’t plan to go to school anymore
2 9th grade
3 10th grade
4 11th grade
5 12th grade or GED
6 Some college or technical school but no degree
7 Technical school degree
8 College degree
9 Graduate school, medical school, or law school
99 Prefer not to answer
G9. How many close friends do you have? (Close friends include people whom you feel at ease with, can talk to about private matters, and can call on for help.)
__________ MIN 0 MAX 7
9 Prefer not to answer
G10. How often do you attend church or religious services? Would you say…
1 Never
2 Less than once a month
3 About once a month
4 About 2 or 3 times a month
5 Once a week
6 More than once a week
9 Prefer not to answer
Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statements.
G11. 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
G12. 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
G13. 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
G14. 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
G15. 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
These next questions ask about how you feel about your current relationship with your parents or guardians. Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statement.
G16. Thinking about the adult or adults you live withwould you say you are satisfied with the way you communicate with each other.
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree (neutral)
4 Agree
5 Strongly Agree
9 Prefer not to answer
G17. How close do you feel to the adult or adults you live with?
1 Not at all close
2 Not very close
3 Somewhat close
4 Quite close
5 Very close
9 Prefer not to answer
G18. How often has a parent or other adult caregiver said things that really hurt your feelings or made you feel like you were not wanted or loved?
1 One time
2 Two times
3 Three to five times
4 Six to ten times
5 More than ten times
6 This has never happened
7 Don’t know
9 Prefer not to answer
G19. Has a parent or other adult caregiver ever talked to you about reasons for not smoking cigarettes or using other types of tobacco like cigars and chewing tobacco?
1 Yes
2 No
9 Prefer not to answer
G20. During the past 7 days, on how many days did you and one or both of your parents or other adult caregivers do something together just for fun?
__________ MIN 0 MAX 7
9 Prefer not to answer
Thank you for taking time to complete this survey.
Form
Approved
OMB No. XXXX-xxxx
Exp. Date xx/xx/xxxx
Evaluation of the Public Education Campaign on Teen Tobacco-First Follow-up (ExPECTT-1)
Subjects
for Questionnaire:
Section
B: Tobacco Use Behavior
Section C: Tobacco Use Intentions and
Self-Efficacy
Section D: Cessation (Intention, Behavior,
Motivation)
Section E: Attitudes, Beliefs & Risk
Perceptions, Social Norm
Section F:Media Use and
Awareness
Section G: Environment
Introduction
Thank you for agreeing to take part in this survey. The survey will take approximately 45 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.
Section B: Tobacco Use Behavior
[IF ON THE YOUTH BASELINE SURVEY B1=2 or 9 (never smokers), ASK B1; IF ON THE YOUTH BASELINE SURVEY B1=1 (smokers) ASK B3]
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, ASK B2. IF B1=2, ASK B9]
B2. How old were you when you first tried cigarette smoking, even one or two puffs?
1 8 years old or younger
2 9 years old
3 10 years old
4 11 years old
5 12 years old
6 13 years old
7 14 years old
8 15 years old
9 16 years old
99 Prefer not to answer
B3. 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 B3=1, ASK B6, otherwise ask B4]
B4. During the past 30 days, were the cigarettes that you usually smoked menthol?
1 Yes
2 No
9 Prefer not to answer
B5. During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?
1 Less than 1 cigarette per day
2 1 cigarette per day
3 2 to 5 cigarettes per day
4 6 to 10 cigarettes per day
5 11 to 20 cigarettes per day
6 More than 20 cigarettes per day
9 Prefer not to answer
B6. Do you consider yourself a smoker?
1 Yes
2 No
9 Prefer not to answer
Other Tobacco Use
[IF ON THE YOUTH BASELINE SURVEY B9=2 or 9 (never users), ASK B7; IF ON THE YOUTH BASELINE SURVEY B9=1 (tobacco users) ASK B8]
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 B7=1, ASK B8]
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 ON THE YOUTH BASELINE SURVEY B11=2 or 9 (never users), ASK B9; IF ON THE YOUTH BASELINE SURVEY B11=1 (tobacco users) ASK B10]
B9. Have you ever smoked cigars, cigarillos, or little cigars such as Swisher Sweets, Black & Mild, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s, even one time?1 Yes
2 No
9 Prefer not to answer
[IF B9=1, ASK B10]
B10. During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?
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 ON THE YOUTH BASELINE SURVEY B13=2 or 9 (never users), ASK B11; IF ON THE YOUTH BASELINE SURVEY B13=1 (tobacco users) ASK B12]
B11. Have you ever tried smoking tobacco out of a water pipe (also called “hookah”), even one time?
1 Yes
2 No
9 Prefer not to answer
[IF B11=1, ASK B12]
B12. During the past 30 days, on how many days did you smoke tobacco out of a water pipe (also called “hookah”)?
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 ON THE YOUTH BASELINE SURVEY B13=2 or 9 (never users), ASK B13; IF ON THE YOUTH BASELINE SURVEY B13=1 (tobacco users) ASK B14]
B13. Have you ever tried smoking tobacco out of a water pipe (also called “hookah”), even one time?
1 Yes
2 No
9 Prefer not to answer
[IF B13=1, ASK B14]
B14. During the past 30 days, on how many days did you smoke tobacco out of a water pipe (also called “hookah”)?
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 ON THE YOUTH BASELINE SURVEY B15=2 or 9 (never users), ASK B15; IF ON THE YOUTH BASELINE SURVEY B15=1 (tobacco users) ASK B16]
B15. Have you ever tried electronic cigarettes, such as blu, NJOY, Mistic, 21st Century Smoke, even one time?
1 Yes
2 No
9 Prefer not to answer
[IF B15=1, ASK B16]
B16. During the past 30 days, on how many days did you use electronic 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 or
7 All 30 days
9 Prefer not to answer
B17. Have you ever tried marijuana, even one time?
1 Yes
2 No
9 Prefer not to answer
[IF B17=1, ASK B18]
B18. During the past 30 days, on how many days did you use marijuana?
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
B19. During the past 30 days, on how many days did you add marijuana to a tobacco product, such as a cigar (sometimes known as a “blunt”)?
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
Section C: Tobacco Use Intentions and Self-Efficacy
C1. Thinking about the future…
|
|
1 |
2 |
3 |
4 |
9 |
C1_1. |
Do you think that you will try a cigarette soon? |
1 |
2 |
3 |
4 |
9 |
C1_2 |
Do you think you will smoke a cigarette at any time in the next year? |
1 |
2 |
3 |
4 |
9 |
C1_3 |
Do you think you will be smoking cigarettes every day one year from now? |
1 |
2 |
3 |
4 |
9 |
C1_4 |
Do you think you will be smoking cigarettes, but not every day, one year from now? |
1 |
2 |
3 |
4 |
9 |
C1_5 |
If one of your best friends were to offer you a cigarette, would you smoke it? |
1 |
2 |
3 |
4 |
9 |
C1_6 |
Do you think that you will try smokeless tobacco such as chewing tobacco, snuff, snus or dip soon? |
1 |
2 |
3 |
4 |
9 |
C1_7 |
Do you think you will use smokeless tobacco such as chewing tobacco, snuff, snus or dip at any time in the next year? |
1 |
2 |
3 |
4 |
9 |
C1_8 |
If one of your best friends were to offer you smokeless tobacco such as chewing tobacco, snuff, snus or dip, would you use it? |
1 |
2 |
3 |
4 |
9 |
C1_9 |
Do you think you will try cigars, cigarillos, or little cigars such as Swisher Sweets, Black & Mild, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s soon? |
1 |
2 |
3 |
4 |
9 |
C1_10 |
Do you think you will try cigars, cigarillos, or little cigars such as Swisher Sweets, Black & Mild, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s at any time in the next year? |
1 |
2 |
3 |
4 |
9 |
C1_11 |
If one of your best friends were to offer you a cigar, cigarillo, or little cigar, would you smoke it? |
1 |
2 |
3 |
4 |
9 |
C2. How sure are you that, if you really wanted to, you could say no to a cigarette offer if…
[RANDOMIZE C6_1-C6_3]
|
1 |
2 |
3 |
4 |
5 |
9 |
C2_1. You are at a party where most people are smoking? |
1 |
2 |
3 |
4 |
5 |
9 |
C2_2. A very close friend offers it? |
1 |
2 |
3 |
4 |
5 |
9 |
C2_3. Someone you know offers it? |
1 |
2 |
3 |
4 |
5 |
9 |
C3. How sure are you that, if you really wanted to, you could say no to a smokeless tobacco offer, such as chewing tobacco, snuff, snus or dip if…
[RANDOMIZE C3_1-C3_3]
|
1 |
2 |
3 |
4 |
5 |
9 |
C3_1. You are at a party where most people are using it? |
1 |
2 |
3 |
4 |
5 |
9 |
C3_2. A very close friend offers it? |
1 |
2 |
3 |
4 |
5 |
9 |
C3_3. Someone you know offers it? |
1 |
2 |
3 |
4 |
5 |
9 |
Section D: Cessation (Intention, Behavior, Motivation)
Cigarette Use [Ask if B3=2-9]
D1. 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
D2. During the past 3 months, did you stop smoking cigarettes for one day or longer because you were trying to quit smoking cigarettes for good?
1 Yes
2 No
9 Prefer not to answer
D3. How much do you want to quit smoking?
1 Not at all
2 A little
3 Somewhat
4 A lot
9 Prefer not to answer
Other Tobacco Use [Ask if B10=2-9]
D4. 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
D5. During the past 3 months, did you stop using smokeless tobacco such as chewing tobacco, snuff or dip for one day or longer because you were trying to quit using smokeless tobacco for good?
1 Yes
2 No
9 Prefer not to answer
D6. How much do you want to stop using smokeless tobacco such as chewing tobacco, snuff or dip?
1 Not at all
2 A little
3 Somewhat
4 A lot
9 Prefer not to answer
Section E: Attitudes, Beliefs & Risk Perceptions, Social Norm
[ASK ALL]
The next set of questions asks for your opinions on cigarette use and other tobacco products.
Attitude
E1. Smoking cigarettes is… (pick one)
[RANDOMIZE E1_1-E1_4]
E1_1. |
Bad |
|
|
|
|
|
|
|
Good |
E1_2. |
Unenjoyable |
|
|
|
|
|
|
|
Enjoyable |
E2. Using smokeless tobacco, such as chewing tobacco, snuff, or dip is… (pick one)
[RANDOMIZE E2_1-E2_4]
E2_1. |
Bad |
|
|
|
|
|
|
|
Good |
E2_2. |
Unenjoyable |
|
|
|
|
|
|
|
Enjoyable |
Attitudinal Beliefs and Risk Perceptions
E3. How much do you agree or disagree with the following statements? If I smoke I will…
|
|
1 |
2 |
3 |
4 |
5 |
9 |
E3_1. |
Damage my body |
1 |
2 |
3 |
4 |
5 |
9 |
E3_2. |
Be controlled by smoking |
1 |
2 |
3 |
4 |
5 |
9 |
E3_3. |
Be unattractive |
1 |
2 |
3 |
4 |
5 |
9 |
E3_4. |
Inhale poisons |
1 |
2 |
3 |
4 |
5 |
9 |
E3_5. |
Develop cancer of the lip, mouth, tongue or throat |
1 |
2 |
3 |
4 |
5 |
9 |
E3_6. |
Develop sexual and/or fertility problems |
1 |
2 |
3 |
4 |
5 |
9 |
E3_7. |
Lose my taste buds |
1 |
2 |
3 |
4 |
5 |
9 |
E3_8. |
Be unable to stop when I want to |
1 |
2 |
3 |
4 |
5 |
9 |
E3_9. |
Get wrinkles |
1 |
2 |
3 |
4 |
5 |
9 |
E3_10. |
Develop skin problems |
1 |
2 |
3 |
4 |
5 |
9 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
E3_11 |
Have problems with my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E3_12. |
Lose my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E3_13. |
Have trouble breathing |
1 |
2 |
3 |
4 |
5 |
9 |
E3_14 |
Shorten my life |
1 |
2 |
3 |
4 |
5 |
9 |
E3_15. |
Develop a smoking-related disease |
1 |
2 |
3 |
4 |
5 |
9 |
E3_16. |
Have bad breath |
1 |
2 |
3 |
4 |
5 |
9 |
E3_17 |
Get sick more often |
1 |
2 |
3 |
4 |
5 |
9 |
E3_18. |
Decrease my sports performance |
1 |
2 |
3 |
4 |
5 |
9 |
E3_19. |
End up wasting money on cigarettes |
1 |
2 |
3 |
4 |
5 |
9 |
E3_20. |
Become addicted |
1 |
2 |
3 |
4 |
5 |
9 |
E3_21. |
Harm others with second-hand smoke |
1 |
2 |
3 |
4 |
5 |
9 |
E3_22. |
Be a bad influence on others |
1 |
2 |
3 |
4 |
5 |
9 |
E4. 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 |
E4_1. |
Damage my body |
1 |
2 |
3 |
4 |
5 |
9 |
E4_2. |
Be controlled by smokeless tobacco |
1 |
2 |
3 |
4 |
5 |
9 |
E4_3. |
Be unattractive |
1 |
2 |
3 |
4 |
5 |
9 |
E4_4. |
Ingest poisons |
1 |
2 |
3 |
4 |
5 |
9 |
E4_5. |
Develop cancer of the lip, mouth, tongue or throat |
1 |
2 |
3 |
4 |
5 |
9 |
E4_6. |
Develop sexual and/or fertility problems |
1 |
2 |
3 |
4 |
5 |
9 |
E4_7. |
Lose my taste buds |
1 |
2 |
3 |
4 |
5 |
9 |
E4_8. |
Be unable to stop when I want to |
1 |
2 |
3 |
4 |
5 |
9 |
E4_9. |
Get wrinkles |
1 |
2 |
3 |
4 |
5 |
9 |
E4_10. |
Develop skin problems |
1 |
2 |
3 |
4 |
5 |
9 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
E4_11 |
Have problems with my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E4_12. |
Lose my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E4_13. |
Shorten my life |
1 |
2 |
3 |
4 |
5 |
9 |
E4_14. |
Develop a tobacco-related disease |
1 |
2 |
3 |
4 |
5 |
9 |
E4_15. |
Have bad breath |
1 |
2 |
3 |
4 |
5 |
9 |
E4_16 |
Get sick more often |
1 |
2 |
3 |
4 |
5 |
9 |
E4_17. |
Decrease my sports performance |
1 |
2 |
3 |
4 |
5 |
9 |
E4_18. |
End up wasting money on cigarettes |
1 |
2 |
3 |
4 |
5 |
9 |
E4_19. |
Become addicted |
1 |
2 |
3 |
4 |
5 |
9 |
E4_20. |
Be a bad influence on others |
1 |
2 |
3 |
4 |
5 |
9 |
E5. How much do you agree or disagree with the following statements about smoking cigarettes?
|
|
1 |
2 |
3 |
4 |
5 |
9 |
E5_1. |
Smoking can cause immediate damage to my body. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_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 |
E5_3. |
If I started to smoke occasionally I would not become addicted. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_4. |
Smoking cigarettes helps people relieve stress. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_5. |
Cigarette ingredients are disgusting. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_6. |
Cigarette ingredients are dangerous. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_7. |
Smoking is a way to show others you’re not afraid to take risks |
1 |
2 |
3 |
4 |
5 |
9 |
E5_8. |
Smoking cigarettes can help keep your weight down |
1 |
2 |
3 |
4 |
5 |
9 |
E6. 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 |
E6_1. |
Using smokeless tobacco can cause immediate damage to my body. |
1 |
2 |
3 |
4 |
5 |
9 |
E6_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 |
E6_3. |
If I started to use smokeless tobacco occasionally I would not become addicted. |
1 |
2 |
3 |
4 |
5 |
9 |
E6_4. |
Using smokeless tobacco helps people relieve stress. |
1 |
2 |
3 |
4 |
5 |
9 |
E6_5. |
Smokeless tobacco is disgusting. |
1 |
2 |
3 |
4 |
5 |
9 |
E6_6. |
Smokeless tobacco is dangerous. |
1 |
2 |
3 |
4 |
5 |
9 |
E6_7. |
Using smokeless tobacco is a way to show others you’re not afraid to take risks |
1 |
2 |
3 |
4 |
5 |
9 |
E6_8. |
Smokeless tobacco, such as chewing tobacco, snuff, or dip, is safer to use than cigarettes |
1 |
2 |
3 |
4 |
5 |
9 |
E7. Do you believe cigarette smoking is related to…
|
|
1 |
2 |
3 |
4 |
Don’t Know |
9 |
E7_1 |
Lung Cancer? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_2 |
Cancer of the lip, mouth, tongue or throat? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_3 |
Heart Disease? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_4 |
Diabetes? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_5 |
Emphysema? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_6 |
Stroke? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_7 |
Hole in throat (stoma or tracheotomy)? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_8 |
Buerger’s Disease? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_9 |
Removal of limbs (amputations)? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_10 |
Asthma? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_11 |
Gallstones? |
1 |
2 |
3 |
4 |
5 |
9 |
E7_12 |
COPD or chronic bronchitis? |
1 |
2 |
3 |
4 |
5 |
9 |
E8. Do you believe smokeless tobacco such as chewing tobacco, snuff, or dip is related to….
|
|
1 |
2 |
3 |
4 |
Don’t Know |
9 |
E8_1 |
Oral cancer? |
1 |
2 |
3 |
4 |
5 |
9 |
E8_2 |
Esophageal cancer? |
1 |
2 |
3 |
4 |
5 |
9 |
E8_3 |
Pancreatic cancer? |
1 |
2 |
3 |
4 |
5 |
9 |
E8_4 |
Gum disease? |
1 |
2 |
3 |
4 |
5 |
9 |
E8_5 |
Tooth loss? |
1 |
2 |
3 |
4 |
5 |
9 |
E8_6 |
Red or white patches in the mouth (such as leukoplakia)? |
1 |
2 |
3 |
4 |
5 |
9 |
E9. Does cigarette smoke contain….
|
|
1 |
2 |
3 |
4 |
Don’t Know |
9 |
E9_1 |
Ammonia, a substance found in fertilizer and household cleaners? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_2 |
Arsenic, a substance found in motor oil? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_3 |
Benzene, a chemical found in gasoline? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_4 |
Beryllium, a substance used in nuclear weapons and nuclear power reactors? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_5 |
Cadmium, a substance found in batteries? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_6 |
Carbon monoxide, a substance found in car exhaust? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_7 |
Formaldehyde, a chemical used to preserve dead animals? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_8 |
Hydrogen cyanide, a substance used to kill insects? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_9 |
Lead, a substance found in bullets? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_10 |
Naphthalene, a chemical found in mothballs? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_11 |
2-Nitropropane, a substance found in paint and ink? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_12 |
Polonium 210, a poison? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_13 |
Uranium, a substance used in nuclear weapons and nuclear power reactors? |
1 |
2 |
3 |
4 |
5 |
9 |
E10. Does smokeless tobacco such as chewing tobacco, snuff, or dip contain….
|
|
1 |
2 |
3 |
4 |
Don’t Know |
9 |
E10_1 |
Ammonia, a substance found in fertilizer and household cleaners? |
1 |
2 |
3 |
4 |
5 |
9 |
E10_2 |
Arsenic, a substance found in motor oil? |
1 |
2 |
3 |
4 |
5 |
9 |
E10_3 |
Beryllium, a substance used in nuclear weapons and nuclear power reactors? |
1 |
2 |
3 |
4 |
5 |
9 |
E10_4 |
Cadmium, a substance found in batteries? |
1 |
2 |
3 |
4 |
5 |
9 |
E10_5 |
Formaldehyde, a chemical used to preserve dead animals? |
1 |
2 |
3 |
4 |
5 |
9 |
E10_6 |
Lead, a substance found in bullets? |
1 |
2 |
3 |
4 |
5 |
9 |
E10_7 |
Naphthalene, a chemical found in mothballs? |
1 |
2 |
3 |
4 |
5 |
9 |
E10_8 |
Polonium 210, a poison? |
1 |
2 |
3 |
4 |
5 |
9 |
E10_9 |
Uranium, a substance used in nuclear weapons and nuclear power reactors? |
1 |
2 |
3 |
4 |
5 |
9 |
Social Norms
E11. How many of your four closest friends…
|
|
0 |
1 |
2 |
3 |
4 |
9 |
E11_1. |
Smoke cigarettes? |
0 |
1 |
2 |
3 |
4 |
9 |
E11_2. |
Smoke menthol cigarettes? |
0 |
1 |
2 |
3 |
4 |
9 |
E11_3. |
Use smokeless tobacco, such as chewing tobacco, snuff, snus or dip? |
0 |
1 |
2 |
3 |
4 |
9 |
E12. How many others your age…
|
|
0 |
1 |
2 |
3 |
4 |
9 |
E12_1. |
Smoke cigarettes every day? |
0 |
1 |
2 |
3 |
4 |
9 |
E12_2. |
Smoke menthol cigarettes every day?? |
0 |
1 |
2 |
3 |
4 |
9 |
E12_3. |
Use smokeless tobacco, such as chewing tobacco, snuff, or dip every day? |
|
|
|
|
|
|
E12_4. |
Smoke cigarettes, but not every day? |
0 |
1 |
2 |
3 |
4 |
9 |
E12_5. |
Smoke menthol cigarettes, but not every day?? |
0 |
1 |
2 |
3 |
4 |
9 |
E12_6. |
Use smokeless tobacco, such as chewing tobacco, snuff, or dip, but not every day? |
0 |
1 |
2 |
3 |
4 |
9 |
Section F: Media Use and Awareness
F1. Thinking only about yesterday, about how much time did you spend watching TV shows on any of the following? [INSERT PHOTOS]
|
1 |
2 |
3 |
4 |
5 |
6 Does Not Apply to Me |
9 |
F1_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 |
6 |
9 |
F1_2. A computer, laptop, or tablet? Include streaming video like Netflix, DVDs, Hulu, etc.? |
1 |
2 |
3 |
4 |
5 |
6 |
9 |
F1_3. A cell phone/smartphone? |
1 |
2 |
3 |
4 |
5 |
6 |
9 |
F1_4. An iPod or other MP3 player? |
1 |
2 |
3 |
4 |
5 |
6 |
9 |
F2. 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 |
|
|
|
|
|
|
F2_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 |
|
|
|
|
|
|
F2_2. Watching or uploading videos such as YouTube on a computer, laptop, or tablet |
1 |
2 |
3 |
4 |
5 |
9 |
F2_3. Using social networking sites like Facebook or twitter on a computer, laptop, or tablet |
1 |
2 |
3 |
4 |
5 |
9 |
F2_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 |
F2_5. Instant messaging or Video chatting (on Skype, Googletalk, iChat, etc.) on a computer, laptop, or tablet |
1 |
2 |
3 |
4 |
5 |
9 |
|
|
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 |
|
|
Using a Cell Phone/Smartphone |
|
|
|
|
|
|
F2_6. Text messaging on a cell phone/smartphone |
1 |
2 |
3 |
4 |
5 |
9 |
F2_7. Watching or uploading videos such as YouTube on a cell phone/smartphone |
1 |
2 |
3 |
4 |
5 |
9 |
F2_8. Going to social networking sites like Facebook or twitter on a cell phone/smartphone |
1 |
2 |
3 |
4 |
5 |
9 |
F2_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 |
|
|
|
|
|
|
F2_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 |
F2_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 |
F2_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 |
F2_12. 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
F3. 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.
F3_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
F3_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
F3_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
F3_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
F3_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
F4. 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 F4=1-6 ASK F5]
F5. Where have you seen or heard about [INSERT CAMPAIGN NAME]?
1 2
Yes No
[RANDOMIZE]
F5_1. On TV
F15_2. On the radio
F5_3. In newspapers or magazines
F5_4. On the Internet
F5_5. Billboards or other outdoor ads
F6. The [INSERT CAMPAIGN NAME] is on social networking sites. Have you ever seen [INSERT CAMPAIGN NAME] on the following sites?
1 2
Yes No
F6_1. Facebook?
F6_2. Twitter?
F6_3. [INSERT SOCIAL MEDIA SITE A]
F6_4. [INSERT SOCIAL MEDIA SITE B]
F7_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]
F8_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 F8x=1, ASK F8a_x]
F8a_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
F9_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 F9_x = 1, ASK F9a_x]
F9a_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 F8_x or F9_x =1 OR 2, GO TO GO TO F10_x; OTHERWISE GO TO G1.]
F10_x. How would you describe this advertisement?
F10_1. |
Bad |
-3 |
-2 |
-1 |
0 |
+1 |
+2 |
+3 |
Good |
F10_2. |
Unenjoyable |
-3 |
-2 |
-1 |
0 |
+1 |
+2 |
+3 |
Enjoyable |
F11_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 |
F11_1. |
This ad is worth remembering |
1 |
2 |
3 |
4 |
5 |
9 |
F11_2. |
This ad grabbed my attention |
1 |
2 |
3 |
4 |
5 |
9 |
F11_3. |
This ad is powerful |
1 |
2 |
3 |
4 |
5 |
9 |
F11_4. |
This ad is informative |
1 |
2 |
3 |
4 |
5 |
9 |
F11_5. |
This ad is meaningful to me |
1 |
2 |
3 |
4 |
5 |
9 |
F11_6. |
This ad is convincing |
1 |
2 |
3 |
4 |
5 |
9 |
F11_7. |
This ad is terrible |
1 |
2 |
3 |
4 |
5 |
9 |
F11_8. |
This ad is ridiculous |
1 |
2 |
3 |
4 |
5 |
9 |
F11_9. |
I trust the information in this ad |
1 |
2 |
3 |
4 |
5 |
9 |
F11_10. |
This ad told me things I never knew before about tobacco |
1 |
2 |
3 |
4 |
5 |
9 |
|
|
|
|
|
|
|
|
F11_11. |
The person/people in this ad are like me |
1 |
2 |
3 |
4 |
5 |
9 |
F10_12. |
This ad gave me good reasons not to use tobacco |
1 |
2 |
3 |
4 |
5 |
9 |
F12_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]
F13_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
F13a_x. Sad
F13b_x. Afraid
F13c_x. Irritated
F13d_x. Angry
F13e_x. [INSERT EMOTION]
[REPEAT F7_x - F13x FOR OTHER ADS]
F14. Did you talk to anyone about any of these ads?
1 Yes
2 No
9 Prefer not to answer
[IF F14=1, ASK F15]
F15. When you talked about the ads, did you talk about any of the following topics?
1 2
Yes No
[RANDOMIZE]
F15_1. These ads were good
F15_2. These ads were NOT good
F15_3. I should not smoke
F15_4. The person I was talking to or someone else I know should not smoke
F15_5. Other, specify________________________
Section G: Environment
The next section asks some questions about your household and peers.
G1. 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
G2. 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
G4. How well would you say you have done in school? Would you say…
1 Much better than average
2 Better than average
3 Average
4 Below average
5 Much worse than average
9 Prefer not to answer
G5. I feel close to people at my school. 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
G6. I am happy to be at my school. 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
G7. I feel like I am a part of my school. 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
G8. How far do you think you will go in school?
1 I don’t plan to go to school anymore
2 9th grade
3 10th grade
4 11th grade
5 12th grade or GED
6 Some college or technical school but no degree
7 Technical school degree
8 College degree
9 Graduate school, medical school, or law school
99 Prefer not to answer
G9. How many close friends do you have? (Close friends include people whom you feel at ease with, can talk to about private matters, and can call on for help.)
__________ MIN 0 MAX 7
9 Prefer not to answer
G10. How often do you attend church or religious services? Would you say…
1 Never
2 Less than once a month
3 About once a month
4 About 2 or 3 times a month
5 Once a week
6 More than once a week
9 Prefer not to answer
Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statements.
G11. 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
G12. 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
G13. 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
G14. 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
G16. 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
These next questions ask about how you feel about your current relationship with your parents or guardians. Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statement.
G17. Thinking about the adult or adults you live withwould you say you are satisfied with the way you communicate with each other.
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree (neutral)
4 Agree
5 Strongly Agree
9 Prefer not to answer
G18. How close do you feel to the adult or adults you live with?
1 Not at all close
2 Not very close
3 Somewhat close
4 Quite close
5 Very close
9 Prefer not to answer
G19. How often has a parent or other adult caregiver said things that really hurt your feelings or made you feel like you were not wanted or loved?
1 One time
2 Two times
3 Three to five times
4 Six to ten times
5 More than ten times
6 this has never happened
7 Don’t know
9 Prefer not to answer
G20. Has your parent or adult caregiver ever talked to you about reasons for not smoking cigarettes or using other types of tobacco like cigars and chewing tobacco?
1 Yes
2 No
9 Prefer not to answer
G21. During the past 7 days, on how many days did you and one or both of your parents or adult caregivers do something together just for fun?
__________ MIN 0 MAX 7
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 41 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 | 2013-10-29 |