Form
Approved
OMB No. 0910-0753
Exp. Date 10/31/2016
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
A3_6. In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme?
Tips from Former Smokers (Tips)
1___ Yes
2___ No
3___ Not Sure
A3_7. In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme?
truth
1___ Yes
2___ No
3___ Not Sure
F4. The next set of questions ask whether or not you’ve seen any of the following advertisements.
[RANDOMIZE ORDER OF F4_1 and F4_2]
F4_1. In the past 3 months, have you seen a Tips from Former Smokers (Tips) advertisement? Examples of some Tips from Former Smokers ads are shown below.
1___ Yes
2___ No
[INSERT Tips from Former Smokers PHOTO COLLAGE]
F4_2. In the past 3 months, have you seen a truth campaign advertisement? Examples of some truth campaign ads are shown below.
1___ Yes
2___ No
[INSERT truth PHOTO COLLAGE]
[If F4_1 =YES, AND F4_2=YES, ASK F5_1 AND F5_2, RANDOMIZE ORDER. IF F4_1=Yes AND F4_2=NO, ask F5_1. If F4_1=NO and F4_2=YES, ASK F5_2.
F5_1. Where have you seen a Tips from Former Smokers (Tips) ad? Examples of some Tips from Former Smokers ads are shown below.
1___ On TV
2___ On the radio
3___ In newspapers or magazines
4___ On the Internet
5___ Billboards or other outdoor ads
[INSERT Tips from Former Smokers PHOTO COLLAGE]
F5_2. Where have you seen a truth campaign ad? Examples of some truth campaign ads are shown below.
[RANDOMIZE ORDER OF CHECKBOX LIST]
1___ On TV
2___ On the radio
3___ In newspapers or magazines
4___ On the Internet
5___ Billboards or other outdoor ads
[INSERT truth campaign PHOTO COLLAGE]
[If F4_1 =YES, AND F4_2=YES, ASK F6_1 AND F6_2, RANDOMIZE ORDER. IF F4_1=Yes AND F4_2=NO, ask F6_1. If F4_1=NO and F4_2=YES, ASK F6_2.
A6_1. The Tips Campaign is on social networking sites. Have you ever seen Tips ads on the following sites?
1 2
Yes No
A6_1a. Facebook?
A6_1b. Twitter?
A6_2. The truth Campaign is on social networking sites. Have you ever seen truth ads on the following sites?
1 2
Yes No
A6_2a. Facebook?
A6_2b. Twitter?
A7_x. Now we would like to show you some screen shots from an 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 in the past three months?
1 Yes
2 No
9 Prefer not to answer
[IF A8x=1, ASK A8a_x]
A8a_x. How frequently have you seen this ad in the past three months??
1 Rarely
2 Sometimes
3 Often
4 Very Often
9 Prefer not to answer
A9ax. Where have you seen this ad? Check all that apply. [Channels]
[RANDOMIZE ORDER OF CHECKBOX LIST]
1___ On TV
2___ On the Internet
3___ On the radio
4___ In newspapers or magazines
5___ Billboards or posters
A9bx. Where have you seen this ad? Check all that apply. [Locations]
[RANDOMIZE ORDER OF CHECKBOX LIST]
1___ At the movie theatre
2___ At school
3___ At the mall, in an arcade or store
4___ On buses, trains or other public transportation
5___ Outdoors
A9cx. Where on the Internet have you seen this ad? Check all that apply. [note we will ask this of everyone even if they did not indicate they saw the campaign online in A9ax.]
[RANDOMIZE ORDER OF CHECKBOX LIST]
1___ Internet or banner ad
2___ Facebook
3___ Twitter
4___ YouTube
5___ Hulu
6___ Other social networking sites
7___ I have not seen this ad on the Internet
[IF A8_x =2,3,4, or 9, 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 silly |
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 |
A11_14 |
This ad is annoying |
1 |
2 |
3 |
4 |
5 |
9 |
A11_15 |
This ad was difficult to watch |
1 |
2 |
3 |
4 |
5 |
9 |
A11_16 |
I can identify with what the ad says
|
1 |
2 |
3 |
4 |
5 |
9 |
A11_17 |
This ad is different from other anti-tobacco ads I’ve seen or heard |
1 |
2 |
3 |
4 |
5 |
9 |
A12a_x. On a scale of 1 to 5, how would you rate the claims or arguments in this ad:
1. Not believable
2
3
4
5. Believable
A12b_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. Ashamed
A13f_x. Discouraged
A13g_x. Hopeful
A13h_x. Motivated
A13i_x. Understood
A13j_x. Amused
A13k_x. Worried
A13l_x. Disgusted or grossed out
A13m_x. Happy
A13n_x. Uneasy
A130_x. Surprised
A14. After seeing this ad, did you look for more information online?
1 Yes
2 No
9 Prefer not to answer
A15. After seeing this ad, did you Visit [insert campaign name] website or Facebook page?
1 Yes
2 No
9 Prefer not to answer
A16. After seeing this ad, did you share [insert campaign name] YouTube channel with a friend?
1 Yes
2 No
9 Prefer not to answer
A17. After seeing this ad, did you mention it on social media?
1 Yes
2 No
9 Prefer not to answer
A18. Did you talk to anyone about any of these ads?
1 Yes
2 No
9 Prefer not to answer
[IF A18=1, ASK A19]
A19. 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]
A20. 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
A21. 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
A22. 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
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. |
Waste 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 |
B13_23. |
Miss out on things |
1 |
2 |
3 |
4 |
5 |
9 |
14. 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. |
Waste 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 |
B14_21. |
Miss out on things |
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 |
B15_9. |
Menthol cigarettes are safer than non-menthol cigarettes |
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 dead animals? |
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 |
Smoke menthol cigarettes |
|
|
|
|
|
|
B21_3. |
Use smokeless tobacco, such as chewing tobacco, snuff or dip? |
0 |
1 |
2 |
3 |
4 |
9 |
E8. How many others your age…
|
|
0 |
1 |
2 |
3 |
4 |
9 |
E8_1. |
Smoke cigarettes every day? |
0 |
1 |
2 |
3 |
4 |
9 |
E8_2. |
Smoke menthol cigarettes every day?? |
0 |
1 |
2 |
3 |
4 |
9 |
E8_3 |
Use smokeless tobacco, such as chewing tobacco, snuff, or dip every day? |
0 |
1 |
2 |
3 |
4 |
9 |
E8_4. |
Smoke cigarettes, but not every day? |
0 |
1 |
2 |
3 |
4 |
9 |
E8_5. |
Smoke menthol cigarettes, but not every day?? |
0 |
1 |
2 |
3 |
4 |
9 |
E8_6 |
Use smokeless tobacco, such as chewing tobacco, snuff, or dip, but not every day? |
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. 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
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 $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
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: 0910-0753 Expiration Date: 10/31/2016
Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 30 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 | 2013-12-18 |
| File Created | 2013-12-18 |