Media Tracking Questionnaires 1st, 2nd and; 3rd

Attachment 2: Youth Follow-up Instrument

Form Approved
OMB No. 0910-0753
Exp. Date 10/31/2016

Evaluation of the Public Education Campaign on Teen Tobacco-First Follow-up (ExPECTT-1)

Subjects for Questionnaire:
Section A: Demographics

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 A: Demographic Items

A1. How old are you? [this should be preloaded from baseline to be baseline age or baseline age +1]

___

A2. Are you male or female?

₁ Female

₂ Male

₉ Prefer not to answer

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. 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

B8. 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 B9; IF ON THE YOUTH BASELINE SURVEY B9=1 (smokeless users) ASK B10]

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

[IF ON THE YOUTH BASELINE SURVEY B11=2 or 9 (never users), ASK B11; IF ON THE YOUTH BASELINE SURVEY B11=1 (cigar users) ASK B12]

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

[IF ON THE YOUTH BASELINE SURVEY B13=2 or 9 (never users), ASK B13; IF ON THE YOUTH BASELINE SURVEY B13=1 (hookah 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 (e-cigarette users) ASK B16]

[EMBED SCREENSHOT OF PRODUCTS]B15. These are examples of electronic cigarettes, often called “e-cigarettes”, “e-cigs”, “vapor pens”, or “e-hookahs”. E-cigarettes sometimes look like regular cigarettes, but run on a battery and produce vapor instead of smoke. Have you ever tried electronic cigarettes, such as blu, NJOY, or Mistic, 21^st Century Smoke, even one or two puffs?

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, e-cigarettes “vapor pens”, or “e-hookahs”?

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, OTHERWISE GO TO SECTION C]

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 Definitely Yes	2 Probably Yes	3 Probably Not	4 Definitely Not	9 Prefer Not to Answer
C1_1.	Do you think that you will smoke 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
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 use 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 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 would you use it?	1	2	3	4	9
C1_9	Do you think you will smoke 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 smoke cigars, cigarillos, or little cigars 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
C1_12	Do you think you will use e-cigarettes, e-cigs, vapor pens, or e-hookahs (such as blu, NJOY, Mistic, 21st Century Smoke) soon?	1	2	3	4	9
C1_13	Do you think you will use e-cigarettes, e-cigs, vapor pens, or e-hookahs at any time in the next year?	1	2	3	4	9
C1_14	If one of your best friends were to offer you a e-cigarettes, e-cigs, vapor pens, or e-hookahs would you use 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 Not at all sure	2 Slightly sure	3 Somewhat sure	4 Mostly sure	5 Completely sure	9 Prefer Not to Answer
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 Not at all sure	2 Slightly sure	3 Somewhat sure	4 Mostly sure	5 Completely sure	9 Prefer Not to Answer
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]

D2. During the past [FILL DATE SINCE LAST INTERVIEW], 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

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

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]

D5. During the past [FILL DATE SINCE LAST INTERVIEW], 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

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_2]

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_2]

E2_1.	Bad								Good
E2_2.	Unenjoyable								Enjoyable

E13. Smoking cigars, cigarillos, or little cigars is… (pick one)

[RANDOMIZE E13_1-E13_2]

E13_1.	Bad								Good
E13_2.	Unenjoyable								Enjoyable

E14. Using e-cigarettes, e-cigs, vapor pens, or e-hookahs is… (pick one)

[RANDOMIZE E14_1-E14_2]

E14_1.	Bad								Good
E14_2.	Unenjoyable								Enjoyable

Attitudinal Beliefs and Risk Perceptions

E3. How much do you agree or disagree with the following statements? If I smoke cigarettes I will…[RANDOMIZE PRESENTATION]

		1 Strongly Disagree	2 Disagree	3 Neither Agree or Disagree (Neutral)	4 Agree	5 Strongly Agree	9 Prefer Not to Answer
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 COPD	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_22.	Become addicted	1	2	3	4	5	9
E3_20.	Harm others with second-hand smoke	1	2	3	4	5	9
E3_21.	Be a bad influence on others	1	2	3	4	5	9
E3_22	Have trouble breathing	1	2	3	4	5	9

E5. How much do you agree or disagree with the following statements about smoking cigarettes? [RANDOMIZE PRESENTATION]

		1 Strongly Disagree	2 Disagree	3 Neither Agree or Disagree (Neutral)	4 Agree	5 Strongly Agree	9 Prefer Not to Answer
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

E7. Do you believe cigarette smoking is related to… [RANDOMIZE PRESENTATION]

		1 Definitely Yes	2 Probably Yes	3 Probably Not	4 Definitely Not	Don’t Know	9 Prefer Not to Answer
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

E9. Does cigarette smoke contain….[RANDOMIZE PRESENTATION]

		1 Definitely Yes	2 Probably Yes	3 Probably Not	4 Definitely Not	Don’t Know	9 Prefer Not to Answer
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
E9_14	Nitromethane, a chemical found in rocket fuel?	1	2	3	4	5	9
E9_15	Over 7,000 chemicals?	1	2	3	4	5	9

Social Norms

E11. How many of your four closest friends…

		0 None	1 One	2 Two	3 Three	4 Four	9 Prefer Not to Answer
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
E11_4.	Use cigars, cigarillos, or little cigars such as Swisher Sweets, Black & Mild, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s?	0	1	2	3	4	9
E11_5.	Use e-cigarettes, e-cigs, vapor pens, or e-hookahs such as blu, NJOY, Mistic, 21st Century Smoke?	0	1	2	3	4	9

E12. How many other people your age…

		0 None	1 A few	2 Some	3 Most	4 All	9 Prefer Not to Answer
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 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… [INSERT PHOTOS]

	1 None	2 5 min – less than 30 min	3 30 min – 1 hour	4 More than 1 hour – 3 hours	5 More than 3 hours	6 Does Not Apply to Me	9 Prefer not to answer
F1_1. watching TV shows on 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. watching TV shows on a computer, laptop, or tablet? Include streaming video like Netflix, DVDs, Hulu, etc.?	1	2	3	4	5	6	9
F1_3. watching TV shows on a cell phone/smartphone?	1	2	3	4	5	6	9
F1_4. watching TV shows on 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…

	None	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	More than 3 hours	Prefer not to answer
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

	None	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	More than 3 hours	Prefer not to answer
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_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

Thinking about the past [FILL MONTHS], that is since [FILL DATE], how frequently have you watched the following shows?

	Never	Rarely	Sometimes	Often	Very Often	Prefer not to Answer
F2_14. The show Awkward on MTV?	1	2	3	4	5	9
F2_15. The show Catfish on MTV?	1	2	3	4	5	9
F2_16. The show Teen Wolf on MTV?	1	2	3	4	5	9
F2_17. The show Real World on MTV?	1	2	3	4	5	9
F2_18. The show Pretty Little Liars on ABC Family?	1	2	3	4	5	9
F2_19. The show The Fosters on ABC Family?	1	2	3	4	5	9
F2_20. The show Twisted on ABC Family?	1	2	3	4	5	9
F2_21. The show Chasing Life on ABC Family?	1	2	3	4	5	9
F2_22. The show Family Guy on Adult Swim?	1	2	3	4	5	9
F2_23. The show Robot Chicken on Adult Swim?	1	2	3	4	5	9
F2_24. The show American Dad on Adult Swim?	1	2	3	4	5	9
F2_25. The show The Cleveland Show on Adult Swim?	1	2	3	4	5	9
F2_26. The show WWE Raw on USA?	1	2	3	4	5	9
F2_27. The show Tosh.O on Comedy Central?	1	2	3	4	5	9
F2_28. The show Workaholics on Comedy Central?	1	2	3	4	5	9
F2_29. The show Kay & Peele on Comedy Central?	1	2	3	4	5	9
F2_30. The show It's Always Sunny in Philadelphia on Comedy Central?	1	2	3	4	5	9
F2_31.[insert show name]	1	2	3	4	5	9
F2_32. [insert show name]	1	2	3	4	5	9
F2_33. [insert show name]	1	2	3	4	5	9

F2_31. In the past [FILL MONTHS], that is since [FILL DATE], how frequently have you been on YouTube or Hulu?

₁ Never

₂ Rarely

₃ Sometimes

₄ Often

₅ Very Often

₉ Prefer not to answer

F2_32. In the past [FILL MONTHS], that is since [FILL DATE], how frequently have you been on Facebook?

₁ Never

₂ Rarely

₃ Sometimes

₄ Often

₅ Very Often

₉ Prefer not to answer

F2_33. In the past [FILL MONTHS], that is since [FILL DATE], how frequently have you been on Twitter?

₁ Never

₂ Rarely

₃ Sometimes

₄ Often

₅ Very Often

₉ Prefer not to answer

F2_34. In the past [FILL MONTHS], that is since [FILL DATE], how frequently have you used Pandora or Spotify?

₁ Never

₂ Rarely

₃ Sometimes

₄ Often

₅ Very Often

₉ Prefer not to answer

F2_35. In the past [FILL MONTHS], that is since [FILL DATE], how frequently have you used PlayStation or Xbox?

₁ Never

₂ Rarely

₃ Sometimes

₄ Often

₅ Very Often

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_3. In the past [FILL 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 [FILL 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_11. In the past [FILL MONTHS] 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

F3_12. In the past [FILL MONTHS] months,, that is since [FILL DATE], have you seen or heard the following slogan or theme?

truth [insert current truth campaign name]

₁___ Yes

₂___ No

₃___ Not Sure

ASK F5_3 IF F3_4=1 or 3, OTHERWISE ASK F7_x.

F5_3. Where have you seen or heard about The Real Cost? Check all that apply.

1 2

Yes No

[RANDOMIZE]

F5_3a. On TV

F5_3b. On the radio

F5_3c. In magazines

F5_3d. On the Internet

F5_3_e. Billboards or other outdoor or mall ads

F5_3_f. At the movie theatre

F6. The Real Cost campaign is online. Have you ever seen the Real Cost on… Check all that apply.

1 2

Yes No

F6_1. Facebook?

F6_2. Twitter?

F6_3. YouTube?

F6_4. Hulu?

F6_5. Pandora or Spotify?

F6_6. In video games?

F7_x. Now we would like to show you some advertisements that have been shown in the U.S. Once you have viewed the video or screenshot, please click on the forward arrow below to continue with the survey.

[DISPLAY VIDEOS OR SCREENSHOTS IN RANDOM ORDER . Use VIDEO for Real Cost and truth ads, Use SCREENSHOTS for Tips from Former Smokers ads ]

F8_x. Apart from this survey, how frequently have you seen this ad [SCREENSHOT LANGUAGE: these ads] in the past [FILL MONTHS SINCE LAST SURVEY]?

₁ Never

₂ Rarely

₃ Sometimes

₄ Often

₅ Very Often

₉ Prefer not to answer

LOOP BACK TO ASK ABOUT NEXT AD HERE.

SHOW SCREENGRAB OF AD

F19_x. What is the main message of this ad? Select only one response

[RANDOMIZE ORDER OF CHECKBOX LIST]

₁___ Smoking can damage your teeth

₂___ Smoking can cause wrinkles

₃___ Cigarettes are addictive

₄___ Cigarettes can control your life

₅___ The cost of a pack of cigarettes is going up

₆___ The legal age for buying cigarettes is going up

₇___ Laws make it difficult for teens to buy cigarettes at convenient stores

₈___ Being with friends is more important than smoking

9. _This generation of teens can play a big role in stopping smoking

10. If you smoke you lose your freedom

11. There are toxic chemicals in cigarette smoke

₉₉___ I am not sure

F10_x. How would you describe this advertisement?

F10_1.	Bad	-3	-2	-1	0	+1	+2	+3	Good

F11_x. Please tell us if you strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree with the following statements.

		1 Strongly Disagree	2 Disagree	3 Neither Agree or Disagree (Neutral)	4 Agree	5 Strongly Agree	9 Prefer Not to Answer
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_10.	This ad told me things I never knew before about tobacco	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. Afraid

F13b_x. Hopeful

F13c_x. Motivated

F13d_x. Worried

F13e_x. Understood

F13f_x. Surprised

[REPEAT F10_x - F18x FOR OTHER REAL COST ADS]

F18a. Have you visited www.therealcost.gov in the past [FILL MONTHS] months, since [FILL DATE]?

1.  Yes

            2.  No

F14_x. Did you talk to anyone in person or online about these ads?

₁ Yes

₂ No

₉ Prefer not to answer

[IF F14=1, ASK F15]

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, e-cigarettes “vapor pens”, or “e-hookahs” such as blu, NJOY, Mistic, 21^st 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 9^th grade

₃ 10^th grade

₄ 11^th grade

₅ 12^th 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

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 with would 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 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

G20. 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: 0910-0753 Expiration Date: 10/31/2016

Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 45 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

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