Form
Approved
OMB No. 0910-0753
Exp. Date 10/31/2016
Evaluation of the Public Education Campaign on Teen Tobacco-Third Follow-up (ExPECTT-3)
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. The first part of the survey asks you some general questions about yourself.
How old are you?
Ο1 11 years old
Ο2 12 years old
Ο3 13 years old
Ο4 14 years old
Ο5 15 years old
Ο6 16 years old
Ο7 17 years old
Ο8 18 years old or older
Ο9 Prefer not to answer
[HOLD CHECK IF A1 ISN’T ANSWERED]
[SOFT CHECK IF A1 = 8: “Are you sure you entered the correct age?”
A2. Are you male or female?
Ο1 Female
Ο2 Male
Ο9 Prefer not to answer
[HOLD CHECK IF A2 ISN’T ANSWERED]
IF A1=[FU1 AGE] OR [FU1 AGE +1] AND A2=[FU1 GENDER] AND S1=1 GO TO B1.
IF A1≠[FU1 AGE] OR [FU1_AGE +1] GO TO S2
S2. To be sure we have the right information, please indicate your age once more.
How old are you?
01 11 years old
02 12 years old
03 13 years old
04 14 years old
05 15 years old
06 16 years old
07 17 years old
08 18 years old or older
09 Prefer not to answer
IF A2≠[BASELINE GENDER] GO TO S3.
S3. To be sure we have the right information, please indicate once more whether you are male or female.
Are you male or female?
1 Female
2 Male
9 Prefer not to answer
FOR WEB RESPONDENTS ONLY: IF S2≠[FU1 AGE] OR [FU1 AGE +1]
OR
S3≠[FU1 GENDER]
SHOW HARD CHECK THAT SAYS:
We’re sorry, we are not able to locate your file in our records. For this reason, you will not be able to take this survey online at this time. An interviewer will contact your parent or guardian to arrange an in-person interview.
THANK YOU FOR YOUR TIME
[IF CAPI AGE AND/OR GENDER ARE INCONSISTENT, ALLOW RESPONSES AND CONTINUE]
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.
The next questions are about smokeless tobacco, such as dip, chewing tobacco, snuff, or snus. Common brands include Copenhagen, Grizzly, Skoal, Camel Snus, Kodiak, and Longhorn.
Have you ever used smokeless tobacco 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 smokeless tobacco?
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. The next questions are about cigars, cigarillos, or little cigars such as Black & Mild, Swisher Sweets, Dutch Masters, Phillies Blunts, Prime Time, and Winchester.
Have you ever smoked cigars, cigarillos, or little cigars 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. The next questions are about e-cigarettes (e-cigs), sometimes also called vape pens, personal vaporizers and mods, e-cigars, e-pipes, e-hookahs and hookah pens.
Have you ever tried any e-cigarettes, 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 e-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, 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 |
2 |
3 |
4 |
9 |
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 dip, chewing tobacco, snuff, or snus 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 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 that you use an e-cigarettes soon? |
1 |
2 |
3 |
4 |
9 |
C1_13 |
Do you think you will use an e-cigarette at any time in the next year? |
1 |
2 |
3 |
4 |
9 |
C1_14 |
If one of your best friends were to offer you an e-cigarette 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 |
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 smokeless tobacco, 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 |
C4. How sure are you that, if you really wanted to, you could say no to an e-cigarette if…, if…
[RANDOMIZE C3_1-C3_3]
|
1 |
2 |
3 |
4 |
5 |
9 |
C4_1. You are at a party where most people are using it? |
1 |
2 |
3 |
4 |
5 |
9 |
C4_2. A very close friend offers it? |
1 |
2 |
3 |
4 |
5 |
9 |
C4_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 dip, chewing tobacco, snuff, or snus 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 |
E1_3. |
Harmful |
|
|
|
|
|
|
|
Not Harmful |
E2. Using smokeless tobacco, such as dip, chewing tobacco, snuff, or snus is… (pick one)
[RANDOMIZE E2_1-E2_2]
E2_1. |
Bad |
|
|
|
|
|
|
|
Good |
E2_2. |
Unenjoyable |
|
|
|
|
|
|
|
Enjoyable |
E2_3. |
Harmful |
|
|
|
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|
|
|
Not Harmful |
E13. Smoking cigars, cigarillos, or little cigars is… (pick one)
[RANDOMIZE E13_1-E13_2]
E13_1. |
Bad |
|
|
|
|
|
|
|
Good |
E13_2. |
Unenjoyable |
|
|
|
|
|
|
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Enjoyable |
E13_3. |
Harmful |
|
|
|
|
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|
|
Not Harmful |
E14. Using e-cigarettes is… (pick one)
[RANDOMIZE E14_1-E14_2]
E14_1. |
Bad |
|
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|
|
|
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Good |
E14_2. |
Unenjoyable |
|
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Enjoyable |
E14_3. |
Harmful |
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Not Harmful |
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 |
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 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 |
E3_23 |
Stunt the growth of my lungs |
1 |
2 |
3 |
4 |
5 |
9 |
E3_24 |
Have yellow, stained teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E13. How much do you agree or disagree with the following statements? If I use e-cigarettes I will…[RANDOMIZE PRESENTATION]
|
|
1 |
2 |
3 |
4 |
5 |
9 |
E13_1. |
Damage my body |
1 |
2 |
3 |
4 |
5 |
9 |
E13_2. |
Inhale poisons |
1 |
2 |
3 |
4 |
5 |
9 |
E13_3. |
Become addicted |
1 |
2 |
3 |
4 |
5 |
9 |
E13_4. |
Inhale nicotine |
1 |
2 |
3 |
4 |
5 |
9 |
E13_5. |
Inhale chemicals |
1 |
2 |
3 |
4 |
5 |
9 |
E13_6. |
Harm my lungs |
1 |
2 |
3 |
4 |
5 |
9 |
E13_7. |
Develop sexual and/or fertility problems |
1 |
2 |
3 |
4 |
5 |
9 |
E13_8. |
Decrease my sports performance |
1 |
2 |
3 |
4 |
5 |
9 |
E13_9 |
End up wasting money. |
1 |
2 |
3 |
4 |
5 |
9 |
E13_10 |
Inhale metal particles |
1 |
2 |
3 |
4 |
5 |
9 |
E5. How much do you agree or disagree with the following statements about smoking cigarettes? [RANDOMIZE PRESENTATION]
|
|
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 smoked 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 |
E5_9. |
The lungs of teenage smokers may not grow to normal size. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_10. |
Smoking just a few cigarettes can make you crave more. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_11. |
If I smoke, nicotine will rewire my brain. |
1 |
2 |
3 |
4 |
5 |
9 |
E15. How much do you agree or disagree with the following statements using e-cigarettes ? [RANDOMIZE PRESENTATION]
|
|
1 |
2 |
3 |
4 |
5 |
9 |
E15_1. |
Some of the chemicals in e-cigarettes are the same as in regular cigarettes. |
1 |
2 |
3 |
4 |
5 |
9 |
E15_2. |
The potential health risks of e-cigarettes use are unknown |
1 |
2 |
3 |
4 |
5 |
9 |
E15_3. |
E-cigs contain potentially harmful chemicals |
1 |
2 |
3 |
4 |
5 |
9 |
E15_4. |
Smoking e-cigarettes may cause lung damage |
1 |
2 |
3 |
4 |
5 |
9 |
E15_5. |
Vaping or using e-cigarettes can result in nicotine addiction |
1 |
2 |
3 |
4 |
5 |
9 |
E15_6. |
The ingredients in e-cigarettes may be dangerous when inhaled. |
1 |
2 |
3 |
4 |
5 |
9 |
E15_7. |
Vaping or using e-cigarettes helps people relieve stress. |
1 |
2 |
3 |
4 |
5 |
9 |
E15_8. |
Using e-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 |
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 |
E9. Does cigarette smoke contain….[RANDOMIZE PRESENTATION]
|
|
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 |
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 |
E16. Does e-cigarette smoke contain….[RANDOMIZE PRESENTATION]
|
|
1 |
2 |
3 |
4 |
Don’t Know |
9 |
E16_1 |
Nicotine, an addictive substance |
1 |
2 |
3 |
4 |
5 |
9 |
E16_2 |
Formaldehyde, a chemical used to preserve dead animals? |
1 |
2 |
3 |
4 |
5 |
9 |
E16_3 |
Acrolein, a chemical that is also found in cigarette smoke |
1 |
2 |
3 |
4 |
5 |
9 |
E16_4 |
Metal Particles
|
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? |
0 |
1 |
2 |
3 |
4 |
9 |
E11_4. |
Use cigars, cigarillos, or little cigars? |
0 |
1 |
2 |
3 |
4 |
9 |
E11_5. |
Use e-cigarettes ? |
0 |
1 |
2 |
3 |
4 |
9 |
E12. How many other people 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 every day? |
0 |
1 |
2 |
3 |
4 |
9 |
E12_7 |
Use e-cigarettes , every day? |
0 |
1 |
2 |
3 |
4 |
9 |
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 |
E12_8 |
Use e-cigarettes 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…
|
1 |
2 |
3 |
4 |
5 |
6 Does Not Apply to Me |
9 |
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…
|
|
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 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_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. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_15. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_16. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_17. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_18. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_19. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_20. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_21. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_22. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_23. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_24. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_25. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_26. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_27. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_28. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_29. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_30. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_31. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_32. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_33. [insert show name] on [insert network 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
F2_36. In the past [FILL MONTHS], that is since [FILL DATE], how frequently have you used Instagram?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very Often
9 Prefer not to answer
F2_37. In the past [FILL MONTHS], that is since [FILL DATE], how frequently have you used Tumblr?
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
F3_13. In the past [FILL MONTHS] months,, that is since [FILL DATE], have you seen or heard the following slogan or theme?
Fresh Empire
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 or the Internet/online
F5_3b. On the radio
F5_3c. In magazines
F5_3d. Billboards or other outdoor or mall ads
F5_3e. At the movie theatre
F5_3f. I have not seen or heard about The Real Cost
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. Instagram
F6_6. Tumblr
F6_7. Pandora or Spotify?
F6_8. 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
13____You don’t need a good reason not to smoke
99___I am not sure
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 |
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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.
ASK G21 IF YOUTH IS AGE 18 (A1=8)
G21. In the past 8 months, have you moved away from home or lived away from home anywhere including in on-campus college housing for an extended period?
1 Yes
2 No
9 Prefer not to answer
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 dip, chewing tobacco, snuff, or snus. Common brands include Copenhagen, Grizzly, Skoal, Camel Snus, Kodiak, and Longhorn. 3 cigars, cigarillos, or little cigars, such as Black & Mild, Swisher Sweets, Dutch Masters, Phillies Blunts, Prime Time, and Winchester
4 tobacco out of a water pipe (also called “hookah”)
5 electronic cigarettes, sometimes also called e-cigs, vape pens, personal vaporizers and mods, e-cigars, e-pipes, e-hookahs and hookah pens
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
IF A1=8, ASK G9.
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
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
IFA1=8, END SURVEY
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.
| File Type | application/msword |
| File Modified | 2015-11-18 |
| File Created | 2015-11-18 |