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 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. At the end of the survey, a link will take you to the GMI website to collect your MarketPoints.
If you have any questions about this study, you can call Jane Allen, at 1-800-334-8571 extension 25115 or send email to jallen@rti.org. If you have any questions about your rights as a study participant, you can call RTI's Human Research Protections Office at 1-866-214-2043 or send email to orpe@rti.org.
I have read and understand this information, and the study purpose and process are clear to me.
Yes, I agree to participate in this study
No, I do not wish to participate in this study
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.“
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 |
|
|
Section A: Media Use and Awareness
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…
|
|
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…
|
|
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 |
|
|
|
|
|
|
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 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A3. We want to ask you about some slogans or themes that might or might not have appeared in the media around here.
A3_2
[RANDOMIZE PRESENTATION OF A3_2b through A3_2f]
A3_2b. 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
9__ Prefer not to Answer
A3_2c. 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
9__ Prefer not to Answer
A3_2e. 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
9__ Prefer not to Answer
A3_2f. 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
9__ Prefer not to Answer
A4. The next set of questions ask whether or not you’ve seen any of the following advertisements.
[RANDOMIZE ORDER OF A4_1 and A4_2]
A4_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
3__ Not sure
9__ Prefer not to Answer
[INSERT Tips from Former Smokers PHOTO COLLAGE]
[INSERT Tips from Former Smokers PHOTO COLLAGE]
A4_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
3__ Not sure
9__ Prefer not to Answer
[INSERT truth PHOTO COLLAGE]
[If A4_1 ≠NO, ASK A5_1. IF A4_2 ≠NO, ASK A5_2. IF BOTH A4_1 and A4_2 =NO ASK A6. IF BOTH A4_1 and A4_2 ≠NOTHEN RANDOMIZE ORDER OF A5_1 and A5_2]
A5_1. Where have you seen or heard a Tips from Former Smokers (Tips) ad? Examples of some Tips from Former Smokers 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
6__ Not sure
9__ Prefer not to Answer
[INSERT Tips from Former Smokers PHOTO COLLAGE]
A5_2. Where have you seen or heard 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
6__ Not sure
9__ Prefer not to Answer
[INSERT truth campaign PHOTO COLLAGE]
[If A4_1 ≠NO, ASK A6_1. IF A4_2 ≠NO, ASK A6_2. IF BOTH A4_1, A4_2 and A4_3 =NO ASK A6. IF BOTH A4_1 and A4_2 ≠NOTHEN RANDOMIZE ORDER OF A6_1 and A6_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?
3__ Not sure
9__ Prefer not to Answer
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?
3__ Not sure
9__ Prefer not to Answer
A7_x. Now we would like to show you some advertisements that have been shown in the U.S. Once you have viewed the video below, please click on the forward arrow below to continue with the survey.
[NOTE, we will ask about all 9 video ads ]
[DISPLAY EMBEDDED AD FOR AD_x]
A8_x. Apart from this survey, have you seen or heard this ad in the past three months?
1 Yes
2 No
9 Prefer not to answer
[IF A8x=1 or 9, ASK A8a_x; OTHERWISE SHOW NEXT AD]
A8a_x. How frequently have you seen or heard this ad in the past three months??
1 Rarely
2 Sometimes
3 Often
4 Very Often
9 Prefer not to answer
ASK A8_x UNTIL ALL 9 ADS HAVE BEEN SEEN/HEARD.
IF A8=1 or 9 FOR ANY AD, ASK A9a.
A9a. Where have you seen or heard these ads? 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
6__ Not sure
9__ Prefer not to Answer
A9bx. Where have you seen these ads? 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
6___ Not sure
7____None of these places
9___ Prefer not to Answer
A9cx. Where on the Internet have you seen these ads? Check all that apply.
[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
9___ Prefer not to Answer
ASK A10_x for a random set of 2 of the 5 currently airing Real Cost TV ads (Found It, Science Class, Fingers, Skinny Jeans, Contract). DO NOT INCLUDE 7,000, teeth, skin or BARBER
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
9__ Prefer not to Answer
A12b_x. On a scale of 1 to 5, indicate whether the ad made smoking look like something you would or wouldn’t want to do.
1. The ad makes me want to smoke
2
3
4
5. The ad makes me want to NOT smoke
9__ Prefer not to Answer
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
REPEAT A10 through A13 for 2 Real Cost TV ads.
Randomize respondents to be asked A14 through A19 for 2 of the 5 currently airing Real Cost TV ads (Found It, Science Class, Fingers, Skinny Jeans, Contract) for which they report prior exposure (A8=1 or 9).
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 this ad?
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 3
Yes No Prefer not to respond
[RANDOMIZE]
A15_1. This ad was good
A15_2. This ad was 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________________________
A23. What do you take away from this ad? [check all that apply]
[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 ingredients in cigarettes are harmful
6___ Every cigarette costs you something
7___ Smoking is scary in a good way, like a horror movie
8___ One cigarette is not all that bad
9___ This makes smoking seem more serious than it really is
10___ Adults want to control me
11___ Smokers don’t care what other people think
12___ Smokers don’t scare easily
13___ You don’t need a good reason not to smoke
99___ I am not sure
[REPEAT A14_x through A19. FOR 2 ADS.]
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 B7]
B2. 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
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, GO TO B7, otherwise GO TO 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. Do you consider yourself a smoker?
1 Yes
2 No
9 Prefer not to answer
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 B7=1 or 9, GO TO B8; IF B7=2 GO TO B10]
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 B8=2-9 GO TO B9; OTHERWISE GO TO B10]
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 B1=2 or 9 ASK B10_1 through B10_3. IF B7=2 or 9 ASK B10_4 through B10_6. OTHERWISE GO TO B11]
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_22. |
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 |
B21. How many of your four closest friends…
|
|
0 |
1 |
2 |
3 |
4 |
9 |
B21_1. |
Smoke cigarettes? |
0 |
1 |
2 |
3 |
4 |
9 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Section C: Demographic Items
[IF C2=2-9, GO TO C4, OTHERWISE GO TO C5]
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
C14. What is your zip code?
3 Don’t know
9 Prefer not to answer
C15. What county do you live in?
[DROP DOWN MENU BASED ON ZIP]
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/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | [Insert Title of Information Collection] |
| Author | jcapezzu |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |