Youth 1st, 2nd, and; 3rd (Male, Rural Smokeless) follow up questionnaire
Evaluation of the Food and Drug Administration's General Market Youth Tobacco Prevention Campaign
Attachment 2_R. Youth Followup1 Instrument (male rural smokeless)_REVISED
Youth 1st, 2nd, and; 3rd (Male, Rural Smokeless) follow up questionnaire
OMB: 0910-0753
Attachment 2_R: Youth FOLLOW-UP 1 INSTRUMENT
Form Approved
OMB No. 0910-0753
Exp. Date XX/XX/XXXX
Evaluation of the Rural Smokeless Tobacco Education Campaign – First Follow-up (RuSTEC-1)
Subjects for Questionnaire:
Section A: Demographic Items
Section B: Tobacco Use Behavior
Section C: Tobacco Use Intentions and Self-Efficacy
Section D: Cessation (Intention, Behavior, Motivation)
Section E: Attitudes, Beliefs & Risk Perceptions, Social Norm
Section F: Media Use and Awareness
Section G: Environment
Assent for Youth
We are talking to boys in 30 cities across the United States. This study is sponsored by the U.S. Food and Drug Administration. About 8 months ago you took part in this study by completing a survey. We are asking for you to participate again by completing this web survey.
The survey asks boys ages 11-17 about their attitudes related to health behaviors. The survey asks about advertisements they may have seen on TV or online. The advertisements may have also been heard on the radio. The survey will take about 45 minutes to complete. Up to 2,200 boys will take this survey. The survey is part of a research study being conducted by RTI International.
Your parent or guardian has given permission for you to complete this survey.
Your name will be kept private. Your answers will be labeled with a number instead of your name. This makes it so only research staff will know these are your answers. We will not share any information you give us with your parents or anyone outside the research team. All of your answers will be kept private. It is not completely safe to send data through the Internet but we are doing everything we can to protect your data.
If you don't want to take the survey, that is okay. If you don't want to answer a certain question, that is okay too. You may also choose to drop out of the survey at any time, for any reason and you may take a break at any time.
e will offer you a check for $25 if you complete the survey before [EARLY BIRD DEADLINE]. If you complete the survey after that we will offer you a check for $20. You will receive $20 in cash if you complete the survey in person.
We may contact you again in the future. It is up to you to decide if you would like to take any future surveys.
You can call us if you have any questions about the study. The phone number is (866) 214-2039. You can also email us at mediastudy@rti.org. You may also have questions about your rights as a study participant. For those questions call the RTI Office of Research Protection. Their phone number is (866) 214-2043. You can send them an email at orpe@rti.org.
After you select your answer, please press “Next.”
1. Yes, I agree to participate in this study.
2. No, I do not wish to participate in this study.
Section A: Demographic Items
DOB What is your date of birth?
MM/ DD/ YYYY
9 Prefer not to answer
[PROGRAMMER: Only allow 1-12 in MM, 1-31 in DD. Please make sure that no invalid dates appear though. That is Feb 30, Nov 31, etc. cannot be valid. Do not allow future dates. If the date is not valid, please display a hard error, “Please enter a valid date.” THIS ITEM SHOULD BE A REQUIRED ITEM.
IF RESPONDENT LEAVES ITEM BLANK, SHOW THE “Prefer not to answer” OPTION.
IF DOB=9, GOTO REALAGE.]
AGE That would make you FILLAGE years old, is that correct?
Yes
No
[PROGRAMMER: FILLAGE= (DATE TODAY)- DOB]
[IF AGE=NO, GOTO REALAGE]
[PROGRAMMER: MAKE THIS A REQUIRED QUESTION.]
REALAGE
How old are you?
[PROGRAMMER: ALLOW 1-99]
[PROGRAMMER: MAKE THIS A REQUIRED QUESTION. IF RESPONDENT DOES NOT ENTER ANYTHING SOFT PROMPT; “Please enter your age. This information is needed since your age is one of the ways we confirm you are the correct participant.”
IF RESPONDENTS TRY TO SKIP THE SECOND TIME AROUND, GOTO INELIG.]
S2. [IF FILLAGE OR REALAGE≠[FU1 AGE] OR [FU1_AGE +1] 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
HARD CHECK: IF WEB AND S2≠[BL1 AGE] OR [BL1 AGE +1]
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 may contact your parent or guardian to arrange an in-person interview.
Thank you for your time.
PROGRAMMER: EXIT PROGRAM
[IF CAPI AGE IS INCONSISTENT, ALLOW RESPONSES AND CONTINUE]
Section B: Tobacco Use Behavior
Cigarette Use
{Programmer: Please randomize the order in which the tobacco questions are presented in each section (i.e., Cigarette questions in section B would come first sometimes while other times, smokeless tobacco questions would come first).
The following are items that go together:
B1- B4 == cigarettes
B5- B9 == smokeless tobacco products
B10- B11== cigars
B12- B13 == hookah
B14- B16 == e-cigs
Please randomize without breaking the blocks of items that go together sequentially.}
B1. [IF BLB1 NE 1] The next section asks about your experiences with tobacco products.
Have you ever tried cigarette smoking, even one or two puffs?
1 Yes
2 No
9 Prefer not to answer
ASK B2. IF B1=2, ASK B5]
[IF BASELINE B1=1] Previously, you reported that you have tried cigarette smoking.
B2. [IF B1=1 or 9 OR BLB1 = 1 OR 9] 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
B3. [IF BLB1=1 OR 9 OR B1=1 OR 9 AND B2 NE 1] 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
B4. [IF B1=1 or 9 OR BLB1 = 1 OR 9] 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
Other Tobacco Product Use
B5. [IF BLB5 NE 1] 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
B6. [IF BLB5=1 OR B5=1 OR 9] 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
B7. [IF BLB5=1 OR B5=1 OR 9] How many times have you used smokeless tobacco in your entire life?
1 1 time
2 2 to 10 times
3 11 to 20 times
4 21 to 50 times
5 51 to 99 times
6 100 or more times
9 Prefer not to answer
B8. [IF BLB5=1 OR B5=1 OR 9] How often do you swallow smokeless tobacco juices?
1 Always
2 Sometimes
3 Rarely
4 Never
9 Prefer not to answer
B9. [IF BLB5=1 OR B5=1 OR 9] How soon after you wake up do you use smokeless tobacco?
1 Within 5 minutes
2 6 to 30 minutes
3 31 to 60 minutes
4 More than 60 minutes
9 Prefer not to answer
B10. [IF BASELINE B10 NE 1]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
B11. [IF BLB10=1 OR B10=1 OR 9] 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
B12. [IF BLB12 NE 1] 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
B13. [IF BLB12=1 OR B12=1 OR 9] 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
B14. [IF BLB14NE 1] The next questions are about e-cigarettes (e-cigs), e-hookahs, vape pens, hookah pens and personal vaporizers. Some common brands include Fin, NJOY, Blu, e-Go, and Vuse.
Have you ever tried any e-cigs or vape pens, even one time?
1 Yes
2 No
9 Prefer not to answer
B15. [IF BLB14=1 OR B14= 1 OR 9] 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
B16. [IF BLB14=1 OR B14= 1 OR 9] Does the e-cig you usually use contain nicotine?
1 Yes
2 No
3 Don’t Know
9 Prefer not to answer
Section C: Tobacco Use Intentions and Self-Efficacy
{Programmer: Randomize the ordering of the sets C1, C2, and C3.}
C1. Thinking about the future…
|
|
Definitely Yes |
Probably Yes |
Probably Not |
Definitely Not |
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. |
If one of your best friends were to offer you a cigarette, would you smoke it? |
1 |
2 |
3 |
4 |
9 |
C1_4. |
Have you ever been curious about smoking cigarettes? |
1 |
2 |
3 |
4 |
9 |
C2. Thinking about the future…
|
|
Definitely Yes |
Probably Yes |
Probably Not |
Definitely Not |
Prefer Not to Answer |
C2_1. |
Do you think that you will use smokeless tobacco? |
1 |
2 |
3 |
4 |
9 |
C2_2. |
Do you think you will use smokeless tobacco at any time in the next year? |
1 |
2 |
3 |
4 |
9 |
C2_3. |
If one of your best friends were to offer you smokeless tobacco would you use it? |
1 |
2 |
3 |
4 |
9 |
C2_4 |
Have you ever been curious about using smokeless tobacco? |
1 |
2 |
3 |
4 |
9 |
C3. Thinking about the future…
|
|
Definitely Yes |
Probably Yes |
Probably Not |
Definitely Not |
Prefer Not to Answer |
C3_1. |
Do you think that you will use an e-cig soon? |
1 |
2 |
3 |
4 |
9 |
C3_2. |
Do you think you will use an e-cig at any time in the next year? |
1 |
2 |
3 |
4 |
9 |
C3_3. |
If one of your best friends were to offer you an e-cig, would you use it? |
1 |
2 |
3 |
4 |
9 |
C3_4 |
Have you ever been curious about using e-cigs? |
1 |
2 |
3 |
4 |
9 |
C4. How sure are you that, if you really wanted to, you could say no to smokeless tobacco, if…
[RANDOMIZE C4_1-C4_3]
|
Not at all sure |
Slightly sure |
Somewhat sure |
Mostly sure |
Completely sure |
Prefer Not to Answer |
C4_1. You are hanging out where most people are using it? |
1 |
2 |
3 |
4 |
5 |
9 |
C4_2. A friend offers it? |
1 |
2 |
3 |
4 |
5 |
9 |
C4_3. If a family member offers it? |
1 |
2 |
3 |
4 |
5 |
9 |
Section D: Cessation (Intention, Behavior, Motivation)
{Programmer: Randomize the set:
D1-D2 ==cigarettes
D3-D4 == smokeless tobacco}
Cigarette Use
D1. [IF B2=2-7 OR 9] During the past 3 months, did you stop smoking cigarettes for one day or longer because you were trying to quit smoking cigarettes for good?
1 Yes
2 No
9 Prefer not to answer
D2. [IF D1 NE BLANK] How much do you want to stop smoking?
1 Not at all
2 A little
3 Somewhat
4 A lot
9 Prefer not to answer
Other Tobacco Use
D3. [IF B5=2-7 OR 9]During the past 3 months, did you stop using smokeless tobacco 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
D4. [IF D3 NE BLANK] How much do you want to stop using smokeless tobacco?
1 Not at all
2 A little
3 Somewhat
4 A lot
9 Prefer not to answer
Section E: Attitudes, Beliefs & Risk Perceptions, Social Norm
[ASK ALL] The next set of questions asks for your opinions on cigarette use and other tobacco products.
Attitude
E1. Smoking cigarettes is…(pick one)
[RANDOMIZE E1_1-E1_3] [MAKE THIS ITEM SKIPPABLE]
PROGRAMMER. DISPLAY ITEM LIKE THAT BELOW. R WILL CLICK BUTTON TO ENTER RESPONSE.
E1_1. |
Bad |
|
|
|
|
|
|
|
Good |
E1_2. |
Unenjoyable |
|
|
|
|
|
|
|
Enjoyable |
E1_3. |
Harmful |
|
|
|
|
|
|
|
Not Harmful |
E2. Using smokeless tobacco is…
[RANDOMIZE E2_1-E2_3] [MAKE THIS ITEM SKIPPABLE]
PROGRAMMER: DISPLAY ITEM LIKE THAT BELOW. R WILL CLICK BUTTON TO ENTER RESPONSE.
E2_1. |
Bad |
|
|
|
|
|
|
|
Good |
E2_2. |
Unenjoyable |
|
|
|
|
|
|
|
Enjoyable |
E2_3. |
Harmful |
|
|
|
|
|
|
|
Not Harmful |
E3. Using e-cigs or vape pens is…
[RANDOMIZE E3_1-E3_3] [MAKE THIS ITEM SKIPPABLE]
DISPLAY ITEM LIKE THAT BELOW. R WILL CLICK BUTTON TO ENTER RESPONSE.
E3_1. |
Bad |
|
|
|
|
|
|
|
Good |
E3_2. |
Unenjoyable |
|
|
|
|
|
|
|
Enjoyable |
E3_3. |
Harmful |
|
|
|
|
|
|
|
Not Harmful |
Attitudinal Beliefs and Risk Perceptions
{PROGRAMMER: RANDOMIZE between the sets “E4_1- E4_9” and “E4_10- E4_18” }
E4. How much do you agree or disagree with the following statements? If I use smokeless tobacco, I will…
{PROGRAMMER: RANDOMIZE E4_1- E4_9. }
|
|
Strongly Disagree |
Disagree |
Neither Agree or Disagree |
Agree |
Strongly Agree |
Prefer Not to Answer |
E4_1. |
Damage my body |
1 |
2 |
3 |
4 |
5 |
9 |
E4_2. |
Be controlled by smokeless tobacco |
1 |
2 |
3 |
4 |
5 |
9 |
E4_3. |
Be more attractive |
1 |
2 |
3 |
4 |
5 |
9 |
E4_4. |
Develop cancer of the lip, mouth, tongue or throat |
1 |
2 |
3 |
4 |
5 |
9 |
E4_5. |
Develop sexual and/or fertility problems |
1 |
2 |
3 |
4 |
5 |
9 |
E4_6. |
Fit in |
1 |
2 |
3 |
4 |
5 |
9 |
E4_7. |
Be unable to stop when I want to |
1 |
2 |
3 |
4 |
5 |
9 |
E4_8. |
Lose my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E4_9 . |
Shorten my life |
1 |
2 |
3 |
4 |
5 |
9 |
E4_10- E4_18. How much do you agree or disagree with the following statements? If I use smokeless tobacco, I will…
{PROGRAMMER: RANDOMIZE E4_10- E4_18. }
|
|
1 |
2 |
3 |
4 |
5 |
|
9 |
E4_10 . |
Get sick more often |
1 |
2 |
3 |
4 |
5 |
9 |
|
E4_11. |
End up wasting money on smokeless tobacco |
1 |
2 |
3 |
4 |
5 |
9 |
|
E4_12. |
Feel more relaxed |
1 |
2 |
3 |
4 |
5 |
9 |
|
E4_13. |
Miss out on things I enjoy doing |
1 |
2 |
3 |
4 |
5 |
9 |
|
E4_14. |
Gross out people I want to date |
1 |
2 |
3 |
4 |
5 |
9 |
|
E4_16. |
Develop gum disease |
1 |
2 |
3 |
4 |
5 |
9 |
|
E4_17. |
Develop red or white patches in the mouth |
1 |
2 |
3 |
4 |
5 |
9 |
|
E4_18. |
Consume harmful chemicals |
1 |
2 |
3 |
4 |
5 |
9 |
E5. How much do you agree or disagree with the following statements? If I smoke cigarettes I will…
{PROGRAMMER: RANDOMIZE E5_1- E5_11.}
|
|
Strongly Disagree |
Disagree |
Neither Agree or Disagree |
Agree |
Strongly Agree |
Prefer Not to Answer |
E5_1. |
Be controlled by smoking |
1 |
2 |
3 |
4 |
5 |
9 |
E5_2. |
Be more attractive |
1 |
2 |
3 |
4 |
5 |
9 |
E5_3. |
Develop cancer of the lip, mouth, tongue or throat |
1 |
2 |
3 |
4 |
5 |
9 |
E5_4. |
Develop sexual and/or fertility problems |
1 |
2 |
3 |
4 |
5 |
9 |
E5_5. |
Be unable to stop when I want to |
1 |
2 |
3 |
4 |
5 |
9 |
E5_6. |
Develop skin problems |
1 |
2 |
3 |
4 |
5 |
9 |
E5_7. |
Lose my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E5_8. |
Feel more relaxed |
1 |
2 |
3 |
4 |
5 |
9 |
E5_9. |
Shorten my life |
1 |
2 |
3 |
4 |
5 |
9 |
E5_10. |
End up wasting money on cigarettes |
1 |
2 |
3 |
4 |
5 |
9 |
E5_11. |
Be more popular |
1 |
2 |
3 |
4 |
5 |
9 |
E6. How much do you agree or disagree with the following statements about smoking cigarettes?
{PROGRAMMER: RANDOMIZE E6_1- E6_4.}
|
|
Strongly Disagree |
Disagree |
Neither Agree or Disagree |
Agree |
Strongly Agree |
Prefer Not to Answer |
E6_1. |
Smoking can cause immediate damage to my body. |
1 |
2 |
3 |
4 |
5 |
9 |
E6_2. |
Smoking cigarettes helps people relieve stress. |
1 |
2 |
3 |
4 |
5 |
9 |
E6_3. |
Cigarette ingredients are disgusting. |
1 |
2 |
3 |
4 |
5 |
9 |
E6_4. |
Smoking cigarettes is a manly thing to do |
1 |
2 |
3 |
4 |
5 |
9 |
E7. How much do you agree or disagree with the following statements about using smokeless tobacco?
{PROGRAMMER: RANDOMIZE E7_1- E7_7.}
|
|
Strongly Disagree |
Disagree |
Neither Agree or Disagree |
Agree |
Strongly Agree |
Prefer Not to Answer |
E7_1. |
Using smokeless tobacco can cause immediate damage to my body. |
1 |
2 |
3 |
4 |
5 |
9 |
E7_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 |
E7_3. |
If I used smokeless tobacco occasionally I would not become addicted. |
1 |
2 |
3 |
4 |
5 |
9 |
E7_4. |
Using smokeless tobacco helps people relieve stress. |
1 |
2 |
3 |
4 |
5 |
9 |
E7_5. |
Using smokeless tobacco is disgusting. |
1 |
2 |
3 |
4 |
5 |
9 |
E7_7. |
Using smokeless tobacco is a way to show others you’re not afraid to take risks |
1 |
2 |
3 |
4 |
5 |
9 |
E7_9 |
Using smokeless tobacco is a manly thing to do |
1 |
2 |
3 |
4 |
5 |
9 |
E8. Does smokeless tobacco such as dip, chewing tobacco, or snuff contain….
[Randomize E8_1 – E8_8]
|
|
Definitely Yes |
Probably Yes |
Probably Not |
Definitely Not |
Don’t Know |
Prefer Not to Answer |
E8_1. |
Arsenic, a substance found in motor oil? |
1 |
2 |
3 |
4 |
5 |
9 |
E8_2. |
Beryllium, a substance used in nuclear weapons and nuclear power reactors? |
1 |
2 |
3 |
4 |
5 |
9 |
E8_3. |
Cadmium, a substance found in batteries? |
1 |
2 |
3 |
4 |
5 |
9 |
E8_4. |
Formaldehyde, a chemical used to preserve dead animals? |
1 |
2 |
3 |
4 |
5 |
9 |
E8_5. |
Lead, a substance found in bullets? |
1 |
2 |
3 |
4 |
5 |
9 |
E8_6. |
Naphthalene, a chemical found in mothballs? |
1 |
2 |
3 |
4 |
5 |
9 |
E8_7. |
Polonium 210, a poison? |
1 |
2 |
3 |
4 |
5 |
9 |
E8_8. |
Uranium, a substance used in nuclear weapons and nuclear power reactors? |
1 |
2 |
3 |
4 |
5 |
9 |
Social Norms
E9. How many of your four closest friends…
[Randomize E9_1 – E9_3]
|
|
None |
One |
Two |
Three |
Four |
Prefer Not to Answer |
E9_1. |
Smoke cigarettes? |
0 |
1 |
2 |
3 |
4 |
9 |
E9_2. |
Use smokeless tobacco? |
0 |
1 |
2 |
3 |
4 |
9 |
E9_3. |
Use e-cigs? |
0 |
1 |
2 |
3 |
4 |
9 |
E10. How many others your age…
[Randomize E10_1 – E10_3]
|
|
None |
A few |
Some |
Most |
All |
Prefer Not to Answer |
E10_1. |
Smoke cigarettes? |
0 |
1 |
2 |
3 |
4 |
9 |
E10_2. |
Use smokeless tobacco? |
0 |
1 |
2 |
3 |
4 |
9 |
E10_3. |
Use e-cigs? |
0 |
1 |
2 |
3 |
4 |
9 |
Section F: Media Use and Awareness
F1. Next, we’d like to ask you about your use of TV and other media.
How often do you… [Randomize F1_1 – F1_8]
|
Several times a day |
About Once a Day |
3-5 days a week |
1-2 days a week |
Every few weeks |
Less often |
Never |
Prefer Not to Answer |
F1_1. Watch television? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F1_2. Watch videos on YouTube/Twitch? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F1_3. Listen to radio? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F1_4. Listen to streaming radio? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F1_5. Play games on any electronic devices including cell phones/ smartphones, computers, laptops, tablets, consoles (Xbox, Wii, PS) and handheld players (Nintendo DS, Sony PSP, iPod)? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F1_6. Look at or read any magazines on a computer, laptop, or tablet. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F1_7. Watch Netflix, Hulu or Amazon Prime video? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F1_8. Go to the movies at a movie theater? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2. Thinking about the social networking sites you use, about how often do you visit or use the following…
{PROGRAMMER: RANDOMIZE F2_1 – F2_9.}
|
Several times a day |
About Once a Day |
3-5 days a week |
1-2 days a week |
Every few weeks |
Less often |
Never |
Prefer Not to Answer |
F2_1. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2_2. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2_3. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2_4. Periscope |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2_5. Snapchat |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2_6. Vine |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2_7. Skype |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2_8. Google Hangouts |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2_9. |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3. Thinking about the following websites, about how often do you visit or use the following…
[RANDOMIZE ALL]
|
Several times a day |
About once a day |
3-5 days a week |
1-2 days a week |
Every few weeks |
Less often |
Never |
Prefer not to answer |
F3_1. http://www.youtube.com |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3_2. http://www.facebook.com |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3_3. http://www.twitter.com |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3_4. http://www.spotify.com |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
|
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F4. 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.
{PROGRAMMER: RANDOMIZE F4_1 – F4_5. }
F4_1. Since [FILL DATE], have you seen or heard the following slogan or theme?
t
ruth
1 Yes
2 No
3 Not Sure
9 Prefer not to answer
F4_2. Since [FILL DATE], have you seen or heard the following slogan or theme?
D
own
and Dirty
1 Yes
2 No
3 Not Sure
9 Prefer not to answer
F4_3. Since [FILL DATE], have you seen or heard the following slogan or theme?
D
igital
Youth Against Tobacco (DYAT)
1 Yes
2 No
3 Not Sure
9 Prefer not to answer
F
4_4. 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
F4_4a. Since [FILL DATE], have you seen or heard the following slogan or theme?
The Real Cost Smokeless Doesn’t Mean Harmless
1
Yes
2 No
3 Not Sure
9 Prefer not to answer
F4_5. Since [FILL DATE], have you seen or heard the following slogan or theme?
T
ips
from Former Smokers (Tips)
1 Yes
2 No
3 Not Sure
9 Prefer not to answer
F4_6. Since [FILL DATE], have you seen or heard the following slogan or theme?
F
resh
Empire
1 Yes
2 No
3 Not Sure
9 Prefer not to answer
ASK F5_3 IF F4_4a =1 or 3, OTHERWISE ASK F7_x.
F5_3. Where have you seen or heard about The Real Cost Smokeless Doesn’t Mean Harmless Campaign? Check all that apply.
[RANDOMIZE]
|
|
Yes |
No |
F5_3a. |
On TV or the Internet/online |
|
|
F5_3b. |
On the radio |
|
|
F5_3c. |
Billboards or other outdoor ads |
|
|
F5_3d. |
At the movie theatre |
|
|
F6a. The Real Cost Smokeless Doesn’t Mean Harmless Campaign is online. Have you ever seen this Campaign on… Check all that apply.
RANDOMIZE
|
|
Yes |
No |
F6_1. |
Facebook? |
|
|
F6_2. |
Twitter? |
|
|
F6_3. |
YouTube? |
|
|
F6_4. |
Pandora or Spotify? |
|
|
F6_5. |
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 The Real Cost Smokeless Doesn’t Mean Harmless Campaign and SCREENSHOTS for ads from other campaigns (i.e., The Real Cost, Tips, Truth, and Fresh Empire). Don’t allow a response until the video has played for 15 seconds. F8_x will be asked after all videos and screenshots. F19_x will only be asked after The Real Cost Smokeless doesn’t Mean Harmless Campaign videos.]
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
SHOW SCREENGRAB OF AD
F19_x. What is the main message of this ad? Select only one response
[RANDOMIZE ORDER OF CHECKBOX LIST] [notes here indicate the ad for which this is a key message]
1___ Smokeless tobacco can damage your teeth [face of denial]
3___ Smokeless tobacco is addictive [football, movie monster]
4___ Smokeless tobacco can control your life [football, movie monster]
5___ Smokeless tobacco can cause mouth cancer [face of denial, jeans]
6___ Smokeless tobacco contains cancer-causing chemicals [pounds]
7___ Smokeless doesn’t mean harmless
99__ I am not sure
F10_x. How would you describe this advertisement?
F10_1. |
Bad |
|
|
|
|
|
|
|
Good |
|
|
|
|
|
|
|
|
|
|
F11_x. Please tell us if you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree with the following statements.
[RANDOMIZE ALL]
|
|
Strongly Disagree |
Disagree |
Neither Agree or Disagree |
Agree |
Strongly Agree |
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 smokeless tobacco look like something you would or wouldn’t want to use.
This ad makes me want to…
USE smokeless tobacco |
1 |
2 |
3 |
4 |
5 |
NOT USE smokeless tobacco |
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
LOOP BACK TO ASK ABOUT NEXT AD HERE.
[REPEAT F10_x - F18x FOR OTHER The Real Cost Smokeless Doesn’t Mean Harmless ADS]
STREAMING RADIO AWARENESS
F24. Since [FILL DATE], have you heard about The Real Cost Smokeless Doesn’t Mean Harmless Campaign on streaming radio? (DISPLAY LOGO)
1 Yes
2 No
3 Not Sure
9 Prefer not to answer
Now we would like to play you some radio clips that have aired in the U.S. Once you have listened the clip, please click on the forward arrow below to continue with the survey.
[PLAY RADIO CLIPS IN RANDOM ORDER. DON’T ALLOW A RESPONSE UNTIL THE AD HAS PLAYED FOR 10 SECONDS]
F25_x. Apart from this survey, how frequently have you heard this on the radio since [FILL DATE]?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very Often
9 Prefer not to answer
F26_x. How much do you agree or disagree with the following statements?
|
|
Strongly Disagree |
Disagree |
Neither Agree or Disagree |
Agree |
Strongly Agree |
Prefer Not to Answer |
|
This radio ad is convincing |
1 |
2 |
3 |
4 |
5 |
9 |
LOOP BACK TO ASK ABOUT NEXT RADIO CLIP HERE. PRESENT ALL CLIPS BEFORE ASKING ANY RECEPTIVITY QUESTIONS.
F18a. Have you visited therealcost.gov/dip 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
F5. 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
F6. 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
F7. Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statements.
I try to do what my parents want me to do.
1 Strongly agree
2 Agree
3 Disagree
4 Strongly disagree
9 Prefer not to answer
F8. What my parents think of me is important.
1 Strongly agree
2 Agree
3 Disagree
4 Strongly disagree
9 Prefer not to answer
F9. I do what my friends want me to do, even if I don’t want to.
1 Strongly agree
2 Agree
3 Disagree
4 Strongly disagree
9 Prefer not to answer
F10. To keep my friends, I’d even do things I don’t want to do.
1 Strongly agree
2 Agree
3 Disagree
4 Strongly disagree
9 Prefer not to answer
Section G: Environment
G1. The next section asks some questions about your household and peers.
Other than you, has anyone who lives with you used any of the following during the past 30 days? Select all that apply.
1 Cigarettes
2 Smokeless tobacco
3 Cigars, cigarillos, or little cigars
4 Tobacco out of a water pipe (also called “hookah”)
5 Electronic cigarettes (also called e-cigs)
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
{Programmer: Allow respondents to select more than one response on 1-6.
If response 7 was chosen with other response options, “You indicated that no one who lives with you used any form of tobacco during the past 30 days and also said that in the past 30 days someone has used a form of tobacco. Please choose either someone or no one has smoked any form of tobacco as your response.”}
G2. Do you have any brother(s) and/or sister(s) who have used smokeless tobacco during the past 30 days?
1 Yes
2 No
3 I don’t know
4 I don’t have any brothers or sisters
9 Prefer not to answer
G3. Which statement best describes the rules about smoking in your home? Would you say…
1 Smoking is not allowed anywhere inside your home
2 Smoking is allowed in some places or at some times
3 Smoking is allowed anywhere inside the home
4 There are no rules about smoking inside the home
9 Prefer not to answer
G4. Which statement best describes the rules about using smokeless tobacco in your home? Would you say…
1 Smokeless tobacco is not allowed anywhere inside your home
2 Smokeless tobacco is allowed in some places or at some times
3 Smokeless tobacco is allowed anywhere inside the home
4 There are no rules about using smokeless tobacco inside the home
9 Prefer not to answer
G5. 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
G6. Please tell us if you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree with the following statements.
I feel close to people at my school. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree
4 Agree
5 Strongly Agree
9 Prefer not to answer
G7. I am happy to be at my school. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree
4 Agree
5 Strongly Agree
9 Prefer not to answer
G8. I feel like I am a part of my school. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree
4 Agree
5 Strongly Agree
9 Prefer not to answer
G9. 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
G10. 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.
__________ (Range: 0-7)
[Programmer: Numeric String. Allow a minimum of 0 and maximum of 7. If anything else is typed in error message should say, “You have entered a number outside the allowed range. Please enter an answer between 0 and 7.”]
9 Prefer not to answer
G11. How often do you attend church or religious services? Would you say…
1 Never
2 Less than once a month
3 About once a month
4 About 2 or 3 times a month
5 Once a week
6 More than once a week
9 Prefer not to answer
G12. Please tell us if you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree with the following statements.
I would like to explore strange places. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree
4 Agree
5 Strongly Agree
9 Prefer not to answer
G13. I like to do frightening things. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree
4 Agree
5 Strongly Agree
9 Prefer not to answer
G14. 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
4 Agree
5 Strongly Agree
9 Prefer not to answer
G15. I prefer friends who are exciting and unpredictable. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree
4 Agree
5 Strongly Agree
9 Prefer not to answer
G16. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
_____ Number of days
3 Don’t know
9 Prefer not to answer
{Programmer: Numeric String. Allow a minimum of 0 and maximum of 30.
If anything else is typed in, error message should say, “You have entered a number outside the allowed range. Please enter a number between 0 and 30.”
Respondents can only respond with the option Don’t Know, or type in a numeric response. If respondents try to do multiple things, error message should say “ You have entered a number and selected Don’t Know. Please choose one or the other as your response.”}
G17. The next section asks some questions about how you feel about your current relationship with your parents or guardians.
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
4 Agree
5 Strongly Agree
9 Prefer not to answer
G18. How close do you feel to the adult or adults you live with?
1 Not at all close
2 Not very close
3 Somewhat close
4 Quite close
5 Very close
9 Prefer not to answer
G19. How often has a parent or other adult caregiver said things that really hurt your feelings or made you feel like you were not wanted or loved?
1 One time
2 Two times
3 Three to five times
4 Six to ten times
5 More than ten times
6 This has never happened
7 Don’t know
9 Prefer not to answer
G20. Has a parent or other adult caregiver ever talked to you about reasons for not using smokeless tobacco?
1 Yes
2 No
9 Prefer not to answer
G21. During the past 7 days, on how many days did you and one or both of your parents or other adult caregivers do something together just for fun?
__________
9 Prefer not to answer
{Programmer: Numeric String. Allow a minimum of 0 and maximum of 7. If anything else is typed in error message should say, “You have entered a number outside the allowed range. Please enter a number between 0 and 7.”}
FINAL
That was the last question. Once you move past this screen, your responses will be locked. They cannot be seen by your interviewer. Please tell your interviewer that you are finished.
Thank you for taking time to complete this survey.
{Programmer: Have a screen with the “Thank you” text bolded.}
CODE INTERVIEWER - ENTER 3 DIGIT CODE TO LOCK RESPONSES
{Programmer: Code is RTI}
Section H: Closing Contact Items
RECON. Thank you for your responses! We will be conducting two other rounds of this survey every 8 months. Your participation in these next rounds is really important, so that we can measure what has changed over time. When we contact you again in the future, you will be able to decide if you want to take part in the survey at that time, and you can change your mind at any point.
Can we contact you to invite you to take the next two rounds of the survey?
Yes
No
[PROGRAMMER: MAKE THIS A REQUIRED QUESTION. IF ITEM IS LEFT BLANK, HARD PROMPT CAPI “Interviewer, this is a required item. Please do your best to fill out the item.” WEB “Please provide a response to this item”]
RECONREF. [IF RECON=NO] Your participation is important for the success of this study. We will find a time that works for you to be interviewed, and you will receive a cash token of appreciation after you complete the interview. Can we contact you for the next two surveys?
Yes
No
[PROGRAMMER: MAKE THIS A REQUIRED QUESTION. IF ITEM IS LEFT BLANK, HARD PROMPT WEB “Interviewer, this is a required item. Please do your best to fill out the item.” WEB “Please provide a response to this item”]
H3. [IF RECON=1 OR RECONREF=1 AND CAPI] INTERVIEWER: ASK ITEM OF PARENT Please provide an email address where we can contact you about the next two rounds of the survey.
OPEN END TEXT
email address:_________________ [ALLOW 50 CHARACTERS]
confirm email address:__________[MUST MATCH FIRST ENTRY]
PROGRAMMER: VALIDATE FORMAT FOR EMAIL ADDRESS. IF FORMAT IS INCORRECT, PLEASE DISPLAY “Please enter a valid email address.” IF THE EMAIL ADDRESSES DON’T MATCH PLEASE DISPLAY “The email addresses do not match. Please try again.”
H4. [IF RECON=1 OR RECONREF=1 AND CAPI] ASK ITEM OF PARENTS Please provide your phone number including area code in case we are unable to reach you by e-mail during the next follow-up survey.
OPEN END NUM
VALIDATION: MIN 0 MAX 9999999999
(__ __ __) __ __ __ - __ __ __ __ Phone Number [ALLOW 10 CHARACTERS]
PROGRAMMER: VALIDATE FORMAT FOR PHONE NUMBER. IF FORMAT IS INCORRECT, PLEASE DISPLAY “Please enter a valid phone number.”
INCENT01 [IF CAPI] PROGRAMMER: DISPLAY CASE ID FROM IFMS ON SCREEN.
INTERVIEWER [IF APPLICABLE]: SIGN COMPENSATION RECEIPT AND HAND $20 TO R
INTERVIEWER, DID YOU GIVE THE RESPONDENT THEIR INCENTIVE?
1 Yes
2 No
[PROGRAMMER:
MAKE SURE THIS ITEM IS REQUIRED. HARD PROMPT ““Interviewer, this is a required item. Please do your best to fill out the item.”]
INCENT02
[IF INCENT01=1 AND CAPI] I have signed this form to indicate that I have given you $25 for completing this interview. Thanks again!
NEXT
INCENT03 [IF INCENT01=2 AND CAPI] INTERVIEWER, PLEASE INDICATE WHY YOU ARE NOT ABLE TO GIVE THE INCENTIVE TO THE RESPONDENT.
_________________
[PROGRAMMER: MAKE THIS A REQUIRED ITEM IF THEY WERE ROUTED HERE. HARD PROMPT “Interviewer, this is a required item. Please do your best to fill out the item.”]
END
WEBTH [IF WEB]To thank you for completing the survey, you will receive a check for [$20/$25 IF EARLY BIRD]. We will need to collect some information from you so that we can mail out a check. This information will be kept completely confidential in secure and protected data files and will be separate from the responses provided in the survey. If you would like to decline receiving this payment, you can leave the information blank and simply press “Next” to continue to the next screen.
[SOFT CHECK IF ANY FIELDS ARE MISSING]
Please provide FILL IF AGE_CONFIRM = 1: “your”; FILL IF AGE_CONFIRM = 2: “your child’s”] first and last name
First name: YFNAME
Last name: YLNAME
What is the best address where we should mail the check?
Street: YSTREET
City: YCITY
State: YSTATE
Zip Code: YZIP
Press “Next” to continue.
[PROGRAMMER INSTRUCTION: PLEASE HAVE YFNAME, YLNAME, YCITY YSTATE ONLY ALLOW ALPHA CHARACTERS AND HAVE YZIP ONLY ALLOW NUMERIC CHARACTERS
EXIT
OMB No: 0910-0753 Expiration Date: XX/XX/XXXX
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/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | PR* |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |
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