Cohort 2--Youth Baseline Questionnaire
Evaluation of the Food and Drug Administration's General Market Youth Tobacco Prevention Campaign
Attachment 2_E2a. Youth Baseline Instrument ExPECTT
Cohort 2--Youth Baseline Questionnaire
OMB: 0910-0753
Attachment 2_E2a: Youth Baseline Instrument
OMB
No. 0910-0753
Exp. Date xx/xx/xxxx
Evaluation of the Public Education Campaign on Teen Tobacco (ExPECTT-B-2nd Cohort)
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
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 private to the fullest extent allowed by law, 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
The first part of the survey asks you some general questions about yourself.
A1_2.
What is your date of birth?
(mm/dd/yyyy)
A1_3. That would make you XX years old, is that correct?
Yes
No
If A1_2 ≠A1_3 ask A1_4.
A1_4. To be sure we have the right information, please enter your birthdate once more.
(mm/dd/yyyy)
A1_5. That would make you XX years old, is that correct?
Yes
No
If A1_4 ≠A1_4, FI resolve and enter birthdate and or age.
A2. Are you male or female?
1 Female
2 Male
9 Prefer not to answer
A3. 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
A4. What race or races do you consider yourself to be? Please select 1 or more of these categories.
-
1
Yes
A4_1. White
1
A4_2. Black or African American
1
A4_3. American Indian or Alaska Native
1
A4_4. Asian Indian
1
A4_5. Chinese
1
A4_6. Filipino
1
A4_7. Japanese
1
A4_8. Korean
1
A4_9. Vietnamese
1
A4_10. Native Hawaiian
1
A4_11. Guamanian or Chamorro
1
A4_12. Samoan
1
A4_13. Other Asian
1
A4_14. Other Pacific Islander
1
[IF A3=2-9, ASK A5, otherwise go to A7]
A5. In general, do you usually speak…
1 Only Spanish
2 Spanish more than English
3 Spanish and English equally
4 English more than Spanish
5 English only
9 Prefer not to answer
[IF A5=1-4, ASK A6, otherwise go to A7]
A6. When you watch TV, what type of programming do you usually watch?
1 Only Spanish
2 Spanish more than English
3 Spanish and English equally
4 English more than Spanish
5 English only
9 Prefer not to answer
A7. What grade are you in?
1 5th
2 6th
3 7th
4 8th
5 9th
6 10th
7 11th
8 12th
9 Ungraded or other grade
99 Prefer not to answer
A8. During the past 30 days, about how much money did you have each week to spend any way you wanted to?
1 None
2 $5 or less
3 $6 to $10
4 $11 to $20
5 $21 to $35
6 $36 to $50
7 $51 to $75
8 $76 to $125
9 $126 or more
99 Prefer not to answer
Section B: Tobacco Use Behavior
The next section asks about your experiences with tobacco products.
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
B7. Do you smoke:
1 Only when you are alone
2 Mainly when you are alone
3 As often alone as with others
4 Mainly when you are with others
5 Only when you are with others
9 Prefer not to answer
B8. Do you consider yourself a smoker?
1 Yes
2 No
9 Prefer not to answer
Other Substance Use
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
The next questions are about cigars, cigarillos, or little cigars such as Black & Mild, Swisher Sweets, Dutch Masters, Phillies Blunts, Prime Time, and Winchester.
B11. 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
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
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.
B15. 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]
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 try 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_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 try 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 try cigars, cigarillos, or little cigars soon? |
1 |
2 |
3 |
4 |
9 |
C1_10 |
Do you think you will try 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
Not at all sure2
Slightly sure3
Somewhat sure4
Mostly sure5
Completely sure9
Prefer Not to AnswerC2_1. You are at a party where most people are smoking?
1
2
3
4
5
9
C2_2. A very close friend offers it?
1
2
3
4
5
9
C2_3. Someone you know offers it?
1
2
3
4
5
9
C3. How sure are you that, if you really wanted to, you could say no to a smokeless tobacco offer, such as chewing tobacco, snuff, snus or dip if…
[RANDOMIZE C3_1-C3_3]
-
1
Not at all sure2
Slightly sure3
Somewhat sure4
Mostly sure5
Completely sure9
Prefer Not to AnswerC3_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…,
[RANDOMIZE C3_1-C3_3]
-
1
Not at all sure2
Slightly sure3
Somewhat sure4
Mostly sure5
Completely sure9
Prefer Not to AnswerC4_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 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
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 3 months, 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_4]
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_4]
E2_1. |
Bad |
|
|
|
|
|
|
|
Good |
E2_2. |
Unenjoyable |
|
|
|
|
|
|
|
Enjoyable |
E2_3. |
Harmful |
|
|
|
|
|
|
|
Not Harmful |
E13. Smoking cigars, cigarillos, or little cigars is… (pick one)
[RANDOMIZE E13_1-E13_2]
E13_1. |
Bad |
|
|
|
|
|
|
|
Good |
E13_2. |
Unenjoyable |
|
|
|
|
|
|
|
Enjoyable |
E13_3. |
Harmful |
|
|
|
|
|
|
|
Not Harmful |
E14. Using e-cigarettes is… (pick one)
[RANDOMIZE E14_1-E14_2]
E14_1. |
Bad |
|
|
|
|
|
|
|
Good |
E14_2. |
Unenjoyable |
|
|
|
|
|
|
|
Enjoyable |
E14_3. |
Harmful |
|
|
|
|
|
|
|
Not Harmful |
Attitudinal Beliefs and Risk Perceptions
E3. How much do you agree or disagree with the following statements? If I smoke I will…
|
If I smoke I will… |
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_23 |
Have trouble breathing |
1 |
2 |
3 |
4 |
5 |
9 |
E3_24 |
Stunt the growth of my lungs |
1 |
2 |
3 |
4 |
5 |
9 |
E3_25 |
Have yellow, stained teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E3_26 |
Develop gum disease |
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?
|
|
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 started to smoke occasionally I would not become addicted. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_4. |
Smoking cigarettes helps people relieve stress. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_5. |
Cigarette ingredients are disgusting. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_6. |
Cigarette ingredients are dangerous. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_7. |
Smoking is a way to show others you’re not afraid to take risks |
1 |
2 |
3 |
4 |
5 |
9 |
E5_8. |
Smoking cigarettes can help keep your weight down |
1 |
2 |
3 |
4 |
5 |
9 |
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 |
E5_12 |
Smoking as a teen can permanently stunt your lungs. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_13 |
Smoking cigarettes will make me have serious breathing problems |
1 |
2 |
3 |
4 |
5 |
9 |
E5_14 |
If I smoke, the consequences will find me. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_15 |
Nicotine can reprogram your brain |
1 |
2 |
3 |
4 |
5 |
9 |
E5_16 |
If I smoke, it will be hard to think about anything but my next cigarette |
1 |
2 |
3 |
4 |
5 |
9 |
E5_17 |
The nicotine in cigarettes may hack your 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 may 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 |
E15_9 |
The nicotine in e-cigarettes may hack your brain |
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 |
E16_5 |
Diacetyl, a chemical that can cause lung damage (or, “popcorn lung”). |
1 |
2 |
3 |
4 |
5 |
9 |
E7. Do you believe cigarette smoking is related to…
|
|
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 |
E7_13 |
Gum Disease |
1 |
2 |
3 |
4 |
5 |
9 |
E9. Does cigarette smoke contain….
|
|
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 |
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? |
|
|
|
|
|
|
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
Next, we’d like to ask you about your use of TV and other media.
F1/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 |
|
|
F2_2. Watching or uploading videos to YouTube? |
1 |
2 |
3 |
4 |
5 |
9 |
F1_1. Watching TV shows a TV, a computer or laptop, tablet, or smartphone? |
1 |
2 |
3 |
4 |
5 |
9 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
F2_3. Using social networking sites like Twitter, Instagram or Tumblr? |
1 |
2 |
3 |
4 |
5 |
9 |
F2_4. Looking at any other type of website for anything besides schoolwork? |
1 |
2 |
3 |
4 |
5 |
9 |
F2_5. Video chatting (on Snapchat, FaceTime, Googletalk, iChat, etc.) |
1 |
2 |
3 |
4 |
5 |
9 |
F2_6. Text messaging? |
1 |
2 |
3 |
4 |
5 |
9 |
F2_10. Playing games on all electronic devices. Include cell phones/smartphones, computers, laptops, tablets, game consoles hooked up to a TV/computer (Xbox, Wii, PSP) and handheld devices (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 [social media property]?
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 [social media property]?
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 [social media property]?
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 [social media property]?
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 [gaming properties]?
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 [social media property]?
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 [social media property]?
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.
F
3_3.
In the past
3 months,
that is since [FILL DATE], have
you seen or heard the following slogan or theme?
Digital Youth Against Tobacco (DYAT)
1___ Yes
2___ No
3___ Not Sure
F3_4. In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme?
T
he
Real Cost
1___ Yes
2___ No
3___ Not Sure
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
F3_11. In the past [FILL MONTHS] months,, that is 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
F3_12. In the past [FILL MONTHS] months,, that is since [FILL DATE], have you seen or heard the following slogan or theme?
t
ruth
[insert current truth campaign name]
1___ Yes
2___ No
3___ Not Sure
F
3_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 ads, Use SCREENSHOTS for truth, Tips from Former Smokers, AND FRESH EMPIRE 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
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
14. Nicotine can reprogram your brain until it’s hard to think about anything but your next cigarette.
15. Cigarettes may leave you with stained teeth, gum disease and more.
16. Smoking as a teen can permanently stunt your lungs.
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 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
F11_13 |
This ad is intense |
1 |
2 |
3 |
4 |
5 |
9 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
F14. Did you talk to anyone about any of these ads?
1 Yes
2 No
9 Prefer not to answer
[IF F14=1, ASK F15]
F15. When you talked about the ads, did you talk about any of the following topics?
1 2
Yes No
[RANDOMIZE]
F15_1. These ads were good
F15_2. These ads were NOT good
F15_3. I should not smoke
F15_4. The person I was talking to or someone else I know should not smoke
F15_5. Other, specify________________________
F16. Do your parents have rules about how much time you can spend using media, such as TV, computer, video games, cell phones, and music?
1 Yes, my parents have lots of rules about it.
2 Yes, my parents have a few rules about it.
3 No, my parents don’t have any rules about it.
9 Prefer not to answer
F17. 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
F18. In general, how often do your parents make sure you follow the rules they have about using media, such as TV, computers, video games, and music?
1 Most of the time
2 Some of the time
3 A little of the time
4 Never
5 My parents don’t have rules about using media
9 Prefer not to answer
F19. 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
Section G: Environment
The next section asks some questions about your household and peers.
G1. Other than you, has anyone who lives with you used any of the following during the past 30 days…? (You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
1 cigarettes
2 smokeless tobacco, such as chewing tobacco, snuff, snus (rhymes with goose) or dip, such as Copenhagen, Skoal, Grizzly, Kodiak, and Red Seal
3 cigars, cigarillos, or little cigars such as Swisher Sweets, Black & Mild, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s
4 tobacco out of a water pipe (also called “hookah”)
5 electronic cigarettes, 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
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
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. 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
G10. 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
Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statements.
G11. 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
G12. 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
G13. 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
G14. 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
G15. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
_____ Number of days
2 None
3 Don’t know
9 Prefer not to answer
These next questions ask about how you feel about your current relationship with your parents or guardians. Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statement.
G16. Thinking about the adult or adults you live with would you say you are satisfied with the way you communicate with each other.
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree (neutral)
4 Agree
5 Strongly Agree
9 Prefer not to answer
G17. How close do you feel to the adult or adults you live with?
1 Not at all close
2 Not very close
3 Somewhat close
4 Quite close
5 Very close
9 Prefer not to answer
G18. How often has a parent or other adult caregiver said things that really hurt your feelings or made you feel like you were not wanted or loved?
1 One time
2 Two times
3 Three to five times
4 Six to ten times
5 More than ten times
6 This has never happened
7 Don’t know
9 Prefer not to answer
G19. Has a parent or other 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 other 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: 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/msword |
| Author | PR* |
| Last Modified By | PR* |
| File Modified | 2016-05-31 |
| File Created | 2016-05-31 |
© 2024 OMB.report | Privacy Policy