Attachment D3 TRC Smokeless screener - survey

Quantitative Study of Tobacco Facts Designed to Inform Youth Tobacco Prevention Messaging

RIHSC No. 18-049CTP

OMB No. 0910-0810

Exp. Date: 10/31/2021

Attachment D3: The Real Cost: Smokeless Screener (Survey)

[THE FOLLOWING TEXT WILL BE PRESENTED BEFORE THE SCREENER]

Fors Marsh Group (FMG), a research organization, is conducting a research study sponsored by the U.S. Food and Drug Administration (FDA). FMG will conduct an online survey with 400 teens ages 13-17 to get their opinions regarding a variety of tobacco-related facts intended to prevent tobacco use among youth. Participants in the study will receive a $10 gift card.

We would like to ask you to take a short screening survey to see if you qualify for this study. The screening survey asks questions about your tobacco-related behaviors as well as some general demographic questions which will only take about 5 minutes. Your answers to the questions will be kept private, meaning we won’t share them with anyone outside the research team. We will try our best to maintain the privacy of data collected. Still, a breach could occur by accident or as a result of hacking.  Your participation is voluntary and you can stop at any time. There is no direct benefit to you for participating in the screening survey. If we determine that you are eligible, you will be invited to take the online survey.

If you have any questions about the study, you may contact the research team through Shane Mannis of FMG at (571) 858-3757 or pi@forsmarshgroup.com.

Do you consent to participate in this short screening survey?

1. Yes, I agree to participate in this short screener  GO TO SCREENER

2. No, I do not want to participate in this short screener  THANK AND TERMINATE

[TERMINATION TEXT]: “Thank you for interest in this study! We appreciate your time.”

[ONLY PARTICIPANTS WHO AGREE TO TAKE THE SCREENER WILL BE TAKEN TO THE QUESTIONS BELOW]

[ONLINE SCREENER]

[Unless otherwise noted, each item will be presented on a separate page, separated by a “NEXT” button.]

1. How old are you?

12 or younger TERMINATE

13

14

15

16

17

_{18 or older} TERMINATE

_[Programmer: ONLY ASK Q2 IF Q1=“17”]

2. Will you turn 18 by [study end date]?

Yes TERMINATE

No

3. What is your gender?

Male

_Female

4. Are you Hispanic or Latino?

Yes

_No

5. Which of the following best describes your race? (Mark all that apply)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

6. What is the 5-digit zip code where you currently live?

_ _ _ _ _

TERMINATION CRITERIA	Terminate if Q1 = “18 or older” AND “12 or younger” Terminates if Q2 = “Yes” Terminate if Q3 = “Female” Terminate if Q5 ≠ “White”
TERMINATION LANGUAGE [shown on separate screen]	Thank you for your interest in participating in this study. Unfortunately, based on the responses you provided, you do not meet the specifications we are looking for to complete this study.

Now, we would like to ask you some questions about your use of tobacco products.

Cigarettes

7. Have you ever tried cigarette smoking, even one or two puffs?

₁ Yes

₀ No

₉ Prefer not to answer

[Programmer: IF Q7=1 | Q7=9, ASK Q8. IF Q7=0, ASK Q10]

8. [Programmer: Ask only if Q7=1 | Q7=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

8. [Programmer: Ask only if Q8= 1]

About how many cigarettes have you smoked in your entire life?  Your best guess is fine.

₁___1 or more puffs but never a whole cigarette

₂___1 cigarette

₃___2–5 cigarettes

₄___6 to 15 cigarettes (about ½ a pack total)

₅___16 to 25 cigarettes (about 1 pack total)

₆___26 to 99 cigarettes (more than 1 pack, but less than 5 packs)

₇___100 or more cigarettes (5 or more packs)

₉___Prefer not to answer

8. [Programmer: Ask only if Q7 =0]

Thinking about the future…

		Yes, definitely	Yes, probably	No, probably not	No, definitely not	Prefer not to answer
10_a	Do you think that you will try a cigarette soon?	1	2	3	4	9
10_b	Do you think you will smoke a cigarette in the next year?	1	2	3	4	9
10_c	If one of your friends were to offer you a cigarette, would you smoke it?	1	2	3	4	9

_{The next set of questions asks about a different type of tobacco product.}

11. Have you ever tried smokeless tobacco (such as snus pouches, moist snuff, dip, spit, or chewing tobacco)?

Yes CONTINUE TO 12

No _{SKIP to 13a}

12. How many times have you used chewing tobacco, snuff, or dip in your entire lifetime? Would you say…

Less than 20 times [CONTINUE to Q13c]

20 times, but less than 50 times [CONTINUE to Q13c]

50 times, but less than 100 times [CONTINUE to Q13c]

More than 100 times

TERMINATION CRITERIA	Terminate if: Q11=“Yes” and Q12=“More than 100 times”
TERMINATION LANGUAGE [shown on separate screen]	Thank you for your interest in participating in this study. Unfortunately, based on the responses you provided, you do not meet the specifications we are looking for to complete this study.

_13a. Have you ever been curious about using smokeless tobacco?

_{Very curious}

_{Somewhat curious}

_{A little curious}

_{Not at all curious}

₁₃b. _{Do you think you will use chewing tobacco, snuff, or dip in the future?}

_{Definitely yes}

_{Probably yes}

_{Probably not}

_{Definitely not}

13c. Do you think you will use chewing tobacco, snuff, or dip in the next year?

Would you say …

_{Definitely yes}

_{Probably yes}

_{Probably not}

_{Definitely not}

_13d. If one of your best friends were to offer you chewing tobacco, snuff, or dip, would you use it? Would you say…

_{Definitely yes}

_{Probably yes}

_{Probably not}

_{Definitely not}

TERMINATION CRITERIA	Terminate if: Q11=“No” and Q13b/Q13c/Q13d=“Definitely Not” and Q13a=“Not at all curious”
TERMINATION LANGUAGE [shown on separate screen]	Thank you for your interest in participating in this study. Unfortunately, based on the responses you provided, you do not meet the specifications we are looking for to complete this study.

[TEXT BELOW WILL BE SHOWN ONLY TO PARTICIPANTS WHO QUALIFY]

What is your email address? We will use it to send you the main survey link: ______________

Please confirm your email address ______________

Before we can send you the link to the survey, we need to email a copy of our Notification/Opt-Out Form to your parent or guardian. The form explains what you will be doing and provides them with a way to contact us only if they do NOT want you to complete the survey.

Parent or guardian’s email address ______________

As a reminder, we will NOT share your answers with anyone outside of the study, including your parents.

[Programmer: SHOW NEW SCREEN]

Thank you! We will send you an email with the link to the survey in about 24 hours. After you complete the survey, you will receive your $10 gift card.

*Please note that you can only submit this survey once and receive one gift card. Fraudulent or duplicate surveys will not be eligible to receive a gift card.

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 5 minutes per response to complete this survey (the time estimated to read and complete). Send comments regarding this burden estimate or any other aspects of this information collection, including suggestions for reducing burden, to PRAStaff@fda.hhs.gov.