Attachment E_ Adult Screener

OMB No. 0910-0810

Exp. Date: 10/31/2021

Attachment D: Adult Screener

FDA Tobacco Prevention Broad Quantitative Research Package

Electronic Screener for Adult Participants

Overview:

Recruitment will be conducted online through an online panel provider. Individuals from a diverse range of racial/ethnic groups and socioeconomic backgrounds are eligible to participate. Recruitment will continue until a representative sample of the required number of participants for each group is obtained. An existing panel participant database that generates lists of individuals who have voluntarily signed up to participate in research will be used to identify individuals interested in research participation.

The research team has demonstrated capability in recruiting individuals from diverse demographic backgrounds. The time necessary to complete this survey is an average of five minutes per response for adults.

Before recruiting begins, all recruiters will attend training to ensure the screening procedures are administered consistently.

Table 2. Summary of Adult Screener Questions

Item(s)	Rationale/Justification
A1-A6	Verify gender, age, race/ethnicity and current zip code
A7	Verify household income
A8	Relationship with a tobacco company, market research company, ad agency, media, or health care
	Termination Point for individuals who work for a tobacco company or have friends or family who work for a tobacco company
A9	Ask if adult has engaged in a discussion group, survey, or interview about tobacco in the last 6 months
	Termination Point for adults who have engaged in a discussion group, survey, or interview about tobacco within the last 6 months
B1-B3	Ask lifestyle questions to determine health behaviors
B4-B9	Verify the tobacco use status. Identify adults who are cigarette smokers, dual users, and thinking about quitting smoking. Exclude adults who have not used 100 or more cigarettes in their lifetime, currently don’t used cigarettes or e-cigarettes and those who have no intention of quitting cigarettes
	Termination Point for adults who do not meet criteria in B4-B9
E1	Collect email address for contact information and to send questionnaire link
	Unique identification number created at this point

Thanks for your interest in participating in this survey. We have to collect a little bit of eligibility information to begin.

DEMOGRAPHICS AND TOBACCO USE

A_1. How old are you? [Open end text]

[Terminate if less than 19 or greater than 54]

A_2. Are you…?

1. Female

2. Male

3. Other (record)

4. Prefer not to answer

A_3. What is the 5-digit zip code where you CURRENTLY live?

___ ___ ___ ___ ___

A_4. Are you Hispanic, Latino/a, or Spanish origin? (You can choose one answer or more than one answer)

1. No, not of Hispanic, Latino/a, or Spanish origin

2. Yes, Mexican, Mexican American, Chicano or Chicana

3. Yes, Puerto Rican

4. Yes, Cuban

5. Yes, another Hispanic, Latino/a, or Spanish origin

A_5. What race or races do you consider yourself to be? (You can choose one answer or more than one answer)

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian or Other Pacific Islander

5. White

A_6. What is the highest grade or level of school that you have completed?

1. Less than high school

2. Some high school, no diploma

3. GED

4. High school graduate−diploma

5. Some college but no degree

6. Associate degree−occupational/vocational

7. Associate degree−academic program

8. Bachelor’s degree (ex: BA, AB, BS)

9. Master’s degree (ex. MA, MS, MEng, Med, MSW)

10. Professional school degree (ex: MD, DDS, DVM, JD)

11. Doctorate degree (ex: PhD, EdD)

12. Don’t know

13. Prefer not to answer

A_7. Do you or any member of your immediate family or a close friend work for...? (Select all that apply)

1. A market research company

2. A tobacco company (manufacturer or importer of tobacco products) [Terminate]

3. An advertising agency or public relations firm

4. The media (TV/radio/newspapers/magazines)

5. A healthcare professional (doctor, nurse, pharmacist, dietician, etc.)

6. None of these

A_8. Have you ever received money or gift cards from a company for sharing your opinions in a discussion group, interview or survey about tobacco?

1. Yes, within the past 6 months [Terminate]

2. Yes, more than 6 months ago

3. No

4. I’m not sure

HEALTH BEHAVIORS

B_1. During the past 7 days, did you drink a can, bottle, or glass of soda or pop, such as Coke, Pepsi, or Sprite? (Do not count diet soda or diet pop.)

1. Yes [CONTINUE TO B_2]

2. No [SKIP TO B_4]

B_2. During the past 7 days, how many times did you drink a can, bottle, or glass of soda or pop, such as Coke, Pepsi, or Sprite? Your best guess is fine. (Do not count diet soda or diet pop.)

1. I did not drink soda or pop during the past 7 days

2. 1 to 3 times during the past 7 days

3. 4 to 6 times during the past 7 days

4. 1 time per day

5. 2 times per day

6. 3 times per day

7. 4 times or more per day

B_3. Do you think that you will drink a can, bottle, or glass of soda or pop, such as Coke, Pepsi, or Sprite, in the next week? (Do not count diet soda or diet pop.)

1. Definitely yes

2. Probably yes

3. Probably not

4. Definitely not

B_4. Have you smoked at least 100 cigarettes in your entire life? [Notes: 5 packs=100 cigarettes]

1. Yes

2. No

3. Don’t know

B_5. Do you smoke cigarettes every day, some days, or not at all?

1. Every day

2. Some days

3. Not at all [Terminate]

B_6. Are you thinking about trying to quit smoking cigarettes?

1. Yes

2. No [Terminate]

3. Don’t know [Terminate]

B_7. How soon are you likely to try to quit smoking cigarettes? Would you say…

1. Within the next 30 days

2. Within the next 6 months

3. Within the year

4. Longer than a year

B_8. In the past 12 months, did you vape nicotine as a way of cutting down on your cigarette smoking?

1 Yes

2 No

[Source: PATH 4 adult]

B_9. [Programmer note: if Q5_1 = Yes ask: When you tried to quit smoking, did you do any of the following? [Programmer note: if Q5_1 = No or Don’t know ask: In the past 12 months, did you do any of the following?]

[Programmer note: Randomize items]	Yes	No
a. Gradually cut back on cigarettes?
b. Switch to vaping nicotine?
c. Give up cigarettes all at once?
d. Use a nicotine patch, gum, inhaler, nasal spray, or lozenge?
e. Use any of the following prescription drugs: Chantix, varenicline, Wellbutrin, Zyban, or bupropion?
f. Attend a stop-smoking clinic, cessation class, or support group?
g. Get counseling to help you stop smoking?
h. Get help from a free telephone quit line?
i. Register for a web-based quit smoking program?

B_10. Thinking back to [the time you tried to quit/the last time you tried to quit/when you quit] smoking cigarettes in the past 12 months, did you use a different tobacco product to help you quit?

	Yes	No
a. I did not use a different tobacco product to help me quit
b. Vapes
c. Traditional cigars
d. Cigarillos
e. Filtered cigars
f. Pipe tobacco
g. Hookah
h. Snus or smokeless tobacco, like dip, chew, or snuff
i. Dissolvable tobacco

B_11. Have you ever:

Used an electronic cigarette, e-cigarette, vape, vape pen, or hookah pen, such as Juul, Fin, NJOY, Blu, e-Go, or Vuse, in your entire life, even one or two puffs?	Yes	No [Terminate]
Smoked a cigar, even one or two puffs?	Yes	No
Smoked a cigarillo or little cigar (for example, Black & Mild or Swisher Sweets), even one or two puffs?	Yes	No
Used or tried any smokeless tobacco products such as chewing tobacco, snuff, or snus? Note: Snus (Swedish for snuff) is a moist smokeless tobacco, usually sold in small pouches, that is placed under the lip against the gum.
Tried smoking tobacco from a hookah or a waterpipe, even just one time?	Yes	No

B_12. ASK FOR EACH “YES” AT QE8: How often would you say you:

	Every Day	Once a week or more/Not every day	Every few months up to 2-3 times a month	Rarely, once or twice a year	Never
Use an electronic cigarette, e-cigarette, vape, vape pen, or hookah pen, such as Juul, Fin, NJOY, Blu, e-Go, or Vuse	5	4	3	2	1
Smoke a cigar	5	4	3	2	1
Smoke a cigarillo or little cigar (for example, Black & Mild or Swisher Sweets)	5	4	3	2	1
Use any smokeless tobacco products such as chewing tobacco, snuff, or snus? Note: Snus (Swedish for snuff) is a moist smokeless tobacco, usually sold in small pouches, that is placed under the lip against the gum.	5	4	3	2	1
Smoke tobacco from a hookah or a waterpipe	5	4	3	2	1

EMAIL ADDRESS

[TERMINATION: TEXT PRESENTED TO DISQUALIFIED PARTICIPANTS]: “Thank you for answering our questions! Unfortunately, you will not be invited to take part in the full survey.”

[TEXT PRESENTED TO QUALIFIED PARTICIPANTS]: “Congrats! You qualify to complete the full survey!

As a reminder, we will not share your answers with anyone outside the study.

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 5 minutes per response to complete this screener (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.

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