Multicultural Campaign: Wave 3 focus group study of reactions to creative advertising concepts designed to prevent multicultural youth tobacco use

OMB# 0910-0796
Exp. 6/30/2018

Check-In Survey

Please fill out this survey. Any information you share about your
attitudes, beliefs, and behaviors will not be shared with your
school or parents/guardians. No one outside the research team
will know what you write. There are no right or wrong answers to
these questions. Read the instructions for each question
carefully and let us know if you have any questions.
Thank you very much for your help.

CONTINUE

Unique ID: ______________

Instructions: For each question, fill in one bubble to indicate the answer you select.
Please fill in your selected responses like this:
1) What grade are you currently in?
6th grade

10th grade

7th grade

11th grade

8th grade

12th grade

9th grade

Ungraded or other grade

2) For the following questions, please fill in ONE bubble in each row.

How likely is someone to become
addicted to:

Very
Unlikely
Unlikely

Neutral

Likely

Very
Likely

Most

All

a) Cigarettes
b) Cigars, cigarillos, or little cigars, such as
Black and Milds, Swisher Sweets, Dutch
Masters, White Owl, or Phillies Blunts
c) Electronic cigarettes, e-cigarettes, vape
pens, or hookah pens, such as Fin, NJOY, eGo, or Use
d) Tobacco from a hookah or waterpipe

3) For the following questions, please fill in ONE bubble in each row.

How many of your best friends:
a) Smoke cigarettes
b) Smoke cigars, cigarillos, or little cigars
c) Use electronic cigarettes, e-cigarettes,
vape pens, or hookah pens
d) Smoke tobacco from a hookah or waterpipe

None

A Few

Some

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4) For EACH box below, select the phrase that best describes you:

a)

Up for anything

OR

Picks & chooses what to do

b)

Low key

OR

Outgoing

c)

Center of attention

OR

Lay low

d)

Street smart

OR

Book smart

e)

Studier

OR

Partier

f)

Plan it out

OR

Wing it

g)

The carefree one

OR

The responsible one

5) In an average week, on how many nights do you go out to have fun?

0

1

2

3

4

5

6

7

Nights

6) For the following questions, please fill in ONE bubble in each row.

HOW MUCH do you think people
HARM THEMSELVES when they:
a) Smoke cigarettes
b) Smoke cigars, cigarillos, or little cigars
c) Use electronic cigarettes, e-cigarettes,
vape pens, or hookah pens
d) Smoke tobacco from a hookah or waterpipe

No
harm

Little
harm

Neutral

Some
harm

A lot of
harm

Unique ID: ______________

Please fill in ONE bubble for each question. Your best guess is fine.

7) How long do you think someone has to
smoke CIGARETTES before it harms their
health?

8) How long do you think someone has to
smoke CIGARS, CIGARILLOS, OR LITTLE
CIGARS before it harms their health?

It will never harm their health

It will never harm their health

Less than a year

Less than a year

5 years

5 years

10 years

10 years

20 years or more

20 years or more

9) How long do you think someone has to
use ELECTRONIC CIGARETTES, ECIGARETTES, VAPE PENS, OR HOOKAH
PENS before it harms their health?

10) How long do you think someone has
to smoke TOBACCO FROM A HOOKAH
OR WATERPIPE before it harms their
health?

It will never harm their health

It will never harm their health

Less than a year

Less than a year

5 years

5 years

10 years

10 years

20 years or more

20 years or more

Thank you! Please let a researcher know that you are finished.

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