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

OMB Control # 0910-0810

Exp. 11-30-2018

ATTACHMENT C:

SCREENER

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

S1. How old are you?

₁ 12 years old or younger (GO TO CLOSING TEXT 1)

₂ 13 years old (GO TO S2)

₃ 14 years old (GO TO S2)

₄ 15 years old (GO TO S2)

₅ 16 years old (GO TO S2)

₆ 17 years old (GO TO S2)

₇ 18 years old or older (GO TO CLOSING TEXT 1)

₉ Prefer not to answer (GO TO CLOSING TEXT 1)

[If S1 = 1, 7 or 9, GO TO CLOSING TEXT1.]

[If S1 = 2-6, GO TO S2.]

CLOSING TEXT 1: “Based on your answers you do not qualify for this survey. Thank you very much for your time and responses.”

S2. Have you ever tried cigarette smoking, even one or two puffs?

₁ Yes

₂ No

₉ Prefer not to answer

[IF S2=1 or 9, GO TO S3. IF S2=2, GO TO S4]

S3. 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

[If S3 = 8 or 9, GO TO CLOSING TEXT 2]

[IF S3=1, GO TO S4, otherwise GO TO S5]

S4. Thinking about the future…

		1 Definitely Yes	2 Probably Yes	3 Probably Not	4 Definitely Not	9 Prefer Not to Answer
S4_1	Do you think that you will try a cigarette soon?	1	2	3	4	9
S4_2	Do you think you will smoke a cigarette at any time in the next year?	1	2	3	4	9
S4_3	If one of your best friends were to offer you a cigarette, would you smoke it?	1	2	3	4	9

[If S4_1 = 4 AND S4_2 = 4 AND S4_3 = 4, GO TO CLOSING TEXT 2.

If S4_1 = 9 AND S4_2 = 9 AND S4_3 = 9, GO TO CLOSING TEXT 2.

Otherwise, GO TO S5.]

CLOSING TEXT 2: “Based on your answers you do not qualify for this survey. Thank you very much for your time and responses.”

S5. Have you participated in a tobacco research survey in the past 6 months?

₁ Yes

₂ No

₉ Prefer not to answer

[IF S5=1 or 9, GO TO CLOSING TEXT 3.]

[IF S5=2, GO TO CLOSINGTEXT 4.]

CLOSING TEXT 3: “Based on your answers you do not qualify for this survey. Thank you very much for your time and responses.”

CLOSING TEXT 4: “You qualify for this study. Please click to go on to the next screen.”

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