Fresh Empire Campaign: Wave 2 Quantitative Study of Reactions to Rough-Cut Advertising Designed to Prevent Youth Tobacco Use

OMB#
OMB #0910-0674
0910-0810
Exp. Date:
Exp.11/30/18

Screener
We are looking for students to take a survey after school. If you are
selected and agree to take part in the research activities, you will
receive a $25 gift card. Please answer the questions on the following
pages to see if you qualify. You will find out during your last period class
today if you have been selected. If so, you will be asked to stay after
school for about 20 minutes to take the main survey.
Only the researchers will know how you answer. We will not share the
answers you give with anyone outside of the research study. There are
no right or wrong answers to these questions.

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 4
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.

CONTINUE

First Name:

Last Name:

Email Address:

Phone:

(Circle One: CELL or HOME)

Email Address (confirmation):
Last Classroom #/Teacher Today:
1) How old are you?
a. 11 years old or younger
b. 12 years old
c. 13 years old

2) 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.)

d. 14 years old

a. Yes

4) Have you ever tried cigarette
smoking, even one or two puffs?

f. 16 years old
g. 17 years old
h. 18 years old or older

a. Yes

5) About how many cigarettes have
you smoked in your entire life? Your
best guess is fine.
a. I have never smoked cigarettes,
not even one or two puffs
b. 1 or more puffs but never a whole
cigarette
c. 1 cigarette

3) 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? (Do not count diet soda or diet pop.)
a. I did not drink soda or pop during the past 7 days
b. 1 to 3 times during the past 7 days

b. No

6) Do you think that you
will smoke a cigarette
soon?
a. Definitely yes

d. 1 time per day
e. 2 times per day
f. 3 times per day
g. 4 times or more per day

7) Do you think that you will
smoke a cigarette in the next
year?

b. Probably yes

a. Definitely yes

c. Probably not

b. Probably yes

d. Definitely not

c. Probably not
d. Definitely not

d. 2 to 5 cigarettes
e. 6 to 15 cigarettes (about 1/2 pack
total)
f. 16 to 25 cigarettes (about 1 pack
total)
g. 26 to 99 cigarettes (more than 1
pack, but less than 5 packs)
h. 100 or more cigarettes (5 or more
packs)

11) What is your sex?
b. Male

13)
race or
orraces
racesdo
doyou
you
13) What
What race
consider
yourselftotobe?
be?
(Youone
can
consider yourself
(Mark
choose
answer or more than
or more one
answers)
one answer)
a. American Indian or Alaska Native
b. Asian
c. Black or African American
d. Native Hawaiian or Other Pacific
Islander
e. White

b. No

:

c. 4 to 6 times during the past 7 days

e. 15 years old

a. Female

Last Classroom #/Teacher on

9) Have you ever been
curious about smoking a
cigarette?

10) If one of your best friends
were to offer you a cigarette,
would you smoke it?

8) 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.)
a. Definitely yes

a. Definitely yes

a. Definitely yes

b. Probably yes

b. Probably yes

b. Probably yes

c. Probably not

c. Probably not

c. Probably not

d. Definitely not

d. Definitely not

d. Definitely not

12) Are you Hispanic, Latino/a, or Spanish origin? (You can choose one answer or
more than one answer)
a. No, not of Hispanic, Latino/a, or Spanish origin d. Yes, Cuban
b. Yes, Mexican, Mexican American, Chicano or
Chicana

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

c. Yes, Puerto Rican

14) Do you or any member of your immediate family
or a close friend work for...? (Select all that apply)
a. A market research company
b. A tobacco company (manufacturer or importer of tobacco
products)

15) Have you ever received
money or gift cards from a
company for sharing your
opinions in a discussion
group, interview, or survey?

c. An advertising agency or public relations firm

a. Yes, within the past 6 months

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

b. Yes, more than 6 months ago

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

c. No

f. None of these

d. I’m not sure

CONTINUE ON NEXT PAGE

16) RANK THE 3 PEOPLE THAT

Rank #1:

WOULD BEST FIT IN YOUR
MAIN GROUP OF FRIENDS,
STARTING WITH THE BEST FIT.

Rank #2:

17) RANK THE 3 PEOPLE THAT
WOULD LEAST FIT IN YOUR
MAIN GROUP OF FRIENDS,
STARTING WITH THE WORST
FIT.

Rank #3:

Rank #1:
Rank #2:
Rank #3:

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18) RANK THE 3 PEOPLE THAT
WOULD BEST FIT IN YOUR
MAIN GROUP OF FRIENDS,
STARTING WITH THE BEST FIT.

Rank #1:

19) RANK THE 3 PEOPLE THAT
WOULD LEAST FIT IN YOUR
MAIN GROUP OF FRIENDS,
STARTING WITH THE WORST
FIT.

Rank #2:
Rank #3:

Rank #1:
Rank #2:
Rank #3:

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