LGBT Campaign: Wave 1B Online Quantitative Study Designed to Prevent Young Adult Tobacco Use

OMB# 0910-0810

Exp. 11/30/2018

LGBT Campaign: Wave 1B Online Quantitative Study Designed to

Prevent Young Adult Tobacco Use

Attachment B: Questionnaire

CONSENT PAGE

[TEXT FOR PARTICIPANTS]: “Please answer the questions on the following pages as honestly as possible. As a thank you for your time, once you complete and submit this survey you will receive a $15 online gift card! You will only be eligible to complete this survey once and receive one gift card. Please scroll and read through the document, and select YES if you would like to participate. Please remember to read the instructions carefully.”

[Informed Consent Form presented to participants]

I have read, understand, and had time to consider all of the information above. I have no questions about the study at this time.

○ Yes, I want to participate.

○  No, I do NOT want to participate.

*If you choose YES, we will email you the form for your records

PART I

[Each item on the Questionnaire will be presented in a separate page, separated by a “NEXT” button.]

A1. Please verify your email address for your incentive.

This should be the same email address you used when completing the original screener survey.

[Open text box here for participant to enter email address]

[A1 is only asked of participants who do not complete the Questionnaire as a follow-through experience. Email address here must match the email address used in the Screener, if the email is not a match, participant will be redirected to the Screener.]

[Questions to be presented prior to showing rough-cut advertisements to ALL PARTICIPANTS – (Part 1 questions are only asked once)]

A2. How many of your four closest friends smoke cigarettes?

0. 0

1. 1

2. 2

3. 3

4. 4

A3. During the past 30 days, have you personally…

(You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)

1. Smoked cigarettes

2. Smoked smoke cigars, cigarillos, or littler cigars (e.g. Swisher Sweets, Black & Milds, White Owl, Cheyenne, Dutch Masters, Garcia y Vega or Middleton’s)?

3. Smoked electronic cigarettes, e-cigarettes, e-cigs, e-hookahs, vapes, vape pens, or hookah pens such as Fin, NJOY, Blu, e-Go, or Vuse?

4. Smoked tobacco from a hookah or waterpipe?

5. Used smokeless tobacco (e.g. chewing tobacco, moist snuff, dip, spit, or snus pouches, such as Copenhagen, Skoal, Grizzly, Kodiak, and Red Seal)?

6. I have not used any form of tobacco in the past 30 days

[A3=6 is an exclusive response and cannot be selected in conjunction with option A3=1,2,3,4, or 5]

PART II

[(Questions to be provided after the rough-cut advertisement) – AD VIEWING PARTICIPANTS ONLY]

[TEXT FOR PARTICIPANTS]: “Please watch the video below. To start watching the video, click on the video or press the play button. When the video ends, click on the button at the bottom of the page to continue with the survey.”

[Perceived Ad Effectiveness]

B1. What do you think [or would you say] is the main message of this advertisement?

[FREE RESPONSE BOX]

B2. What do you like about this advertisement? Please be as specific as possible.

[FREE RESPONSE BOX]

B3. What do you dislike about this advertisement? Please be as specific as possible.

[FREE RESPONSE BOX]

B4. People sometimes have different emotional reactions when they see or hear advertisements. On a scale from 1 to 5, where 1 means “not at all” and 5 means “very”, please indicate how much this ad made you feel:

Not at all Very

1 2 3 4 5

[RANDOMIZE ORDER]

B4_1. Sad

B4_2. Afraid

B4_3. Irritated

B4_4. Ashamed

B4_5. Discouraged

B4_6. Hopeful

B4_7. Motivated

B4_8. Confident

B4_9. Determined

B4_10. Understood

B4_11. Angry

B4_12. Amused

B4_13. Disgusted

B4_14. Worried

B4_15. Inspired

B4_16. Happy

B4_17. Uneasy

B4_18. Surprised

B5. Please tell us if you strongly disagree, disagree, neither disagree nor agree, agree, or strongly agree with the following statements:

[RANDOMIZE ORDER]

B5_1. This ad is worth remembering

B5_2. This ad grabbed my attention

B5_3. This ad is powerful

B5_4. This ad is informative

B5_5. This ad is meaningful to me

B5_6. This ad is convincing

B5_7. This ad is terrible

B5_8. This ad is silly

B5_9. This ad is annoying

B5_10. This ad was difficult to watch

B5_11. I trust the information in this ad

B5_12. This ad told me things I never knew before about tobacco

B5_13. The person/people in this ad are like me

B5_14. This ad gave me a reason not to use tobacco

B5_15. I can identify with what the ad says

B5_16. This ad is different from other anti-tobacco ads I’ve seen or heard

B6. On a scale of 1 to 5, how would you rate the claims or arguments in this ad:

Not believable Believable

1 2 3 4 5

B7. On a scale of 1 to 5, indicate whether the ad made smoking look like something you would or would not want to do.

Makes me want to smoke Makes me not want to smoke

1 2 3 4 5

B8. Is there anything confusing, unclear, or hard to understand in this ad?

1. Yes

0. No

[If B8=1, Ask B9. If B8=0, Ask B10]

B9. What is confusing about this ad?

[FREE RESPONSE BOX]

B10. If you saw this advertisement, on a scale from 1 to 5, where 1 is not at all likely and 5 is very likely, how likely would you be to do each of the following:

Not at all Very

1 2 3 4 5

B10_1. Tell a friend 

B10_2. Look for more information online

B10_3. Visit the [campaign name here] ™ website, Facebook, or Tumblr

B10_4. Share the [campaign name here]™ YouTube channel with a friend

B10_5. Mention or like it on social media such as Facebook, Tumblr, Twitter, or Instagram

B10_6. Do nothing

PART III

[Questions to be presented to ALL PARTICIPANTS – Part III questions are only asked once]

[Attitudes, Beliefs and Risk Perceptions]

[RANDOMIZE ORDER]

How much do you disagree or agree with following statements:

C1. If I smoke I will…

C1_1. Damage my physical appearance

1. Strongly Disagree

2. Disagree

3. Neither Agree or Disagree

4. Agree

5. Strongly Agree

C1_2. Be less attractive to others

6. Strongly Disagree

7. Disagree

8. Neither Agree or Disagree

9. Agree

10. Strongly Agree

C1_3. Negatively affect my health

1. Strongly Disagree

2. Disagree

3. Neither Agree or Disagree

4. Agree

5. Strongly Agree

C1_4. Cut my life short

1. Strongly Disagree

2. Disagree

3. Neither Agree or Disagree

4. Agree

5. Strongly Agree

C1_5. Damage my body

1. Strongly Disagree

2. Disagree

3. Neither Agree or Disagree

4. Agree

5. Strongly Agree

C1_6. Be controlled by tobacco

1. Strongly Disagree

2. Disagree

3. Neither Agree or Disagree

4. Agree

5. Strongly Agree

C1_7. Consume harmful chemicals

1. Strongly Disagree

2. Disagree

3. Neither Agree or Disagree

4. Agree

5. Strongly Agree

C1_8. Develop cancer

1. Strongly Disagree

2. Disagree

3. Neither Agree or Disagree

4. Agree

5. Strongly Agree

C1_9. Miss out on activities I enjoy

1. Strongly Disagree

2. Disagree

3. Neither Agree or Disagree

4. Agree

5. Strongly Agree

C2. Even casual smoking would put me at risk

1. Strongly Disagree

2. Disagree

3. Neither Agree or Disagree

4. Agree

5. Strongly Agree

C3. Smoking cigarettes is . . .

1. Very Bad

2. Bad

3. Neither Good or Bad

4. Good

5. Very Good

C4. Smoking cigarettes is . . .

1. Very Unenjoyable

2. Unenjoyable

3. Neither enjoyable or unenjoyable

4. Enjoyable

5. Very Enjoyable

PART IV

[Questions to be presented to ALL PARTICIPANTS – Part IV questions only asked once]

D1. Other than you, has anyone who lives with you used any of the following during the past 30 days…? (You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)

1. Cigarettes

2. Smokeless tobacco, such as chewing tobacco, snuff, snus (rhymes with goose) or dip, such as Copenhagen, Skoal, Grizzly, Kodiak, and Red Seal

3. Cigars, cigarillos, or little cigars such as Swisher Sweets, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s

4. Tobacco out of a water pipe (also called “hookah”)

5. Electronic cigarettes, such as blu, NJOY, Mistic, 21^st Century Smoke

6. Any other form of tobacco

7. No, no one who lives with me has used any form of tobacco during the past 30 days

8. Prefer not to answer

D2. 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. Do not know

13. Prefer not to answer

D3. Which of the following categories best describes your total household income in the past 12 months?

This is the total income before taxes of all persons in your household combined. Please include money from jobs, relatives, pensions, dividends, interest, social security payments or retirement benefits, net income from business, farm or rent, and any other money received by household members.

1. Less than $10,000

2. $10,000 to $14,999

3. $15,000 to $24,999

4. $25,000 to $34,999

5. $35,000 to $49,999

6. $50,000 to $74,999

7. $75,000 to $99,999

8. $100,000 to $149,999

9. $150,000 to $199,999

10. $200,000 or more

11. Do not know

12. Prefer not to answer

[TEXT FOR COMPLETED PARTICIPANTS ONLY]: “Thanks for completing the survey! You will receive your $15 online gift card at the email address you provided within 72 hours.”

END PAGE

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated up to 10 minutes on average 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.

Page 15 of 15