The Real Cost Campaign: Online Quantitative Study of Reactions to Rough-Cut Advertising Designed to Prevent Youth Tobacco Use

RIHSC NO. 18-028CTP

The Real Cost Campaign: Online Quantitative Study of Reactions to Rough-Cut Advertising Designed to Prevent Youth Tobacco Use

Electronic Screener for Adult Participants

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

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

6. Other

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. 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. Don’t know

12. Prefer not to answer

A_8. 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_9. 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

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. 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 ever tried smoking tobacco from a hookah or a waterpipe, even just one time?	Yes	No

B_9. 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.

1