Cohort 2--Youth Baseline Questionnaire
Evaluation of the Food and Drug Administration's General Market Youth Tobacco Prevention Campaign
Attachment 2_E2a. ExPECTT Instrument
Cohort 2--Youth Baseline Questionnaire
OMB: 0910-0753
ATTACHMENT 2_E2A: BASELINE YOUTH INSTRUMENT
Form Approved
OMB No. 0910-0753
Exp. Date 09/30/2019
RIHSC No. 17-XXXCTP
Evaluation of the Public Education Campaign on Teen Tobacco (ExPECTT-B-2nd Cohort)
Subjects for Questionnaire:
Section A: Demographic Items
Section B: Tobacco Use Behavior
Section C: Tobacco Use Intentions and Self-Efficacy
Section D: Cessation (Intention, Behavior, Motivation)
Section E: Attitudes, Beliefs & Risk Perceptions, Social Norm
Section F: Media Use and Awareness
Section G: Environment
Introduction
This survey is all about you.
Your thoughts, your opinions, your experiences.
We want to know about your background, what television and other media you use, and your thoughts about cigarettes and other tobacco products. Even if you don’t use tobacco, we want to know what you think.
It will take about 45 minutes for you to complete this survey. Please take your time and answer as honestly and thoughtfully as you can.
We will keep what you tell us here private to the fullest extent allowable by law. We will make sure there is no way anyone can connect your name and personal information with your survey responses.
Your responses will be combined with those of others who are taking this survey before the data are analyzed or reported.
Section A: Demographic Items
First, we want to ask you some questions about yourself.
A1_2. What is your date of birth?
_ _ / _ _ / _ _ _ _ MM/DD/YYYY
PROGRAMMER: ONLY ALLOW 01–12 IN MM, 01–31 IN DD. PLEASE MAKE SURE THAT NO INVALID DATES APPEAR. THAT IS, FEB 30, NOV 31, ETC. CANNOT BE VALID. DO NOT ALLOW FUTURE DATES. IF THE DATE IS NOT VALID, PLEASE DISPLAY A HARD ERROR, “PLEASE ENTER A VALID DATE.”
ASK: All respondents.
A1_3. That would make you XX years old, is that correct?
1 Yes GO TO A2
2 No
ASK: All respondents.
DISPLAY: XX is the age of the respondent calculated from question A1_2.
A1_4. [IF A1_3 = NO]
To be sure we have the right information, please enter your birthdate once more.
_ _ / _ _ / _ _ _ _ MM/DD/YYYY
PROGRAMMER: ONLY ALLOW 01–12 IN MM, 01–31 IN DD. PLEASE MAKE SURE THAT NO INVALID DATES APPEAR. THAT IS, FEB 30, NOV 31, ETC. CANNOT BE VALID. DO NOT ALLOW FUTURE DATES. IF THE DATE IS NOT VALID, PLEASE DISPLAY A HARD ERROR, “PLEASE ENTER A VALID DATE.”
ASK: All respondents for whom birthdate (A1_2) and age (A1_3) do not correspond.
A1_5. That would make you XX years old, is that correct?
1 Yes GO TO A2
2 No
ASK: All respondents for whom birthdate (A1_2) and age (A1_3) do not correspond.
DISPLAY: XX is the age of the respondent calculated from question A1_4.
A1_6. [IF A1_5 = NO]
How sure are you that your birthdate is [FILL DAY] [FILL MONTH]?
1 Very Sure
2 Somewhat Sure
3 Not Sure
9 Prefer not to answer
ASK: All respondents for whom birthdate (A1_4) and age (A1_5) do not correspond.
DISPLAY: FILL DAY AND FILL MONTH are from A1_2.
A1_7. [IF A1_5 = NO]
How old are you now?
__________ MIN 11 MAX 20
9 Prefer not to answer
PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 7.
IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 11 AND 20.”
ASK: All respondents for whom birthdate (A1_4) and age (A1_5) do not correspond.
A2. Are you male or female?
1 Female
2 Male
9 Prefer not to answer
ASK: All respondents.
A3. Are you Hispanic, Latino/a, or of Spanish origin?
1 No, not of Hispanic, Latino/a, or Spanish origin
2 Yes, Mexican American, Chicano/a
3 Yes, Puerto Rican
4 Yes, Cuban
5 Yes, another Hispanic, Latino/a, or Spanish origin
9 Prefer not to answer
ASK: All respondents.
A4. What race or races do you consider yourself to be? Please select 1 or more of these categories.
-
1
Yes
A4_1. White
1
A4_2. Black or African American
1
A4_3. American Indian or Alaska Native
1
A4_4. Asian Indian
1
A4_5. Chinese
1
A4_6. Filipino
1
A4_7. Japanese
1
A4_8. Korean
1
A4_9. Vietnamese
1
A4_10. Native Hawaiian
1
A4_11. Guamanian or Chamorro
1
A4_12. Samoan
1
A4_13. Other Asian
1
A4_14. Other Pacific Islander
1
ASK: All respondents.
A5. [IF A3=2-9]
In general, do you usually speak…
1 Only Spanish
2 Spanish more than English
3 Spanish and English equally
4 English more than Spanish
5 English only GO TO A6
9 Prefer not to answer GO TO A6
ASK: Respondents who reported they are Hispanic, Latino/a, or of Spanish origin or prefers not to answer they are Hispanic, Latino/a, or of Spanish origin.
GO TO: If the respondent usually speaks only Spanish, Spanish more than English, Spanish and English equally, or English more than Spanish, go to next question A6. If respondent usually speaks English only or prefers not to answer which language they usually speak, go to A7.
A6. [IF A5=1-4]
When you watch TV, what type of programming do you usually watch?
1 Only Spanish
2 Spanish more than English
3 Spanish and English equally
4 English more than Spanish
5 English only
9 Prefer not to answer
ASK: Respondents who usually speak only Spanish, Spanish more than English, Spanish and English equally, or English more than Spanish.
A7. What grade are you in?
1 5th
2 6th
3 7th
4 8th
5 9th
6 10th
7 11th
8 12th
9 Ungraded or other grade
99 Prefer not to answer
ASK: All respondents.
A8. During the past 30 days, about how much money did you have each week to spend any way you wanted to?
1 None
2 $5 or less
3 $6 to $10
4 $11 to $20
5 $21 to $35
6 $36 to $50
7 $51 to $75
8 $76 to $125
9 $126 or more
99 Prefer not to answer
ASK: All respondents.
Section B: Tobacco Use Behavior
Thanks for your responses so far!
Now we want to know about your experiences with tobacco products.
Cigarette Use
B1. Have you ever tried cigarette smoking, even one or two puffs?
1 Yes
2 No GO TO B9
9 Prefer not to answer
ASK: All respondents.
GO TO: If respondent ever tried cigarette smoking, even one or two puffs or prefers not to answer whether they ever tried cigarette smoking, even one or two puffs, go to next question B3. If respondent never tried cigarette smoking, even one or two puffs, go to question B9.
B2. [IF B1=1 OR 9]
How old were you when you first tried cigarette smoking, even one or two puffs?
1 8 years old or younger
2 9 years old
3 10 years old
4 11 years old
5 12 years old
6 13 years old
7 14 years old
8 15 years old
9 16 years old
99 Prefer not to answer
ASK: Respondents who ever tried cigarette smoking, even one or two puffs, or preferred not to answer whether they ever tried cigarette smoking, even one or two puffs.
M1. Think back to when you first started smoking cigarettes. Was the first cigarette that you smoked menthol?
a. Yes
b. No
c. Don’t remember/Prefer not to answer
B3. During the past 30 days, on how many days did you smoke cigarettes?
1 0 days GO TO B6
2 1 or 2 days
3 3 to 5 days
4 6 to 9 days
5 10 to 19 days
6 20 to 29 days
7 All 30 days
9 Prefer not to answer
ASK: Respondents who ever tried cigarette smoking, even one or two puffs, or preferred not to answer whether they ever tried cigarette smoking, even one or two puffs.
GO TO: If respondent smoked cigarettes on 0 days during the past 30 days, go to question B6. If respondent smoked cigarettes on at least 1 day in the past 30 days or prefers not to report the number of days he or she smoked cigarettes in the past 30 days, go to next question B4.
B4. [IF B3=2-9]
During the past 30 days, what type of cigarettes did you usually smoke?
a. Regular
b. Menthol
c. Both Regular and Menthol, equally
d. Prefer not to answer
ASK: Respondents who smoked cigarettes on at least 1 day in the past 30 days or prefers not to report the number of days they smoked cigarettes in the past 30 days.
B5. [IF B3=2-9]
During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?
1 Less than 1 cigarette per day
2 1 cigarette per day
3 2 to 5 cigarettes per day
4 6 to 10 cigarettes per day
5 11 to 20 cigarettes per day
6 More than 20 cigarettes per day
9 Prefer not to answer
ASK: Respondents who smoked cigarettes on at least 1 day in the past 30 days or prefers not to report the number of days they smoked cigarettes in the past 30 days.
B6. [IF B1=1 OR 9]
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
ASK: Respondents who ever tried cigarette smoking, even one or two puffs, or preferred not to answer whether they ever tried cigarette smoking, even one or two puffs.
Other Substance Use
B9.
The next questions are about smokeless tobacco, such as dip, chewing tobacco, snuff, or snus. Common brands include [EDIT IF NECESSARY Copenhagen, Grizzly, Skoal, Camel Snus, Kodiak, and Longhorn].
Have you ever used smokeless tobacco even just a small amount?
1 Yes
2 No GO TO B11
9 Prefer not to answer GO TO B11
ASK: All respondents.
GO TO: If respondent ever used smokeless tobacco even just a small amount, go to next question B10. If respondent never used smokeless tobacco even just a small amount or prefers not to answer whether they ever used smokeless tobacco even just a small amount, go to question B11.
B10. [IF B9=1]
During the past 30 days, on how many days did you use smokeless tobacco?
1 0 days
2 1 or 2 days
3 3 to 5 days
4 6 to 9 days
5 10 to 19 days
6 20 to 29 days or
7 All 30 days
9 Prefer not to answer
ASK: Respondents who ever used smokeless tobacco even just a small amount.
The next questions are about cigars, cigarillos, or little cigars such as Black & Mild, Swisher Sweets, Dutch Masters, Phillies Blunts, Prime Time, and Winchester.
B11. Have you ever smoked cigars, cigarillos, or little cigars even one time?
1 Yes
2 No GO TO B13
9 Prefer not to answer GO TO B13
ASK: All respondents
GO TO: If respondent ever smoked cigars, cigarillos, or little cigars even one time, go to next question B12. If respondent never smoked cigars, cigarillos, or little cigars even one time or prefers not to answer whether they ever smoked cigars, cigarillos, or little cigars even one time, go to question B13.
B12. [IF B11=1]
During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?
1 0 days
2 1 or 2 days
3 3 to 5 days
4 6 to 9 days
5 10 to 19 days
6 20 to 29 days or
7 All 30 days
9 Prefer not to answer
ASK: Respondents who ever smoked cigars, cigarillos, or little cigars even one time.
B13. Have you ever tried smoking tobacco out of a water pipe (also called “hookah”), even one time?
1 Yes
2 No GO TO B15
9 Prefer not to answer GO TO B15
ASK: All respondents.
GO TO: If respondent ever smoked tobacco out of a water pipe even one time, go to next question B14. If respondent never smoked tobacco out of a water pipe even one time or prefers not to answer whether they ever smoked tobacco out of a water pipe even one time, go to question B15.
B14. [IF B13=1]
During the past 30 days, on how many days did you smoke tobacco out of a water pipe (also called “hookah”)?
1 0 days
2 1 or 2 days
3 3 to 5 days
4 6 to 9 days
5 10 to 19 days
6 20 to 29 days or
7 All 30 days
9 Prefer not to answer
ASK: Respondents who ever smoked tobacco out of a water pipe even one time.
The next questions are about vaping products or vapes. You may also know them as electronic cigarettes, e-cigarettes, vape pens, hookah pens, e-hookahs or mods. Some look like cigarettes, and others look like pens, pipes, or small boxes.
B15. Have you ever tried any vaping product, even one time?
1 Yes
2 No GO TO B17
9 Prefer not to answer GO TO B17
ASK: All respondents
GO TO: If respondent ever tried an electronic vaping product even one time, go to next question B16. If respondent never tried an electronic vaping product even one time or prefers not to answer whether they ever tried an electronic vaping product even one time, go to question B17.
B16. [IF B15=1]
During the past 30 days, on how many days did you vape?
1 0 days
2 1 or 2 days
3 3 to 5 days
4 6 to 9 days
5 10 to 19 days
6 20 to 29 days or
7 All 30 days
9 Prefer not to answer
ASK: Respondents who ever tried an electronic vaping product even one time.
M6. What was the first tobacco product you used?
a. Cigarette
b. Cigar
c. Hookah/Waterpipe
d. Smokeless
e. Vaping product
f. Don’t remember/Prefer not to answer
ASK: Respondents who report having used more than one tobacco product.
B17. Have you ever tried marijuana, even one time?
1 Yes
2 No GO TO C1
9 Prefer not to answer GO TO C1
ASK: All respondents
GO TO: If respondent ever tried marijuana even one time, go to next question B18. If respondent never tried marijuana even one time or prefers not to answer whether they ever tried marijuana even one time, go to question C1.
B18. [IF B17=1]
During the past 30 days, on how many days did you use marijuana?
1 0 days
2 1 or 2 days
3 3 to 5 days
4 6 to 9 days
5 10 to 19 days
6 20 to 29 days or
7 All 30 days
9 Prefer not to answer
ASK: Respondents who ever tried marijuana even one time.
B19. [IF B17=1]
During the past 30 days, on how many days did you add marijuana to a tobacco product, such as a cigar, cigarillo or little cigar (sometimes known as a “blunt”)?
1 0 days
2 1 or 2 days
3 3 to 5 days
4 6 to 9 days
5 10 to 19 days
6 20 to 29 days or
7 All 30 days
9 Prefer not to answer
ASK: Respondents who ever tried marijuana even one time.
Section C: Tobacco Use Intentions and Self-Efficacy
Doing great! Now we want you to think about what you might do in the future.
C1. Thinking about the future…
|
|
1 Definitely Yes |
2 Probably Yes |
3 Probably Not |
4 Definitely Not |
9 Prefer Not to Answer |
C1_1. |
Do you think that you will smoke a cigarette soon? |
1 |
2 |
3 |
4 |
9 |
C1_2 |
Do you think you will smoke a cigarette at any time in the next year? |
1 |
2 |
3 |
4 |
9 |
C1_5 |
If one of your best friends were to offer you a cigarette, would you smoke it? |
1 |
2 |
3 |
4 |
9 |
C1_18 |
Have you been curious about smoking a cigarette? |
1 |
2 |
3 |
4 |
9 |
C1_9 |
Do you think you will smoke cigars, cigarillos, or little cigars soon? |
1 |
2 |
3 |
4 |
9 |
C1_10 |
Do you think you will smoke cigars, cigarillos, or little cigars at any time in the next year? |
1 |
2 |
3 |
4 |
9 |
C1_11 |
If one of your best friends were to offer you a cigar, cigarillo, or little cigar, would you smoke it? |
1 |
2 |
3 |
4 |
9 |
C1_19 |
Have you been curious about smoking a cigar, cigarillo, or little cigar? |
1 |
2 |
3 |
4 |
9 |
C1_12 |
Do you think that you will vape soon? |
1 |
2 |
3 |
4 |
9 |
C1_13 |
Do you think you will vape at any time in the next year? |
1 |
2 |
3 |
4 |
9 |
C1_14 |
If one of your best friends were to offer you a vaping product/vape would you use it? |
1 |
2 |
3 |
4 |
9 |
C1_20 |
Have you been curious about vaping? |
1 |
2 |
3 |
4 |
9 |
C1_15 |
Do you think that you will smoke a hookah soon? |
1 |
2 |
3 |
4 |
9 |
C1_16 |
Do you think you will smoke a hookah at any time in the next year? |
1 |
2 |
3 |
4 |
9 |
C1_17 |
If one of your best friends were to offer you a hookah would you smoke it? |
1 |
2 |
3 |
4 |
9 |
C1_21 |
Have you been curious about smoking a hookah? |
1 |
2 |
3 |
4 |
9 |
C1_6 |
Do you think that you will use smokeless tobacco such as dip, chewing tobacco, snuff, or snus soon? |
1 |
2 |
3 |
4 |
9 |
C1_7 |
Do you think you will use smokeless tobacco at any time in the next year? |
1 |
2 |
3 |
4 |
9 |
C1_8 |
If one of your best friends were to offer you smokeless tobacco, would you use it? |
1 |
2 |
3 |
4 |
9 |
C1_22 |
Have you been curious about using smokeless tobacco? |
1 |
2 |
3 |
4 |
9 |
ASK: All respondents
ATTNCHK1.
Please select Tuesday as the answer to this question.
1 Monday
2 Tuesday
3 Wednesday
4 Thursday
5 Friday
6 Saturday
7 Sunday
9 Prefer not to answer
ASK: All respondents
C2. How sure are you that, if you really wanted to, you could say no to a cigarette offer if…
RANDOMIZE OPTIONS
|
1 Not at all sure |
2 Slightly sure |
3 Somewhat sure |
4 Mostly sure |
5 Completely sure |
9 Prefer Not to Answer |
C2_1. You are at a party where most people are smoking? |
1 |
2 |
3 |
4 |
5 |
9 |
C2_2. A very close friend offers it? |
1 |
2 |
3 |
4 |
5 |
9 |
C2_3. Someone you know offers it? |
1 |
2 |
3 |
4 |
5 |
9 |
ASK: All respondents
C4. How sure are you that, if you really wanted to, you could say no to vaping if…,
[RANDOMIZE OPTIONS]
|
1 Not at all sure |
2 Slightly sure |
3 Somewhat sure |
4 Mostly sure |
5 Completely sure |
9 Prefer Not to Answer |
C4_1. You are at a party where most people are vaping? |
1 |
2 |
3 |
4 |
5 |
9 |
C4_2. A very close friend offers it? |
1 |
2 |
3 |
4 |
5 |
9 |
C4_3. Someone you know offers it? |
1 |
2 |
3 |
4 |
5 |
9 |
ASK: All respondents
Section D: Cessation (Intention, Behavior, Motivation)
CHECKPOINT: ASK D1, D2 AND D3 OF RESPONDENTS WHO HAVE SMOKED ON 1 OR MORE DAYS IN THE PAST 30 DAYS OR PREFERRED NOT TO REPORT THE NUMBER OF DAYS THEY SMOKED IN THE PAST 30 DAYS.
D2. [IF B3=2-9]
During the past 3 months, did you stop smoking cigarettes for one day or longer because you were trying to quit smoking cigarettes for good?
1 Yes
2 No
9 Prefer not to answer
ASK: Respondents who smoked cigarettes on at least 1 day in the past 30 days or prefer not to report the number of days they smoked cigarettes in the past 30 days.
D1. [IF B3=2-9]
I plan to stop smoking cigarettes for good within the next… (PLEASE CHOOSE THE FIRST ANSWER THAT FITS)
1 7 days
2 30 days
3 6 months
4 1 year
5 I do not plan to stop smoking cigarettes within the next year
9 Prefer not to answer
ASK: Respondents who smoked cigarettes on at least 1 day in the past 30 days or prefers not to report the number of days they smoked cigarettes in the past 30 days.
D3. [IF B3=2-9]
How much do you want to quit smoking?
1 Not at all
2 A little
3 Somewhat
4 A lot
9 Prefer not to answer
ASK: Respondents who smoked cigarettes on at least 1 day in the past 30 days or prefers not to report the number of days they smoked cigarettes in the past 30 days.
Section E: Attitudes, Beliefs & Risk Perceptions, Social Norm
What do you think? We want your opinions on cigarette use and other tobacco products.
Attitude
E1. Smoking cigarettes is… (pick one)
RANDOMIZE OPTIONS
E1_1. |
Bad |
|
|
|
|
|
|
|
Good |
E1_2. |
Unenjoyable |
|
|
|
|
|
|
|
Enjoyable |
E1_3. |
Harmful |
|
|
|
|
|
|
|
Not Harmful |
ASK: All respondents
E14. Vaping is… (pick one)
RANDOMIZE OPTIONS
E14_1. |
Bad |
|
|
|
|
|
|
|
Good |
E14_2. |
Unenjoyable |
|
|
|
|
|
|
|
Enjoyable |
E14_3. |
Harmful |
|
|
|
|
|
|
|
Not Harmful |
ASK: All respondents
Attitudinal Beliefs and Risk Perceptions
E3. How much do you agree or disagree with the following statements? If I smoke I will…
|
If I smoke I will… |
1 Strongly Disagree |
2 Disagree |
3 Neither Agree or Disagree (Neutral) |
4 Agree |
5 Strongly Agree |
9 Prefer Not to Answer |
E3_1. |
Damage my body |
1 |
2 |
3 |
4 |
5 |
9 |
E3_2. |
Be controlled by smoking |
1 |
2 |
3 |
4 |
5 |
9 |
E3_3. |
Be unattractive |
1 |
2 |
3 |
4 |
5 |
9 |
E3_4. |
Inhale poisons |
1 |
2 |
3 |
4 |
5 |
9 |
E3_5. |
Develop cancer of the lip, mouth, tongue or throat |
1 |
2 |
3 |
4 |
5 |
9 |
E3_6. |
Develop sexual and/or fertility problems |
1 |
2 |
3 |
4 |
5 |
9 |
E3_7. |
Lose my taste buds |
1 |
2 |
3 |
4 |
5 |
9 |
E3_8. |
Be unable to stop when I want to |
1 |
2 |
3 |
4 |
5 |
9 |
E3_9. |
Get wrinkles |
1 |
2 |
3 |
4 |
5 |
9 |
E3_10. |
Develop skin problems |
1 |
2 |
3 |
4 |
5 |
9 |
E3_11 |
Have problems with my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E3_12. |
Lose my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E3_13. |
Have COPD |
1 |
2 |
3 |
4 |
5 |
9 |
E3_14 |
Shorten my life |
1 |
2 |
3 |
4 |
5 |
9 |
E3_15. |
Develop a smoking-related disease |
1 |
2 |
3 |
4 |
5 |
9 |
E3_16. |
Have bad breath |
1 |
2 |
3 |
4 |
5 |
9 |
E3_17 |
Get sick more often |
1 |
2 |
3 |
4 |
5 |
9 |
E3_18. |
Decrease my sports performance |
1 |
2 |
3 |
4 |
5 |
9 |
E3_19. |
End up wasting money on cigarettes |
1 |
2 |
3 |
4 |
5 |
9 |
E3_22. |
Become addicted |
1 |
2 |
3 |
4 |
5 |
9 |
E3_20. |
Harm others with second-hand smoke |
1 |
2 |
3 |
4 |
5 |
9 |
E3_21. |
Be a bad influence on others |
1 |
2 |
3 |
4 |
5 |
9 |
E3_23. |
Have trouble breathing |
1 |
2 |
3 |
4 |
5 |
9 |
E3_24. |
Stunt the growth of my lungs |
1 |
2 |
3 |
4 |
5 |
9 |
E3_25. |
Have yellow, stained teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E3_26. |
Develop gum disease |
1 |
2 |
3 |
4 |
5 |
9 |
E3_27. |
[ADD KEY BELIEF FROM REAL COST ADVERTISING] |
1 |
2 |
3 |
4 |
5 |
9 |
ASK: All respondents
What do you think?
E13. How much do you agree or disagree with the following statements? If I use If I use vaping products/vapes I will…
RANDOMIZE OPTIONS
|
|
1 Strongly Disagree |
2 Disagree |
3 Neither Agree or Disagree (Neutral) |
4 Agree |
5 Strongly Agree |
9 Prefer Not to Answer |
E13_1. |
Damage my body |
1 |
2 |
3 |
4 |
5 |
9 |
E13_2. |
Inhale poisons |
1 |
2 |
3 |
4 |
5 |
9 |
E13_3. |
Become addicted |
1 |
2 |
3 |
4 |
5 |
9 |
E13_4. |
Inhale nicotine |
1 |
2 |
3 |
4 |
5 |
9 |
E13_5. |
Inhale chemicals |
1 |
2 |
3 |
4 |
5 |
9 |
E13_6. |
Harm my lungs |
1 |
2 |
3 |
4 |
5 |
9 |
E13_7. |
Develop sexual and/or fertility problems |
1 |
2 |
3 |
4 |
5 |
9 |
E13_8. |
Decrease my sports performance |
1 |
2 |
3 |
4 |
5 |
9 |
E13_9. |
End up wasting money |
1 |
2 |
3 |
4 |
5 |
9 |
E13_10. |
Inhale metal particles |
1 |
2 |
3 |
4 |
5 |
9 |
E13_11. |
Be controlled by nicotine |
1 |
2 |
3 |
4 |
5 |
9 |
E13_12 |
[ADD KEY BELIEF FROM REAL COST ADVERTISING] |
1 |
2 |
3 |
4 |
5 |
9 |
ASK: All respondents
E5. How much do you agree or disagree with the following statements about smoking cigarettes?
|
|
1 Strongly Disagree |
2 Disagree |
3 Neither Agree or Disagree (Neutral) |
4 Agree |
5 Strongly Agree |
9 Prefer Not to Answer |
E5_1. |
Smoking can cause immediate damage to my body. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_2. |
It is safe for me to smoke for only a year or two, as long as I quit after that. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_3. |
If I started to smoke occasionally I would not become addicted. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_4. |
Smoking cigarettes helps people relieve stress. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_5. |
Cigarette ingredients are disgusting. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_6. |
Cigarette ingredients are dangerous. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_7. |
Smoking is a way to show others you’re not afraid to take risks |
1 |
2 |
3 |
4 |
5 |
9 |
E5_8. |
Smoking cigarettes can help keep your weight down |
1 |
2 |
3 |
4 |
5 |
9 |
E5_9. |
The lungs of teenage smokers may not grow to normal size. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_10. |
Smoking just a few cigarettes can make you crave more. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_11. |
If I smoke, nicotine will rewire my brain. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_12. |
Smoking as a teen can permanently stunt your lungs. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_13. |
Smoking cigarettes will make me have serious breathing problems. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_14. |
If I smoke, the consequences will find me. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_15. |
Nicotine can reprogram your brain. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_16. |
If I smoke, it will be hard to think about anything but my next cigarette. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_17. |
The nicotine in cigarettes may hack your brain. |
1 |
2 |
3 |
4 |
5 |
9 |
E5_18. |
[ADD KEY BELIEF FROM REAL COST ADVERTISING] |
1 |
2 |
3 |
4 |
5 |
9 |
ASK: All respondents
What do you think?
E15. How much do you agree or disagree with the following statements about vaping?
RANDOMIZE OPTIONS
|
|
1 Strongly Disagree |
2 Disagree |
3 Neither Agree or Disagree (Neutral) |
4 Agree |
5 Strongly Agree |
9 Prefer Not to Answer |
E15_1. |
Some of the chemicals in vapes/vaping products are the same as in regular cigarettes. |
1 |
2 |
3 |
4 |
5 |
9 |
E15_2. |
The potential health risks of vaping are unknown. |
1 |
2 |
3 |
4 |
5 |
9 |
E15_3. |
Vapes/vaping products contain potentially harmful chemicals. |
1 |
2 |
3 |
4 |
5 |
9 |
E15_4. |
Vaping causes lung damage. |
1 |
2 |
3 |
4 |
5 |
9 |
E15_5. |
Vaping may result in nicotine addiction. |
1 |
2 |
3 |
4 |
5 |
9 |
E15_6. |
The ingredients in vapes/vaping products are dangerous when inhaled. |
1 |
2 |
3 |
4 |
5 |
9 |
E15_7. |
Vaping helps people relieve stress. |
1 |
2 |
3 |
4 |
5 |
9 |
E15_8. |
Vaping can help keep your weight down. |
1 |
2 |
3 |
4 |
5 |
9 |
E15_9. |
The nicotine in vapes/vaping products may hack your brain. |
1 |
2 |
3 |
4 |
5 |
9 |
E15_10. |
Vaping as a teen can cause nicotine addiction. |
1 |
2 |
3 |
4 |
5 |
9 |
E15_11. |
[ADD KEY BELIEF FROM REAL COST ADVERTISING] |
1 |
2 |
3 |
4 |
5 |
9 |
ASK: All respondents.
E16. Does the vapor from vaping products contain…
RANDOMIZE OPTIONS
|
|
1 Definitely Yes |
2 Probably Yes |
3 Probably Not |
4 Definitely Not |
Don’t Know |
9 Prefer Not to Answer |
E16_1. |
Nicotine, an addictive substance |
1 |
2 |
3 |
4 |
5 |
9 |
E16_5. |
Diacetyl, a chemical that can cause lung damage (“popcorn lung”). |
1 |
2 |
3 |
4 |
5 |
9 |
E16_2. |
[ADD KEY BELIEF FROM REAL COST ADVERTISING] |
1 |
2 |
3 |
4 |
5 |
9 |
ASK: All respondents
E9. Does cigarette smoke contain….
|
|
1 Definitely Yes |
2 Probably Yes |
3 Probably Not |
4 Definitely Not |
Don’t Know |
9 Prefer Not to Answer |
E9_15. |
Over 7,000 chemicals? |
1 |
2 |
3 |
4 |
5 |
9 |
E9_16. |
[ADD KEY BELIEF FROM REAL COST ADVERTISING] |
1 |
2 |
3 |
4 |
5 |
9 |
ASK: All respondents
Social Norms
Thank you for telling us your opinions.
We have a couple of questions about your friends, and people your age.
E11. How many of your four closest friends…
|
|
0 None |
1 One |
2 Two |
3 Three |
4 Four |
9 Prefer Not to Answer |
E11_1. |
Smoke cigarettes? |
0 |
1 |
2 |
3 |
4 |
9 |
E11_5. |
Vape? |
0 |
1 |
2 |
3 |
4 |
9 |
ASK: All respondents
E12. How many other people your age…
|
|
0 None |
1 A few |
2 Some |
3 Most |
4 All |
9 Prefer Not to Answer |
E12_1. |
Smoke cigarettes every day? |
0 |
1 |
2 |
3 |
4 |
9 |
E12_7 |
Vape every day? |
0 |
1 |
2 |
3 |
4 |
9 |
E12_4. |
Smoke cigarettes, but not every day? |
0 |
1 |
2 |
3 |
4 |
9 |
E12_8 |
Vape, but not every day? |
0 |
1 |
2 |
3 |
4 |
9 |
ASK: All respondents
Section F: Media Use and Awareness
Next, we’d like to ask you about your use of TV and other media.
F1. How often do you…
PROGRAMMER: RANDOMIZE F1_1 – F1_8
|
Several times a day |
About once a day |
3-5 days a week |
1-2 days a week |
Every few weeks |
Less often |
Never |
Prefer Not to Answer |
F1_1. Watch television? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F1_2. Watch videos on YouTube/Twitch? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F1_3. Listen to radio? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F1_4. Listen to streaming radio? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F1_5. Play games on any electronic devices including cell phones/ smartphones, computers, laptops, tablets, consoles (Xbox, Wii, PS) and handheld players (Nintendo DS, Sony PSP, iPod)? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F1_6. Look at or read any magazines on a computer, laptop, or tablet? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F1_7. Watch Netflix, Hulu or Amazon Prime video? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F1_8. Go to the movies at a movie theater? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
ASK: All respondents.
Thinking only about yesterday, about how much time did you spend…
|
None |
At least one minute, but less than 1 hour |
1 hour or more, but less than 2 hours |
2 hours or more, but less than 3 hours |
More than 3 hours |
Prefer not to answer |
F1_9. Watching TV shows a TV, a computer or laptop, tablet, or smartphone? |
1 |
2 |
3 |
4 |
5 |
9 |
F1_10. Listening to radio? |
1 |
2 |
3 |
4 |
5 |
9 |
ASK: All respondents
ATTNCHK2
Please select basketball as the answer to this question.
1 Soccer
2 Baseball
3 Swimming
4 Softball
5 Basketball
9 Prefer not to answer
ASK: All respondents
F2. Thinking about the past [FILL MONTHS], that is since [FILL DATE], how frequently have you watched the following shows?
|
Never |
Rarely |
Sometimes |
Often |
Very Often |
Prefer not to Answer |
F2_14. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_15. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_16. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_17. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_18. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_19. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_20. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_21. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_22. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_23. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_24. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_25. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_26. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_27. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
F2_28. [insert show name] on [insert network name] |
1 |
2 |
3 |
4 |
5 |
9 |
ASK: All respondents
DISPLAY: FILL MONTHS is the equal to three months in the baseline survey. In subsequent surveys it will represent the number of months since the last interview. FILL DATE is equal to three months prior in the baseline survey. In subsequent surveys it will represent the date of the last interview. INSERT SHOW NAME is the name of the television show. INSERT NETWORK NAME is the name of the television network on which the television show aired.
F2_31. In the past [FILL MONTHS], that is since [FILL DATE], how frequently have you been on YouTube or Hulu?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very Often
9 Prefer not to answer
ASK: All respondents
DISPLAY: FILL MONTHS is the total number of months of the recall period of interest. FILL DATE is the first day of the recall period.
F2_32. In the past [FILL MONTHS], that is since [FILL DATE], how frequently have you been on Facebook?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very Often
9 Prefer not to answer
ASK: All respondents
DISPLAY: FILL MONTHS is the total number of months of the recall period of interest. FILL DATE is the first day of the recall period.
F2_33. In the past [FILL MONTHS], that is since [FILL DATE], how frequently have you been on Twitter?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very Often
9 Prefer not to answer
ASK: All respondents
DISPLAY: FILL MONTHS is the total number of months of the recall period of interest. FILL DATE is the first day of the recall period.
F2_34. In the past [FILL MONTHS], that is since [FILL DATE], how frequently have you used Pandora or Spotify?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very Often
9 Prefer not to answer
ASK: All respondents
DISPLAY: FILL MONTHS is the total number of months of the recall period of interest. FILL DATE is the first day of the recall period.
F2_35. In the past [FILL MONTHS], that is since [FILL DATE], how frequently have you used PlayStation or Xbox?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very Often
9 Prefer not to answer
ASK: All respondents
DISPLAY: FILL MONTHS is the total number of months of the recall period of interest. FILL DATE is the first day of the recall period.
F2_36. In the past [FILL MONTHS], that is since [FILL DATE], how frequently have you used Instagram?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very Often
9 Prefer not to answer
ASK: All respondents
DISPLAY: FILL MONTHS is the total number of months of the recall period of interest. FILL DATE is the first day of the recall period.
F2_37. In the past [FILL MONTHS], that is since [FILL DATE], how frequently have you used Snapchat?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very Often
9 Prefer not to answer
ASK: All respondents
DISPLAY: FILL MONTHS is the total number of months of the recall period of interest. FILL DATE is the first day of the recall period.
F2_38. In the past [FILL MONTHS], that is since [FILL DATE], how frequently have you used [ADD social media property]?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very Often
9 Prefer not to answer
ASK: All respondents
DISPLAY: FILL MONTHS is the total number of months of the recall period of interest. FILL DATE is the first day of the recall period. Social media property is the social media outlet of interest.
We want to ask you about some slogans or themes that might or might not have appeared in the media around here, as part of ads about tobacco.
F
3_3.
In the past [FILL
MONTHS] months,, that is since [FILL
DATE], have you seen or heard the following slogan or theme?
Digital Youth Against Tobacco (DYAT)
1___ Yes
2___ No
3___ Not Sure
ASK: All respondents
DISPLAY: FILL MONTHS is the recall period of interest. FILL DATE is the date the first day of the recall period of interest.
F3_4. In the past [FILL MONTHS] months,, that is since [FILL DATE], have you seen or heard the following slogan or theme?
T
he
Real Cost
1___ Yes
2___ No
3___ Not Sure
ASK: All respondents
DISPLAY: FILL MONTHS is the recall period of interest. FILL DATE is the date the first day of the recall period of interest.
F3_11. In the past [FILL MONTHS] months, that is since [FILL DATE], have you seen or heard the following slogan or theme?
T
ips
from Former Smokers (Tips)
1___ Yes
2___ No
3___ Not Sure
ASK: All respondents
DISPLAY: FILL MONTHS is the recall period of interest. FILL DATE is the date the first day of the recall period of interest.
F3_12.
In the past [FILL
MONTHS] months, that is since [FILL DATE],
have you seen or heard the following slogan or theme?
truth [insert current truth campaign name]
1___ Yes
2___ No
3___ Not Sure
ASK: All respondents
DISPLAY: FILL MONTHS is the recall period of interest. FILL DATE is the date the first day of the recall period of interest.
F3_13. In the past [FILL MONTHS] months,, that is since [FILL DATE], have you seen or heard the following slogan or theme?
Fresh
Empire
1___ Yes
2___ No
3___ Not Sure
ASK: All respondents
DISPLAY: FILL MONTHS is the recall period of interest. FILL DATE is the date the first day of the recall period of interest.
F5_14. In the past [FILL MONTHS] months, that is since [FILL DATE], have you seen or heard the following slogan or theme?
Drop Vape
1___ Yes
2___ No
3___ Not Sure
ASK: All respondents
DISPLAY: FILL MONTHS is the recall period of interest. FILL DATE is the date the first day of the recall period of interest.
F5_3. [IF F3_4=1 OR 3]
Where have you seen or heard about The Real Cost? Check all that apply.
1 2
Yes No
RANDOMIZE OPTIONS
F5_3a. On TV or the Internet/online
F5_3b. On the radio
F5_3c. In magazines
F5_3d. Billboards or other outdoor or mall ads
F5_3e. At the movie theatre
F5_3f. I have not seen or heard about The Real Cost
ASK: Respondents who have seen or heard of The Real Cost slogan or theme in the past 3 months or were not sure if they have seen or heard of The Real Cost slogan or theme in the past 3 months.
F6. [IF F3_4=1 OR 3]
The Real Cost campaign is online. Have you ever seen The Real Cost on…Check all that apply.
1 2
Yes No
F6_1. YouTube or Hulu?
F6_2. Facebook?
F6_3. Twitter?
F6_4. Pandora or Spotify?
F6_5. PlayStation or Xbox?
F6_6. Instagram?
F6_7. Snapchat?
F6_8. [ADD SOCIAL MEDIA PROPERYT]
ASK: Respondents who have seen or heard of The Real Cost slogan or theme in the past 3 months or were not sure if they have seen or heard of The Real Cost slogan or theme in the past 3 months.
Thanks for your responses!
F7_x. Now we would like to show you some advertisements that have been shown in the U.S. Once you have viewed the video or screenshot, please click on the forward arrow below to continue with the survey.
PROGRAMMER: DISPLAY VIDEOS OR SCREENSHOTS IN RANDOM ORDER. Use VIDEO for Real Cost ads, Use SCREENSHOTS for truth, Tips from Former Smokers, AND FRESH EMPIRE ads.
F8_x. Apart from this survey, how frequently have you seen this ad [SCREENSHOT LANGUAGE: these ads] in the past [FILL MONTHS]?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very Often
9 Prefer not to answer
ASK: All respondents
DISPLAY: SCREENSHOT LANGUAGE is entered when respondents are view screenshots for the truth, Tips From Former Smokers, and Fresh Empire ads. FILL MONTHS is the recall period of interest.
PROGRAMER: LOOP BACK TO ASK ABOUT NEXT AD HERE. SHOW SCREENGRAB OF AD
F19_x. What is the main message of this ad? Select only one response
[RANDOMIZE ORDER OF CHECKBOX LIST]
1 Smoking can damage your teeth
2 Smoking can cause wrinkles
4 Cigarettes can control your life
8 Being with friends is more important than smoking
9 This generation of teens can play a big role in stopping smoking
10 If you smoke you lose your freedom
11 There are toxic chemicals in cigarette smoke
14 Nicotine can reprogram your brain until it’s hard to think about anything but your next cigarette.
15 Cigarettes may leave you with stained teeth, gum disease and more.
16 Smoking as a teen can permanently stunt your lungs.
17 [ADD KEY MESSAGE FROM REAL COST ADVERTISING]
99 I am not sure
ASK: All respondents
F11. Please tell us if you strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree with the following statements.
|
|
1 Strongly Disagree |
2 Disagree |
3 Neither Agree or Disagree (Neutral) |
4 Agree |
5 Strongly Agree |
9 Prefer Not to Answer |
F11_1. |
This ad is worth remembering |
1 |
2 |
3 |
4 |
5 |
9 |
F11_2. |
This ad grabbed my attention |
1 |
2 |
3 |
4 |
5 |
9 |
F11_3. |
This ad is powerful |
1 |
2 |
3 |
4 |
5 |
9 |
F11_4. |
This ad is informative |
1 |
2 |
3 |
4 |
5 |
9 |
F11_5. |
This ad is meaningful to me |
1 |
2 |
3 |
4 |
5 |
9 |
F11_6. |
This ad is convincing |
1 |
2 |
3 |
4 |
5 |
9 |
F11_13 |
This ad is irritating |
1 |
2 |
3 |
4 |
5 |
9 |
ASK: All respondents
F14. Did you talk to anyone about any of these ads?
1 Yes
2 No
9 Prefer not to answer
ASK: All respondents
F15. [IF F14=1]
When you talked about the ads, did you talk about any of the following topics?
RANDOMIZE OPTIONS
Yes |
No |
|
1 |
2 |
F15_1. These ads were good |
1 |
2 |
F15_2. These ads were NOT good |
1 |
2 |
F15_3. I should not smoke |
1 |
2 |
F15_4. The person I was talking to or someone else I know should not smoke |
1 |
2 |
F15_5. Other, specify________________________ |
ASK: Respondents who talked to someone about any of the ads they viewed.
F16. Do your parents have rules about how much time you can spend using media, such as TV, computer, video games, cell phones, and music?
1 Yes, my parents have lots of rules about it.
2 Yes, my parents have a few rules about it.
3 No, my parents don’t have any rules about it.
9 Prefer not to answer
ASK: All respondents
F17. Do your parents have rules about what you are allowed to do on the computer, which video games you are allowed to play, or what music you’re allowed to listen to?
1 Yes, my parents have lots of rules about it.
2 Yes, my parents have a few rules about it.
3 No, my parents don’t have any rules about it.
9 Prefer not to answer
ASK: All respondents
F18. In general, how often do your parents make sure you follow the rules they have about using media, such as TV, computers, video games, and music?
1 Most of the time
2 Some of the time
3 A little of the time
4 Never
5 My parents don’t have rules about using media
9 Prefer not to answer
ASK: All respondents
F19. How often do your parents let you watch movies or videos that are rated R?
1 Never
2 Once in awhile
3 Sometimes
4 All the time
9 Prefer not to answer
ASK: All respondents
Section G: Environment
You’re almost done!
Just a few more questions about yourself and the people you live with.
G1. 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 [NAME TOP BRANDS]
3 cigars, cigarillos, or little cigars such as [NAME TOP BRANDS]
4 tobacco out of a water pipe (also called “hookah”)
5 electronic vaping products or electronic cigarettes, such as [NAME TOP BRANDS]
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
9 Prefer not to answer
ASK: All respondents
DISPLAY: The text NAME TOP BRANDS is a placeholder for the names of the top brands in this category.
G2. Do you have any brother(s) and/or sister(s) who have smoked cigarettes during the past 30 days?
1 Yes
2 No
3 I don’t know
4 I don’t have any brothers or sisters
9 Prefer not to answer
ASK: All respondents
G3. Which statement best describes the rules about smoking in your home? Would you say…
1 Smoking is not allowed anywhere inside your home
2 Smoking is allowed in some places or at some times
3 Smoking is allowed anywhere inside the home
4 There are no rules about smoking inside the home
9 Prefer not to answer
ASK: All respondents
G4. How well would you say you have done in school? Would you say…
1 Much better than average
2 Better than average
3 Average
4 Below average
5 Much worse than average
9 Prefer not to answer
ASK: All respondents
G5. I feel close to people at my school. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree (neutral)
4 Agree
5 Strongly Agree
9 Prefer not to answer
ASK: All respondents
G6. I am happy to be at my school. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree (neutral)
4 Agree
5 Strongly Agree
9 Prefer not to answer
ASK: All respondents
G7. I feel like I am a part of my school. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree (neutral)
4 Agree
5 Strongly Agree
9 Prefer not to answer
ASK: All respondents
G8. How far do you think you will go in school?
1 I don’t plan to go to school anymore
2 9th grade
3 10th grade
4 11th grade
5 12th grade or GED
6 Some college or technical school but no degree
7 Technical school degree
8 College degree
9 Graduate school, medical school, or law school
99 Prefer not to answer
ASK: All respondents
G9. How many close friends do you have? (Close friends include people whom you feel at ease with, can talk to about private matters, and can call on for help.)
__________ MIN 0 MAX 7
9 Prefer not to answer
PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 7.
IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 7.” IN LOWERCASE LETTERS
ASK: All respondents
G10. How often do you attend church or religious services? Would you say…
1 Never
2 Less than once a month
3 About once a month
4 About 2 or 3 times a month
5 Once a week
6 More than once a week
9 Prefer not to answer
ASK: All respondents
Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statements.
G11. I would like to explore strange places. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree (neutral)
4 Agree
5 Strongly Agree
9 Prefer not to answer
ASK: All respondents
G12. I like to do frightening things. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree (neutral)
4 Agree
5 Strongly Agree
9 Prefer not to answer
ASK: All respondents
G13. I like new and exciting experiences, even if I have to break the rules. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree (neutral)
4 Agree
5 Strongly Agree
9 Prefer not to answer
ASK: All respondents
G14. I prefer friends who are exciting and unpredictable. Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree (neutral)
4 Agree
5 Strongly Agree
9 Prefer not to answer
ASK: All respondents
G15. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
_____ Number of days
2 None
3 Don’t know
9 Prefer not to answer
PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 1 AND MAXIMUM OF 30.
IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE FOR THE NUMBER OF DAYS. PLEASE ENTER A NUMBER BETWEEN 1 AND 30.” IN LOWERCASE LETTERS
RESPONDENTS CAN ONLY RESPOND WITH THE OPTION NONE, DON’T KNOW, OR TYPE IN A NUMERIC RESPONSE OF 1-30. IF RESPONDENTS TRY TO ENTER A NUMBER OF DAYS AND EITHER NONE OR DON’T KNOW, ERROR MESSAGE SHOULD SAY “YOU HAVE ENTERED A NUMBER AND SELECTED NONE OR DON’T KNOW. PLEASE ENTER A NUMBER OF DAYS, CHOOSE NONE, OR CHOOSE DON’T KNOW AS YOUR RESPONSE.”
ASK: All respondents
These next questions ask about how you feel about your current relationship with your parents or guardians. Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statement.
G16. Thinking about the adult or adults you live with would you say you are satisfied with the way you communicate with each other.
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree (neutral)
4 Agree
5 Strongly Agree
9 Prefer not to answer
ASK: All respondents
G17. How close do you feel to the adult or adults you live with?
1 Not at all close
2 Not very close
3 Somewhat close
4 Quite close
5 Very close
9 Prefer not to answer
ASK: All respondents
G18. How often has a parent or other adult caregiver said things that really hurt your feelings or made you feel like you were not wanted or loved?
1 One time
2 Two times
3 Three to five times
4 Six to ten times
5 More than ten times
6 This has never happened
7 Don’t know
9 Prefer not to answer
ASK: All respondents
G19. Has a parent or other adult caregiver ever talked to you about reasons for not smoking cigarettes or using other types of tobacco like cigars and chewing tobacco?
1 Yes
2 No
9 Prefer not to answer
ASK: All respondents
G20. During the past 7 days, on how many days did you and one or both of your parents or other adult caregivers do something together just for fun?
__________ MIN 0 MAX 7
9 Prefer not to answer
PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 0 AND MAXIMUM OF 7.
IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE. PLEASE ENTER A NUMBER BETWEEN 0 AND 7.” IN LOWERCASE LETTERS
ASK: All respondents
Thank you for taking this survey!
Thank you for taking time to complete this survey.
OMB No: 0910-0753 Expiration Date: 09/30/2019
Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 45 minutes per response. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to PRAStaff@fda.hhs.gov.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | PR* |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |
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