Adult - Screener

OMB#XXX-XXXX

Exp: XX/XX/XXXX

Appendix J:
Online Survey Screening Questions

Thank you for your interest in this study. To get started, we first need to ask you a few

questions to see if you are eligible to take the longer survey.

S1. What is your age? _______years old

[IF S1 < 13, GO TO TERMINATE]

S2. Have you ever smoked a cigarette, even one or two puffs? (Select one.)

1) Yes

2) No

S3. In the past 30 days, have you used smokeless tobacco products, such as snuff, dip, or snus? (Select one.)

1) Every day

2) Some days

3) Not at all

S4. [ASK IF S2=1] During the past 30 days, how many days did you smoke a cigarette? (Select one.)

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

7) All 30 days

[ASK S5-S7 ONLY IF 13 ≤ S1 < 18 AND S2 =2 OR IF 13 ≤ S1 < 18 AND S2=1 & S4=1]

S5. Have you ever been curious about cigarettes? (Select one.)

1) Very curious

2) Somewhat curious

3) A little curious

4) Not at all curious

S6. Do you think you will smoke a cigarette at any time in the next year? (Select one.)

1) Definitely yes

2) Probably yes

3) Probably not

4) Definitely not

S7. If one of your best friends offered you a cigarette, would you smoke it? (Select one.)

1) Definitely yes

2) Probably yes

3) Probably not

4) Definitely not

S8. [ASK IF S1 ≥ 18 AND S2=1] Have you smoked at least 100 cigarettes in your entire life? (Select one.)

1) Yes

2) No

S9. [RANDOMIZE ORDER OF PRODUCTS] Which of the following products have you used in the past 30 days?

	Yes	No
Electronic nicotine product (including e‑cigarettes, JUULS, vape pens, hookah pens, personal vaporizers and mods, e‑cigars, e‑pipes, and e‑hookahs)
Traditional cigars, cigarillos, or filtered cigars
Tobacco pipe
Waterpipe/hookah

G1. [ASK IF S1 ≥ 18] What is the highest level of school you completed or the highest degree you received? (Select one.)

1 Never attended school

2 Grades K through 8 (Elementary or grade school)

3 Grades 9 through 12 (Some high school)

4 Grade 12 (High school graduate) or GED

5 Some college or technical training school

6 College graduate

7 Postgraduate/master’s/doctorate/law/MD

8 I do not wish to answer

G2. [ASK IF S1 ≥ 18] What was your annual household income from all sources last year? Was it…? (Select one.)

1. Less than $25,000

2. Between $25,000 and $49,999

3. Between $50,000 and $74,999

4. More than $75,000

5. I do not wish to answer

G3. What is your sex?

1. Male

2. Female

3. Other

4. I do not wish to answer

G4. Are you Hispanic or Latino? (Select all that apply.)

1. No

2. Yes

3. I do not wish to answer

G5. What is your race? (Select all that apply.)

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian

5. Native Hawaiian or Other Pacific Islander

6. I do not wish to answer

G6. In the past 6 months, how many times have you participated in paid research about cigarettes, smoking, or tobacco?

1. 0

2. 1

3. 2 or more

[IF QUALIFIED FOR GROUP, GO TO SURVEY]

[IF NOT QUALIFIED FOR ANY GROUP, TERMINATE]

TERMINATE

You do not qualify for the longer survey. Thank you for your time.

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 3 minutes per response to complete the screener (the time estimated to read, review, respond). Send comments regarding this burden estimate or any other aspects of this information collection, including suggestions for reducing burden, to PRAStaff@fda.hhs.gov.

J-5