Appendix D- Screener

OMB# 0910-0810

Exp. 12/31/2024

APPENDIX D

SCREENER

TITLE OF INFORMATION COLLECTION:

The Real Cost Campaign: Media Tracking Study

Thank you for your interest in participating in this survey. Before we begin, we need to collect some of your background information to determine your eligibility to participate in this study.

[AGE]

1. How old are you?

_____________years old [RANGE: 5-100] [Terminate if under 13 or over 17]

99. Prefer not to answer [Terminate]

[RACE/ETHNICITY]

2. Which of these best describes your racial and/or ethnic background? (Select all that apply) 

1. American Indian or Alaska Native 

2. Asian

3. Black or African American 

4. Hispanic or Latino 

5. Native Hawaiian or Other Pacific Islander  

6. White 

99. Prefer not to answer

[GENDER]

Below is a personal question about how you identify with your gender/sexuality. Remember, no one outside of the research team will know what you write. There are no right or wrong answers to these questions.

3. Do you currently describe yourself as male, female or transgender?

1. Male

2. Female

3. Transgender

99. None of these

4. What is the 5-digit zip code where you CURRENTLY live? [Write response]

___ ___ ___ ___ ___

5. 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

99. Prefer not to answer [Terminate]

6. 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

99. Prefer not to answer [Terminate]

[CIG_EVER]

7. About how many cigarettes have you smoked in your entire life? Your best guess is fine.

1. I have never smoked cigarettes, not even one or two puffs

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 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)

99. Prefer not to answer [Terminate]

[If 7 = 1; skip to 10]

8. When did you last smoke a cigarette, even one or two puffs?

1. Sometime during the past 3 months

2. Not during the past 3 months but sometime during the past 6 months

3. Not during the past 6 months but sometime in the past year

4. 1 to 4 years ago

5. 5 or more years ago

99. Prefer not to answer [Terminate]

[If 8 = 1, CONTINUE TO 9. ELSE, SKIP TO 10]

9. During the past 30 days, on how many days did you use a cigarette?

1. 0 days

2. 1 or 2 days

3. 3 to 5 days

4. 6 to 9 days

5. 10 to 15 days

6. 16 to 20 days

7. 21 to 29 days

8. 30 days

99. Prefer not to answer [Terminate]

[CIG_SUSCEPT]

10. Thinking about the future…

		Definitely Yes	Probably Yes	Probably Not	Definitely Not	Prefer Not to Answer
a.	Do you think that you will smoke a cigarette soon?	☐1	☐2	☐3	☐4	☐99
b.	Do you think you will smoke a cigarette at any time in the next year?	☐1	☐2	☐3	☐4	☐99
c.	If one of your best friends were to offer you a cigarette would you use it?	☐1	☐2	☐3	☐4	☐99
d.	Are you curious about smoking a cigarette?	☐1	☐2	☐3	☐4	☐99

[CIGAR_INTRO]

The next questions are about cigarillos and filtered little cigars. These products go by lots of different names, so please use these descriptions and photos to understand what they are.

Some common brands of cigarillos and filtered little cigars are Black & Mild, Swisher Sweets, Dutch Masters, Phillies Blunts, Zig Zag, Prime Time, Game cigars and Cheyenne. Sometimes they are used with marijuana and called “blunts”.

[CIGAR_EVER]

11. About how many cigarillos or filtered little cigars (the items pictured above) have you smoked in your entire life? Your best guess is fine.

1. I have never smoked cigarillos or filtered little cigars, not even one or two puffs

2. 1 or more puffs but never a whole cigarillo or filtered little cigar

3. 1 cigarillo or filtered little cigar

4. 2 to 5 cigarillos or filtered little cigars

5. 6 to 15 cigarillos or filtered little cigars

6. 16 to 25 cigarillos or filtered little cigars

7. 26 to 99 cigarillos or filtered little cigars

8. 100 or more cigarillos or filtered little cigars

99. Prefer not to answer [Terminate]

[If 11 = 1; SKIP TO 14]

12. When did you last smoke a cigarillo or filtered little cigar, even one or two puffs?

1. Sometime during the past 3 months

2. Not during the past 3 months but sometime during the past 6 months

3. Not during the past 6 months but sometime in the past year

4. 1 to 4 years ago

5. 5 or more years ago

99.Prefer not to answer [Terminate]

[If 12 = 1, CONTINUE TO 13. ELSE, SKIP TO 14.]

13. During the past 30 days, on how many days did you use a little filtered cigar or cigarillo?

1. 0 days

2. 1 or 2 days

3. 3 to 5 days

4. 6 to 9 days

5. 10 to 15 days

6. 16 to 20 days

7. 21 to 29 days

8. 30 days

99. Prefer not to answer [Terminate]

[CIGAR_SUSCEPT]

14. Thinking about the future…

		Definitely Yes	Probably Yes	Probably Not	Definitely Not	Prefer Not to Answer
a.	Do you think that you will smoke a cigarillo or filtered little cigar soon?	☐1	☐2	☐3	☐4	☐99
b.	Do you think you will smoke a cigarillo or filtered little cigar at any time in the next year?	☐1	☐2	☐3	☐4	☐99
c.	If one of your best friends were to offer you a cigarillo or filtered little cigar would you use it?	☐1	☐2	☐3	☐4	☐99
d.	Are you curious about smoking a cigarillo or filtered little cigar?	☐1	☐2	☐3	☐4	☐99

[VAPE_INTRO]

The next questions are about vaping products or vapes. You may also know them as e-cigarettes. They can contain nicotine and/or flavors. Some common brands are JUUL, Suorin, and Puff Bar. Please do NOT include vaping marijuana/THC/CBD when answering these questions

[VAPE_EVER]

15. About how many times have you used a vape in your entire life? Your best guess is fine.

1. I have never used a vape, not even one or two puffs

2. 1 time

3. 2 to 5 times

4. 6 to 15 times

5. 16 to 25 times

6. 26 to 49 times

7. 50 to 99 times

8. 100 or more

99. Prefer not to answer [Terminate]

If 15= 1, skip to 18

16. When did you last use a vaping product, even one or two times?

1. Sometime during the past 3 months

2. Not during the past 3 months but sometime during the past 6 months

3. Not during the past 6 months but sometime in the past year

4. 1 to 4 years ago

5. 5 or more years ago

99. Prefer not to answer [Terminate]

[If 16 = 1, CONTINUE TO 17. ELSE, SKIP TO 18.]

17. During the past 30 days, on how many days did you use a vape?

1. 0 days

2. 1 or 2 days

3. 3 to 5 days

4. 6 to 9 days

5. 10 to 15 days

6. 16 to 20 days

7. 21 to 29 days

8. 30 days

99. Prefer not to answer [Terminate

[VAPE_SUSCEPT]

18. Please do NOT include vaping marijuana/THC/CBD when answering these questions.

Thinking about the future…

		Definitely Yes	Probably Yes	Probably Not	Definitely Not	Prefer Not to Answer
a.	Do you think that you will vape soon?	☐1	☐2	☐3	☐4	☐99
b.	Do you think you will vape at any time in the next year?	☐1	☐2	☐3	☐4	☐99
c.	If one of your best friends were to offer you a vape would you use it?	☐1	☐2	☐3	☐4	☐99
d.	Are you curious about using a vape?	☐1	☐2	☐3	☐4	☐99

QUALIFICATIONS

We will use the different tobacco product responses to recruit for different participants, depending on the ads being tested in that quarter’s fielding. We may move product questions not used for inclusion/exclusion into the questionnaire depending on OMB requirements.

Cigarette Recruitment [Questions 7-10]:

IF 7=2-7, QUALIFY FOR EXPERIMENTER GROUP

IF 10 ALL A, B, C, AND D = 4, EXCLUDE FROM SUSCEPTIBLE GROUP AND TERMINATE.

IF 10 ANY A, B, C, OR D = 99, EXCLUDE FROM SUSCEPTIBLE GROUP AND TERMINATE.

ELSE QUALIFY FOR SUSCEPTIBLE GROUP

LCC Recruitment: [Questions 11-14]:

If 11 = 2-7, QUALIFY FOR EXPERIMENTER GROUP

IF 14 ALL A, B, C, AND D = 4, EXCLUDE FROM SUSCEPTIBLE GROUP AND TERMINATE.

IF 14 ANY A, B, C, OR D = 99, EXCLUDE FROM SUSCEPTIBLE GROUP AND TERMINATE.

ELSE QUALIFY FOR SUSCEPTIBLE GROUP

ENDS Recruitment: [Questions 15-18]:

If 15 = 2-7, QUALIFY FOR EXPERIMENTER GROUP

IF 18 ALL A, B, C, AND D = 4, EXCLUDE FROM SUSCEPTIBLE GROUP AND TERMINATE.

IF 18 ANY A, B, C, OR D = 99, EXCLUDE FROM SUSCEPTIBLE GROUP AND TERMINATE.

ELSE QUALIFY FOR SUSCEPTIBLE GROUP

[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! You should now have access to the full survey. Please complete the survey by continuing to the next page to access it.”

As a reminder, we will not share your answers with anyone outside the study, including your parents.

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 2 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.