3. 0810 Rough Cut Screener 8-16-2022

OMB# 0910-0810

EXP: 12/31/2024

STUDY 1 (ENDS): ATTACHMENT A1

SCREENER

TITLE OF INFORMATION COLLECTION:

The Real Cost Campaign (W3): Online Quantitative Study of Reactions to Rough-Cut Advertising Designed to Prevent Youth Tobacco Use

ASSENT

We have to ask you a few questions to determine if you are eligible to participate in this study. Do you agree to answer these screening questions?

Yes, I agree to answer these screening questions.

No, I do not agree to answer these screening questions.

[if answer is “no”, terminate and provide thank you message.]

INTRODUCTION:

Thanks for your interest in participating in this survey. Given the sensitive nature of some of the questions in the survey, we recommend you move to a private area.

To see if you are eligible, we need to ask you some questions about yourself. However, keep in mind that we will not share the answers with anyone, including parents

[Programming Note: Prefer Not to Answer will be included as a response option for all screener items.] 

S1. How old are you?

1. Under 13 years old [SCREEN OUT]

2. 13 years old

3. 14 years old

4. 15 years old

5. 16 years old

6. 17 years old

7. 18 years old or older [SCREEN OUT]

8. Prefer Not to Answer [SCREEN OUT]

S2. About how many cigarettes have you smoked in your entire life? Your best guess is fine.

1. I have never tried smoking a cigarette, even one or two puffs

2. 1 or more puffs but never a whole cigarette

3. 1 cigarette

4. 2-5 cigarettes

5. 6-15 cigarettes (about 1/2 a pack total)

6. 16-25 cigarettes (about 1 pack total)

7. 26-99 cigarettes (more than 1 pack, but less than 5 packs)

8. 100 or more cigarettes (5 or more packs) [SCREEN OUT]

9. Prefer not to Answer [SCREEN OUT]

S3. [Ask if S2 ≠ A] Have you smoked a cigarette in the past 30 days?

1. Yes

2. No

3. Prefer not to Answer [SCREEN OUT]

S4. Please do NOT include vaping marijuana/THC/CBD when answering this question. How many times have you vaped in your entire life?

1. 0 times

2. 1 time

3. 2-10 times

4. 11-20 times

5. 21-50 times

6. 51-99 times

7. 100 or more times

8. Prefer not to answer [SCREEN OUT]

S5. [Ask if S4≠ A] Please do NOT include vaping marijuana/THC/CBD when answering this question. During the past 30 days, on how many days did you vape?

A. 0 days

B. 1 or 2 days

C. 3-5 days

D. 6-9 days

E. 10-19 days

G. 20-29 days

H. All 30 days

I. Prefer not to Answer [SCREEN OUT]

S6. [Ask if S4=A OR S5=A] (Definitely yes, probably yes, probably not, definitely not, prefer not to answer)

1. Do you think that you will vape soon?

2. Do you think you will vape at any time in the next year?

3. If one of your best friends were to offer you a vape, would you try it?

[Screen out if “Definitely not” for all three items; Screen out if prefer not to answer for all three items]

S7. 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 [SCREEN OUT]

2. Yes, more than 6 months ago

3. No

4. I’m not sure

99. Prefer not to answer [SCREEN OUT]

S8. What is your gender identity? (Select all that apply)

1. Woman/girl

2. Man/boy

3. Non-binary or gender non-conforming

4. Transgender woman/girl

5. Transgender man/boy

6. Another gender identity

7. Prefer not to say

S9. 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

White S10. How much money does your family have?

1. Not enough to get by

2. Just enough to get by

3. Only have to worry about money for fun and extras

4. Never have to worry about money

5. Prefer not to answer

S11. What is your zip code?

Paperwork Reduction Act Statement: According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0910-0810. The time required to complete this information collection is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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.