Screener

Appendix A
Questionnaire
Intro1
[DISPLAY FOR ADULTS]
This study is funded by the U.S. Food and Drug Administration’s (FDA’s) Center for Tobacco
Products (CTP) and conducted by RTI International. This survey asks you about your smoking
habits and your opinions about tobacco products. Your participation in this research study is
completely voluntary, and you may skip any questions you do not want to answer. No one will
be able to link your responses to your identity. This survey will take about 20 minutes to
complete.
If you have any questions about this study, you may call Katherine Kosa of RTI at
1-800-334-8571, extension 23901. If you have any questions about your rights as a study
participant, you may call RTI’s Office of Research Protection at 1-866-214-2043
Intro2
[DISPLAY FOR YOUTH]
This study is funded by the U.S. Food and Drug Administration’s (FDA’s) Center for Tobacco
Products (CTP) and conducted by RTI International. This survey asks teenagers what they think
about cigarette smoking and other tobacco products. About 1,700 teenagers will complete this
survey. This survey will take about 20 minutes to complete.
Your participation in this research study is completely up to you. As part of the survey, you will
view some information related to cigarette smoking and other tobacco products. You’ve probably
read similar information online or in health class. The survey asks questions about your
experiences and thoughts regarding cigarette smoking. You may skip any questions you do not
want to answer. During the survey, we do not ask for your name; therefore, your name will not
be connected to your answers. Additionally, we will not share any information you provide in the
survey with anyone outside the research team, including your parents.
To ensure your answers are kept private, please complete the survey in a place where no one can
look over your shoulder and view your answers. Also, please complete the survey in one sitting
and close the screen when you are done taking the survey.
If you have any questions about the study, you may call Katherine Kosa of RTI at
1-800-334-8571, extension 23901. If you have any questions about your rights as a study
participant, you may call RTI’s Office of Research Protection at 1-866-214-2043.
S. Screening Questions
S1. What is your age? _______years old
[IF S1 < 13, NOT ELIGIBLE.]
S2. Have you ever smoked a cigarette, even one or two puffs? (Select one.)
1) Yes
2) No
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S3. Do you use smokeless tobacco products, such as snuff, dip, or Snus…? (Select one.)
1) Every day
2) Some days
3) Rarely
4) Not at all
[IF 13 ≤ S1 < 18 AND S2 =2 AND S3=4, GO TO S5.]
[IF S2 =2 AND S3≠4 (SMOKELESS ONLY = YES), GO TO SECTION A.]
[IF S1 ≥ 18 AND S2 = 2 AND S3=4 NOT ELIGIBLE.]
S4. 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
[If S1 ≥ 18 AND S4 = 1 AND S3=4 NOT ELIGIBLE.]
[If S1 ≥ 18 AND S4 = 1 AND S3≠4 (SMOKELESS ONLY = YES), GO TO SECTION A.]
[If S1 ≥ 18 AND S4 ≠ 1 GO TO S8.]
[IF 13 ≤ S1 < 18 AND S4 ≠ 1 (CURRENT YOUTH SMOKER=YES) GO TO Section B.]
[IF 13 ≤ S1 < 18 AND S4 = 1 AND S3≠4 (SMOKELESS ONLY =YES) GO TO Section B.]
S5. Do you think you will smoke a cigarette at any time in the next year? (Select one.)
5) Definitely Not
6) Probably Not
7) Probably Yes
8) Definitely Yes
S6. Do you think in the future you might try a cigarette? (Select one.)
1) Definitely Not
2) Probably Not
3) Probably Yes
4) Definitely Yes
S7. If one of your best friends offered you a cigarette, would you smoke it? (Select one.)
1) Definitely Not
2) Probably Not
3) Probably Yes
4) Definitely Yes
[IF S5 = S6 = S7 = 2, 3, 4 (YOUTH SUSCEPTIBLE TO SMOKING = YES). IF S5 = S6 =
S7 = 1 NOT ELIGIBLE.]
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S8. Have you smoked at least 100 cigarettes in your entire life?
1) Yes
2) No
[IF S1 ≥ 25 AND S8 = 1 (CURRENT ADULT SMOKER=YES). IF 18 ≤ S1 ≤ 24 AND S8 = 1
= 2 (YOUNG ADULT SMOKER=YES). IF S1 ≥ 25 AND S8 = 2 NOT ELIGIBLE.]
SECTION B: TOBACCO USE BEHAVIOR
[FOR B1-B3, EXCLUDE YOUTH SUSCEPTIBLE TO SMOKING AND SMOKELESS
ONLY.]
The next set of questions asks about your use and beliefs about tobacco.
B1. On average, in the past 30 days, about how many cigarettes did you smoke a day? (Select
one.)
1) Fewer than 5 cigarettes
2) 5-9 cigarettes
3) 10 cigarettes (1/2 a pack)
4) 11-19 cigarettes (more than 1/2 pack but less than 1 pack)
5) 20 cigarettes (1 pack) or more
B2. When you smoke, how often do you use hand-rolled or “roll-your-own” cigarettes? (Select
one.)
1) Never
2) Rarely when I smoke
3) Sometimes when I smoke
4) Often when I smoke
5) Always when I smoke
B3. On the days that you smoke, how soon after you wake up do you have your first cigarette?
(Select one.)
1) Within 5 minutes
2) 6-30 minutes
3) 31-60 minutes
4) After 60 minutes
[IF S3 ≠ 4, THEN B4-B6; OTHERWISE SKIP.]
The next set of questions asks about your use of smokeless tobacco.
B4. During the past 30 days, how many days did you use a smokeless tobacco product, such as
snuff, dip, or Snus…? (Select one.)? (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
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B5. On average, in the past 30 days, about how many times did you use smokeless tobacco a
day? (Select one.)
1. Once a day
2. 2 to 3 times a day
3. 4 to 5 times a day
4. More than 5 times a day
B6. On the days that you use smokeless tobacco, how soon after you wake up do you place your
first dip? (Select one.)
1. Within 5 minutes
2. 6-30 minutes
3. 31-60 minutes
4. After 60 minutes
SECTION A: COMMUNICATION OBJECTIVE QUESTIONS
[RANDOMLY ASSIGN R TO TREATMENT AND STIMULI or CONTROL.]
[IF TREATMENT GROUP, DISPLAY TEXT AND RANDOMLY SELECT AND DISPLAY
STIMULI IN POP-UP WINDOW. KEEP STIMULI VISIBLE THROUGHT SECTION A.]
Please click on the icon here to display a list of chemicals that are in [smokeless tobacco
products such as snuff, dip, or Snus / cigarettes / roll-your-own cigarettes]. Please take a
moment to look over this list. You can keep the list open while you complete the survey and can
click on the icon at any time to view the list.
Please use information provided on the list to answer the following questions.
A1. Do chemicals in cigarettes come from…? (Select one for each item.) [RANDOMIZE
LIST.]
Yes
1. The tobacco leaf
2. Tobacco smoke
3. The cigarette carton
4. Glues, inks, and paper
5. The filter
6. Additives

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No

[CONTROL & TX=CIG & RYO.]
A2. How many of the chemicals in cigarettes come from the tobacco leaf and the smoke?
(Select one.)
1) None of the chemicals
2) A few of the chemicals
3) Many of the chemicals
4) All of the chemicals
[CONTROL & TX=SMK.]
A3. How many of the chemicals in smokeless tobacco products come from the tobacco leaf?
(Select one.)
1) None of the chemicals
2) A few of the chemicals
3) Many of the chemicals
4) All of the chemicals
A4. For each question, please answer YES or NO. (Select one for each question.)
[RANDOMIZE LIST.]
Yes
1. Imagine one tobacco product has a greater number of
chemicals than another tobacco product. Can you tell
which of these products is more likely to cause a tobaccorelated health problem?
2. Formaldehyde has been linked to cancer. Now imagine
one brand of tobacco product has more formaldehyde in it
than another brand. Can you tell which of these brands of
tobacco product is more likely to cause cancer?
A5. Who tests tobacco products for harmful chemicals? (Select one.)
1) Tobacco farmers
2) Federal government
3) State and local health departments
4) Tobacco companies
5) No one
6) None of the above

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No

A6. For each of the following statements, please select True or False. (Select one for each
statement.) [RANDOMIZE LIST.]
True

False

1. Researchers have linked some of the chemicals from
tobacco products to health problems.
2. Researchers have discovered all of the health problems
that may be caused by harmful chemicals from tobacco
products.
3. Researchers have discovered all of the harmful chemicals
that come from using tobacco products.
4. All tobacco products contain chemicals that may cause
harm.
5. Research is ongoing to find out which chemicals cause
harm.
6. Nicotine causes cancer.
7. Nicotine is one reason why people have trouble quitting
tobacco products.
A7. For each question, please answer YES or NO. (Select one for each question.)
[RANDOMIZE LIST.]
Yes

No

1. Can you tell a tobacco user’s chance of developing a
tobacco-related health problem by counting the total
number of chemicals in his/her tobacco product?
2. Can you tell a tobacco user’s chance of developing a
health problem by looking at the amount of a harmful
chemical in his/her tobacco product?
[IF TX GROUP]
A8. For each of the following statements, please select True or False. (Select one for each
statement.) [RANDOMIZE LIST.]
True
1. When a chemical is listed without an amount it may mean
the chemical was not detected.
2. When a chemical is listed without an amount it may mean
the information is not currently available.

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False

SECTION C: DESIRE TO QUIT / STAGE OF CHANGE
[FOR C1-C3, EXCLUDE YOUTH SUSCEPTIBLE TO SMOKING AND SMOKELESS
ONLY.]
C1. Are you seriously considering stopping smoking within the next 6 months? (Select one.)
1) Yes
2) No
C2. Are you planning to stop smoking within the next 30 days? (Select one.)
1) Yes
2) No
C3. On a scale from 1 to 5 with 1 being “not at all” and 5 being the “a lot,” how much do you
want to quit smoking? (Select one.)
1) Not at all
2) .
3) .
4) .
5) A lot
[IF S3 ≠ 4]
C4. Are you seriously considering stopping using smokeless tobacco products such as snuff, dip,
or Snus within the next 6 months? (Select one.)
1) Yes
2) No
[IF S3 ≠ 4]
C5. Are you planning to stop using smokeless tobacco products such as snuff, dip, or Snus within
the next 30 days? (Select one.)
1) Yes
2) No
[IF S3 ≠ 4]
C6. On a scale from 1 to 5 with 1 being “not at all” and 5 being the “a lot,” how much do you
want to stop using smokeless tobacco? (Select one.)
6) Not at all
7) .
8) .
9) .
10) A lot

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SECTION D: RISK PERCEPTION
D1. On a scale of 1 to 5 with 1 being not harmful at all and 5 being extremely harmful, how
harmful to someone’s health is…? (Select one for each statement.) [RANDOMIZE 1-3.]
not at all
harmful
1

2

3

4

extremely
harmful
5

1. Smoking cigarettes
2. Smoking roll-your-own tobacco
3. Using smokeless tobacco
4. [TX = CIG. SHOW STIMULI.] Smoking this
brand of cigarettes
5. [TX = RYO. SHOW STIMULI.] Smoking this
brand of roll-your-own tobacco
6. [TX = SMK. SHOW STIMULI.] Using this
brand of smokeless tobacco
D2. How strongly do you agree or disagree with the following statement? There is no safe
tobacco product. (Select one.)
1) Strongly agree
2) Somewhat agree
3) Somewhat disagree
4) Strongly disagree
[FOR D3-D7, EXCLUDE YOUTH SUSCEPTIBLE TO SMOKING AND SMOKELESS
ONLY.]
D3. How likely do you think you are to get a disease from smoking cigarettes? (Select one.)
1) Very unlikely
2) Somewhat unlikely
3) Somewhat likely
4) Very likely
D4. Do you think your smoking has affected your health? (Select one.)
1) Yes
2) No
D5. How concerned are you that your smoking could affect your health? (Select one.)
1) Not at all concerned
2) Only slightly concerned
3) Fairly concerned
4) Very concerned
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D6. Do you think that your smoking has affected the health of someone else (e.g. spouse,
partner, child, grandchild)? (Select one.)
1) Yes
2) No
D7. How concerned are you that your smoking could affect the health of someone else? (Select
one.)
1) Not at all concerned
2) Only slightly concerned
3) Fairly concerned
4) Very concerned
[IF S3 ≠ 4]
D8. How likely do you think you are to get a disease from using smokeless tobacco? (Select
one.)
1) Very unlikely
2) Somewhat unlikely
3) Somewhat likely
4) Very like
[IF S3 ≠ 4]
D9. Do you think your use of smokeless tobacco has affected your health? (Select one.)
1) Yes
2) No
[IF S3 ≠ 4]
D10. How concerned are you that your use of smokeless tobacco could affect your health?
(Select one.)
1) Not at all concerned
2) Only slightly concerned
3) Fairly concerned
4) Very concerned

9 

SECTION E: YOUTH BELIEFS/ATTITUDES ABOUT TOBACCO USE
[IF YOUTH SUSCEPTIBLE TO SMOKING]
E6. On a scale of 1 to 5 with 1 being strongly disagree and 5 being strongly agree, how much
do you agree or disagree that cigarette smoking is…? (Select one for each item.)
[RANDOMIZE LIST.]
strongly
strongly
disagree
agree
1
2 3 4
5
1. Glamorous
2. Rebellious
3. Cool
4. Disgusting
5. Foolish
SECTION E: HEALTH LITERACY
The remaining questions are not about tobacco. These questions are to help us get a better sense
of who you are and how you make decisions about your health. The information below is from
the back of a container of a pint of ice cream. Please use this information to answer the
following questions.

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F1. If you eat the entire container, how many calories will you eat?
________________ Calories
[ENTER NUMBER]
F2. If you are allowed to eat 60 grams of carbohydrates as a snack, how many cups of ice cream
could you have?
________________ Cups
[ENTER NUMBER]
F3. Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have
42 g of saturated fat each day, which includes one serving of ice cream. If you stop eating ice
cream, how many grams of saturated fat would you be consuming each day?
________________ Grams
[ENTER NUMBER]
F4. If you usually eat 2,500 calories in a day, what percentage of your daily value of calories will
you be eating if you eat one serving?
________________ %
[ENTER NUMBER]
For the next few questions, pretend that you are allergic to the following substances: penicillin,
peanuts, latex gloves, and bee stings.
F5. Is it safe for you to eat this ice cream?
1) Yes
2) No
[If F5 = 1 GO TO G1]
F6. Why isn’t it safe to eat this ice cream? (Select one)
1) It is high in calories
2) It contains peanut oil
3) It is high in fat
4) The ice cream container is coated with latex
5) People who are allergic to penicillin should not eat ice cream
CLOSING QUESTIONS
G1. What is your sex? (Select one.)
1) Male
2) Female
G2. Are you Hispanic or Latino? (Select one.)
1 Yes
2 No
99 I do not wish to answer
11 

G3. What is your race? (Select all that apply.)
1 American Indian or Alaska Native
2 Asian
3 Black or African American
5 Native Hawaiian or Other Pacific Islander
6 White
99 I do not wish to answer
[ADULTS ONLY]
G4. 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
6 College graduate
7 Postgraduate/masters/doctorate/law/MD
99 I do not wish to answer
[YOUTH ONLY]
G5. What grade or year of school are you currently in? (Select one.)
1 4th grade
2 5th grade
3 6th grade
4 7th grade
5 8th grade
6 9th grade
7 10th grade
8 11th grade
9 12th grade or GED
10 Not currently in school
11 Graduated high school or GED
99 I do not wish to answer
[ADULTS ONLY]
G6. What was your annual household income from all sources in 2011? 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
99 I do not wish to answer

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[ADULTS ONLY]
G7. Which statement best describes your current employment status? (Select one.)
1. Working full time as a paid employee
2. Working full time, self-employed
3. Not working, on temporary layoff from a job
4. Not working, looking for work
5. Not working, retired
6. Not working, disabled
7. Not working, other
G8. Please enter your 5-digit zip code –OR– your city and state.
5-digit zip code: ________________________
–OR–
City: ________________________
State (2 letter abbreviation): ________________________
99
I do not wish to answer
Thank you for completing today’s survey. You will be awarded XX for completing this survey.
If you would like to learn more about the dangers of smoking or to get information about quitting
smoking, please visit www.smokefree.gov.

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