OMB#
0910-0674
Exp.
03/31/2016
Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 20 minutes per response to complete the questionnaire (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 [email protected]
Q
UESTIONNAIRE
Part I
ALL PARTICIPANTS
(Questions to be presented prior to showing rough-cut advertisements)
(Part 1 questions are only asked once)
A1. Does anyone who lives with you now…
Smoke cigarettes
Use smokless tobacco (such as snus pouches, moist snuff, dip, spit, or chewing tobacco)?
Use any other form of tobacco (e.g., cigars, pipes or hookah)?
No one who lives with me now uses any form of tobacco
A2. How many of your four closest friends use smokless tobacco?
0
1
2
3
4
A3. How many times have you used smokeless tobacco in your entire lifetime?
Never
Less than 20 times
Between 20 and 49 times
Between 50 and 99 times
100 times or more
Part II
AD VIEW PARTICIPANTS ONLY
(Questions to be provided after each rough-cut advertisement)
Perceived Ad Effectiveness
[We would now like to show you a television ad and then gather your reactions to that ad. Please make sure the volume on your tablet is turned up, so that you can both see and hear the video. Please tap the forward arrow to continue.]
B1. What do you think [or would you say] is the main message of this advertisement?
B2. What do you like about this advertisement? Please be as specific as possible.
B3. What do you dislike about this advertisement? Please be as specific as possible.
B4. People sometimes have different emotional reactions when they see or hear advertisements. On a scale from 1 to 5, where 1 means “not at all” and 5 means “very”, please indicate how much this ad made you feel:
Not at all Very
1 2 3 4 5
[RANDOMIZE ORDER]
Sad
Afraid
Irritated
Hopeful
Motivated
Understood
Angry
Worried
Disgusted or grossed out
Uneasy
Surprised
B5. Please tell us if you strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree with the following statements:
[RANDOMIZE ORDER]
This ad is worth remembering
This ad grabbed my attention
This ad is powerful
This ad is informative
This ad is meaningful to me
This ad is convincing
This ad is terrible
This ad is silly
This ad is annoying
This ad was difficult to watch
I trust the information in this ad
This ad told me things I never knew before about smokeless tobacco
The person/people in this ad are like me
This ad gave me a reason not to use smokeless tobacco
I can identify with what the ad says
This ad is different from other anti-tobacco ads I’ve seen or heard
B6. On a scale of 1 to 5, how would you rate the main message in this ad:
Not believable Believable
2 3 4 5
B7. On a scale of 1 to 5, indicate whether the ad made using smokeless tobacco look like something you would or wouldn’t want to do.
Makes me want to use smokeless tobacco Makes me not want to use smokeless tobacco
2 3 4 5
B8. Is there anything confusing, unclear, or hard to understand in this ad?
Yes
No
[If B8 = Yes, Ask B9. If B6 = No, Ask B10]
B9. What is confusing about this ad?
B10. If you saw this advertisement, on a scale from 1 to 5, where 1 is not at all likely and 5 is extremely likely, how likely would you be to do each of the following:
Not at all Very
1 2 3 4 5
A. Visit ‘The Real Cost’ website
B. Look for more information online
C. Tell a friend
D. Tell a family member
E. Share the ad online (website or social media page)
F. Share the ad online using [insert social media platform]
For exposure groups show second ad when applicable, then re-ask Part II questions only
Part III
ALL PARTICIPANTS
Attitudes, Beliefs and Risk Perceptions
How much do you agree or disagree with following statements:
C1. If I use smokless tobacco (such as snus pouches, moist snuff, dip, spit, or chewing tobacco), I will…
C1_1. Damage my body
A. Strongly Disagree
B. Disagree
C. Neither Agree or Disagree
D. Agree
E. Strongly Agree
C1_2. Be controlled by smokeless tobacco
Strongly Disagree
Disagree
Neither Agree or Disagree
Agree
Strongly Agree
C1_3. Consume harmful chemicals
Strongly Disagree
Disagree
Neither Agree or Disagree
Agree
Strongly Agree
C1_4. Develop cancer
Strongly Disagree
Disagree
Neither Agree or Disagree
Agree
Strongly Agree
C1_5. Miss out on activities or things that I enjoy
Strongly Disagree
Disagree
Neither Agree or Disagree
Agree
Strongly Agree
C2. Using smokeless tobacco is…
A. Very Bad
B. Bad
C. Neither Good or Bad
D. Good
E. Very Good
C3. Using smokeless tobacco is…
A. Very Unenjoyable
B. Unenjoyable
C. Neither enjoyable or unenjoyable
D. Enjoyable
E. Very Enjoyable
C4. Out of every 10 people your age, how many do you think use smokeless tobacco? (Circle One)
0 people 1 2 3 4 5 6 7 8 9 10 people
C7. Do you think that you will use smokeless tobacco soon?
Definitely yes
Probably yes
Don’t know
Probably not
Definitely not
Additional Demographics
C8.What is your birthdate?
MM/DD/YYYY
C9. What is your zip code?
[___________]
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Cameron Wimpy |
| File Modified | 0000-00-00 |
| File Created | 2021-01-27 |