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Youth Baseline Questionnaire (Experimenter and Non-Trier)
ICR 201506-0910-029 · OMB 0910-0753 · Object 56769301.
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| File Type | application/msword |
|---|---|
| File Title | Youth Baseline Questionnaire (Experimenter and Non-Trier) |
| Last Modified By | Writer |
| File Modified | 2015-03-03 |
| File Created | 2026-10-07 |
| Conversion State | complete |
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Attachment 4: Youth Media Tracking SCREENER AND Instrument Form Approved OMB No. 0910-0753 Exp. Date 10/31/2016 Evaluation of the Public Education Campaign on Teen Tobacco-Media Tracking (ExPECTT-MT) Subjects for Questionnaire: Study Screener Section A: Media Use and Awareness Section B: Tobacco Use Behavior, Attitudes & Beliefs Section C: Demographic Items Study Screener (Email invitation to pre-selected parents from existing panel) Greetings! We have a new survey and your participation is requested. The survey is meant for children (males/females) ages 13-17. If [he/she] qualifies and completes, your Global Test Market account will be credited with the Market Points stated in the invitation. Best Regards – Global Test Market Team Study Introduction Thank you for agreeing to take part in this survey. The survey will take approximately 30 minutes to complete. You will be asked various questions about your experiences with tobacco products, media use, as well as some questions about your background. Even if you do not use tobacco products, the information you provide will still be very important. Your responses will be kept strictly confidential, and neither your name nor other personal information will be associated with your responses. The data collected for this study will be combined with that of all participants before it is analyzed. At the end of the survey, a link will take you to the GMI website to collect your MarketPoints. If you have any questions about this study, you can call Jane Allen, at 1-800-334-8571 extension 25115 or send email to [email protected]. If you have any questions about your rights as a study participant, you can call RTI's Human Research Protections Office at 1-866-214-2043 or send email to [email protected]. I have read and understand this information, and the study purpose and process are clear to me. Yes, I agree to participate in this study No, I do not wish to participate in this study S1. How old are you? 1 11 years old or younger (GO TO CLOSING TEXT) 2 12 years old (GO TO CLOSING TEXT) 3 13 years old (GO TO A1) 4 14 years old (GO TO A1) 5 15 years old (GO TO A1) 6 16 years old (GO TO A1) 7 17 years old (GO TO A1) 8 18 years old or older (GO TO CLOSING TEXT) 9 Prefer not to answer (GO TO CLOSING TEXT) CLOSING TEXT “You do not qualify for this survey, which is for children ages 13 to 17. Thank you very much for your response.“ C1. Are you male or female? 1 Female 2 Male 9 Prefer not to answer C2. Are you Hispanic, Latino/a, or of Spanish origin? 1 No, not of Hispanic, Latino/a, or Spanish origin 2 Yes, Mexican American, Chicano/a 3 Yes, Puerto Rican 4 Yes, Cuban 5 Yes, another Hispanic, Latino/a, or Spanish origin 9 Prefer not to answer C3. What race or races do you consider yourself to be? Please select 1 or more of these categories. 1 Yes C3_1. White 1 C3_2. Black or African American 1 C3_3. American Indian or Alaska Native 1 C3_4. Asian Indian 1 C3_5. Chinese 1 C3_6. Filipino 1 C3_7. Japanese 1 C3_8. Korean 1 C3_9. Vietnamese 1 C3_10. Native Hawaiian 1 C3_11. Guamanian or Chamorro 1 C3_12. Samoan 1 C3_13. Other Asian 1 C3_14. Other Pacific Islander 1 Section A: Media Use and Awareness [INSERT STUDY CONSENT LANGUAGE HERE] First, we’d like to ask you about your use of TV and other media. A1. Thinking only about yesterday, about how much time did you spend watching TV shows or movies on any of the following? None At least one minute, but less than 1 hour 1 hour or more, but less than 2 hours 2 hours or more, but less than 3 hours More than 3 hours Prefer not to answer A1_1. A TV set? Include time spent watching DVDs, streaming video like Netflix, shows that you recorded earlier, or shows “On Demand” 1 2 3 4 5 9 A1_2. A computer, laptop, or tablet? Include streaming video like Netflix, DVDs, Hulu, etc.? 1 2 3 4 5 9 A1_3. A cell phone/smartphone? 1 2 3 4 5 9 A1_4. An iPod or other MP3 player? 1 2 3 4 5 9 A2. Thinking only about yesterday, about how much time did you spend doing the following activities? You may be doing some of these activities while you are doing another (for example, listening to music while you instant messaging). None At least one minute, but less than 1 hour 1 hour or more, but less than 2 hours 2 hours or more, but less than 3 hours More than 3 hours Prefer not to answer Listening to Music A2_1. Listening to music across all devices including Ipods, MP3 players, cell phones, computer, laptop, tablet, Internet radio like Pandora, CD players, and car radios. 1 2 3 4 5 9 Using a Computer, Laptop, or Tablet A2_2. Watching or uploading videos such as YouTube on a computer, laptop, or tablet 1 2 3 4 5 9 A2_3. Using social networking sites like Facebook or twitter on a computer, laptop, or tablet 1 2 3 4 5 9 A2_4. Browsing any other type of website for anything besides schoolwork on a computer, laptop, or tablet, like news or entertainment. 1 2 3 4 5 9 A2_5. Instant messaging or Video chatting (on Skype, Googletalk, iChat, etc.) on a computer, laptop, or tablet 1 2 3 4 5 9 Using a Cell Phone/Smartphone A2_6. Text messaging on a cell phone/smartphone 1 2 3 4 5 9 A2_7. Watching or uploading videos such as YouTube on a cell phone/smartphone 1 2 3 4 5 9 A2_8. Going to social networking sites like Facebook or twitter on a cell phone/smartphone 1 2 3 4 5 9 A2_9. Browsing any other type of website on a cell phone/smartphone like news or entertainment. Include smartphone apps. 1 2 3 4 5 9 Playing Games and Reading A2_10. Playing games on all electronic devices. Include cell phones/smartphones, computers, laptops, tablets, game players hooked up to a TV/computer (Xbox, Wii, PSP) and handheld players (Nintendo DS, Sony PSP, iPod) 1 2 3 4 5 9 A2_11. Reading a book that was for your own enjoyment (not a homework assignment). Include e-book or e-readers. 1 2 3 4 5 9 A2_12. Looking at or reading any magazines? Do not include time spent reading magazines on a computer, laptop, or tablet. 1 2 3 4 5 9 A2_13. How often do you go to the movies at a movie theater? 1 Once a week or more often 2 One or two times a month 3 Once every two or three months 4 One or two times a year 5 I do not see movies at a movie theater 9 Prefer not to answer A3. We want to ask you about some slogans or themes that might or might not have appeared in the media around here. [RANDOMIZE PRESENTATION OF A3_1a through A3_1c] A3_1 In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme? Skittles 1___ Yes 2___ No 3___ Not Sure 9__ Prefer not to Answer A3_1b In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme? Xbox 1___ Yes 2___ No 3___ Not Sure 9__ Prefer not to Answer A3_1c In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme? Proactiv 1___ Yes 2___ No 3___ Not Sure 9__ Prefer not to Answer A3_2 [RANDOMIZE PRESENTATION OF A3_2a through A3_2f] A3_3. In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme? Digital Youth Against Tobacco (DYAT) 1___ Yes 2___ No 3___ Not Sure A3_4. In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme? The Real Cost 1___ Yes 2___ No 3___ Not Sure A3_6. In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme? Tips from Former Smokers (Tips) 1___ Yes 2___ No 3___ Not Sure A3_7. In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme? truth 1___ Yes 2___ No 3___ Not Sure A4. The next set of questions ask whether or not you’ve seen any of the following advertisements. [RANDOMIZE ORDER OF A4_1 and A4_2] A4_1. In the past 3 months, have you seen a Tips from Former Smokers (Tips) advertisement? Examples of some Tips from Former Smokers ads are shown below. 1___ Yes 2___ No 3__ Not sure 9__ Prefer not to Answer [INSERT Tips from Former Smokers PHOTO COLLAGE] [INSERT Tips from Former Smokers PHOTO COLLAGE] A4_2. In the past 3 months, have you seen a truth campaign advertisement? Examples of some truth campaign ads are shown below. 1___ Yes 2___ No 3__ Not sure 9__ Prefer not to Answer [INSERT truth PHOTO COLLAGE] A5. Where have you seen or heard about [INSERT CAMPAIGN NAME]? 1 2 Yes No [RANDOMIZE] A5_1. On TV A5_2. On the radio A5_3. In newspapers or magazines A5_4. On the Internet A5_5. Billboards or other outdoor ads A6. The [INSERT CAMPAIGN NAME] is on social networking sites. Have you ever seen [INSERT CAMPAIGN NAME] on the following sites? 1 2 Yes No A6_1. Facebook? A6_2. Twitter? A6_3. [INSERT SOCIAL MEDIA SITE A] A6_4. [INSERT SOCIAL MEDIA SITE B] A7_x. Now we would like to show you some screen shots from a television advertisement that has been shown in the U.S. Once you have viewed the images displayed below, please click on the forward arrow below to continue with the survey. [DISPLAY STORYBOARD IMAGES FOR AD_x] A8_x. Have you seen this ad in the past [FILL MONTHS], [FILL DATE]? 1 Yes 2 No 9 Prefer not to answer [IF A8x=1, ASK A8a_x] A8a_x. In the past [FILL MONTHS], how frequently have you seen this ad? 1 Rarely 2 Sometimes 3 Often 4 Very Often 9 Prefer not to answer A9ax. Where have you seen or heard these ads? Check all that apply. [Channels] [RANDOMIZE ORDER OF CHECKBOX LIST] 1___ On TV 2___ On the Internet 3___ On the radio 4___ In newspapers or magazines 5___ Billboards or posters 6__ Not sure 9__ Prefer not to Answer A9bx. Where have you seen these ads? Check all that apply. [Locations] [RANDOMIZE ORDER OF CHECKBOX LIST] 1___ At the movie theatre 2___ At school 3___ At the mall, in an arcade or store 4___ On buses, trains or other public transportation 5___ Outdoors 6__ Not sure 9__ Prefer not to Answer A9cx. Where on the Internet have you seen these ads? Check all that apply. [RANDOMIZE ORDER OF CHECKBOX LIST] 1___ Internet or banner ad 2___ Facebook 3___ Twitter 4___ YouTube 5___ Hulu 6___ Other social networking sites 7___ I have not seen this ad on the Internet 9__ Prefer not to Answer F19_x. What is the main message of this ad? Select only one response [RANDOMIZE ORDER OF CHECKBOX LIST] 1___ Smoking can damage your teeth 2___ Smoking can cause wrinkles 3___ Cigarettes are addictive 4___ Cigarettes can control your life 5___ The cost of a pack of cigarettes is going up 6___ The legal age for buying cigarettes is going up 7___ Laws make it difficult for teens to buy cigarettes at convenient stores 8___ Being with friends is more important than smoking 9. _This generation of teens can play a big role in stopping smoking 10. If you smoke you lose your freedom 11. There are toxic chemicals in cigarette smoke 99___ I am not sure A10_x. How would you describe this advertisement? A10_1. Bad -3 -2 -1 0 +1 +2 +3 Good A10_2. Unenjoyable -3 -2 -1 0 +1 +2 +3 Enjoyable A11_x. Please tell us if you strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree with the following statements. 1 Strongly Disagree 2 Disagree 3 Neither Agree or Disagree (Neutral) 4 Agree 5 Strongly Agree 9 Prefer Not to Answer A11_1 This ad is worth remembering 1 2 3 4 5 9 A11_2 This ad grabbed my attention 1 2 3 4 5 9 A11_3 This ad is powerful 1 2 3 4 5 9 A11_4 This ad is informative 1 2 3 4 5 9 A11_5 This ad is meaningful to me 1 2 3 4 5 9 A11_6 This ad is convincing 1 2 3 4 5 9 A11_7 This ad is terrible 1 2 3 4 5 9 A11_8 This ad is ridiculous 1 2 3 4 5 9 A11_9 I trust the information in this ad 1 2 3 4 5 9 A11_10 This ad told me things I never knew before about tobacco 1 2 3 4 5 9 A11_12 The person/people in this ad are like me 1 2 3 4 5 9 A11_13 This ad gave me good reasons not to use tobacco 1 2 3 4 5 9 A12_x. On a scale of 1 to 5, indicate whether the ad made [INSERT TOBACCO PRODUCT] look like something you would or wouldn’t want to do. 1. The ad makes me want to USE [INSERT TOBACCO PRODUCT] 2 3 4 5. The ad makes me want to not USE made [INSERT TOBACCO PRODUCT] A12b_x. On a scale of 1 to 5, indicate whether the ad made [INSERT TOBACCO PRODUCT] look like something you would or wouldn’t want to do. 1. The ad makes me want to USE [INSERT TOBACCO PRODUCT] 2 3 4 5. The ad makes me want to not USE made [INSERT TOBACCO PRODUCT] 9__ Prefer not to Answer A13_x. On scale of 1 to 5, where 1 means “not at all” and 5 means “very”, please indicate how much this ad made you feel… 1 2 3 4 5 [RANDOMIZE ORDER] Not at all Very A13a_x. Sad A13b_x. Afraid A13c_x. Irritated A13d_x. Angry A13d_x. Angry A13e_x. Ashamed A13f_x. Discouraged A13g_x. Hopeful A13h_x. Motivated A13i_x. Understood A13j_x. Amused A13k_x. Worried A13l_x. Disgusted or grossed out A13m_x. Happy A13n_x. Uneasy A130_x. Surprised A14. After seeing this ad, did you look for more information online? 1 Yes 2 No 9 Prefer not to answer A15. After seeing this ad, did you visit [insert campaign name] website or Facebook page? 1 Yes 2 No 9 Prefer not to answer A16. After seeing this ad, did you share [insert campaign name] YouTube channel with a friend? 1 Yes 2 No 9 Prefer not to answer A17. After seeing this ad, did you mention it on social media? 1 Yes 2 No 9 Prefer not to answer A18. Did you talk to anyone about this ad? 1 Yes 2 No 9 Prefer not to answer A15. When you talked about the ads, did you talk about any of the following topics? 1 2 Yes No [RANDOMIZE] A15_1. These ads were good A15_2. These ads were NOT good A15_3. I should not smoke A15_4. The person I was talking to or someone else I know should not smoke A15_5. Other, specify________________________ [REPEAT A7_x. FOR OTHER ADS] A16. Do your parents have rules about how much time you can spend using media, such as TV, computer, video games, cell phones, and music? 1 Yes, my parents have lots of rules about it. 2 Yes, my parents have a few rules about it. 3 No, my parents don’t have any rules about it. 9 Prefer not to answer A17. Do your parents have rules about what you are allowed to do on the computer, which video games you are allowed to play, or what music you’re allowed to listen to? 1 Yes, my parents have lots of rules about it. 2 Yes, my parents have a few rules about it. 3 No, my parents don’t have any rules about it. 9 Prefer not to answer A18. In general, how often do your parents make sure you follow the rules they have about using media, such as TV, computers, video games, and music? 1 Most of the time 2 Some of the time 3 A little of the time 4 Never 5 My parents don’t have rules about using media 9 Prefer not to answer Section B: Tobacco Use Behavior, Attitudes & Beliefs Cigarette Use B1. Have you ever tried cigarette smoking, even one or two puffs? 1 Yes 2 No 9 Prefer not to answer [IF B1=1 or 9, GO TO B2. IF B1=2, GO TO B5] B2. During the past 30 days, on how many days did you smoke cigarettes? 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 9 Prefer not to answer [IF B2=1, GO TO B5, otherwise GO TO B3] B3 During the past 30 days, were the cigarettes that you usually smoked menthol? 1 Yes 2 No 9 Prefer not to answer B4. About how many cigarettes have you smoked in your entire life? Your best guess is fine. 1 0 cigarettes 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 a 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) 9 Prefer not to answer B5. Do you consider yourself a smoker? 1 Yes 2 No 9 Prefer not to answer [IF B2=2-9 GO TO B5; OTHERWISE GO TO B6] B6. I plan to stop smoking cigarettes for good within the next… (PLEASE CHOOSE THE FIRST ANSWER THAT FITS) 1 7 days 2 30 days 3 6 months 4 1 year 5 I do not plan to stop smoking cigarettes within the next year 9 Prefer not to answer Other Tobacco Use B7. Have you ever used smokeless tobacco, such as chewing tobacco, snuff, snus (rhymes with goose) or dip, such as Copenhagen, Skoal, Grizzly, Kodiak, and Red Seal even just a small amount? 1 Yes 2 No 9 Prefer not to answer [IF C6=1, GO TO C7; OTHERWISE GO TO C8] B8. During the past 30 days, on how many days did you use chewing tobacco, snuff or dip? 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 or 7 All 30 days 9 Prefer not to answer [IF B7=2-9 GO TO B8; OTHERWISE GO TO B9] B9. I plan to stop using smokeless tobacco such as chewing tobacco, snuff, or dip for good within the next… (PLEASE CHOOSE THE FIRST ANSWER THAT FITS) 1 7 days 2 30 days 3 6 months 4 1 year 5 I do not plan to stop using smokeless tobacco within the next year 9 Prefer not to answer [IF B2=1 OR B7=1 GO TO B9; OTHERWISE GO TO B10] B10. Thinking about the future… 1 Definitely Yes 2 Probably Yes 3 Probably Not 4 Definitely Not 9 Prefer Not to Answer B10_1 Do you think that you will try a cigarette soon? 1 2 3 4 9 B10_2 Do you think you will smoke a cigarette at any time in the next year? 1 2 3 4 9 B10_3 If one of your best friends were to offer you a cigarette, would you smoke it? 1 2 3 4 9 B10_4 Do you think that you will try smokeless tobacco such as chewing tobacco, snuff or dip soon? 1 2 3 4 9 B10_5 Do you think you will use smokeless tobacco such as chewing tobacco, snuff or dip at any time in the next year? 1 2 3 4 9 B10_6 If one of your best friends were to offer you smokeless tobacco such as chewing tobacco, snuff or dip, would you use it? 1 2 3 4 9 B11. Smoking cigarettes is… B11_1 Bad -3 -2 -1 0 +1 +2 +3 Good B11_2 Unenjoyable -3 -2 -1 0 +1 +2 +3 Enjoyable B12. Using smokeless tobacco, such as chewing tobacco, snuff, or dip is… B12_1 Bad -3 -2 -1 0 +1 +2 +3 Good B12_2 Unenjoyable -3 -2 -1 0 +1 +2 +3 Enjoyable B13. How much do you agree or disagree with the following statements? If I smoke I will… 1 Strongly Disagree 2 Disagree 3 Neither Agree or Disagree (Neutral) 4 Agree 5 Strongly Agree 9 Prefer Not to Answer B13_1. Damage my body 1 2 3 4 5 9 B13_2. Be controlled by smoking 1 2 3 4 5 9 B13_3. Be unattractive 1 2 3 4 5 9 B13_4. Inhale poisons 1 2 3 4 5 9 B13_5. Develop cancer of the lip, mouth, tongue or throat 1 2 3 4 5 9 B13_6. Develop sexual and/or fertility problems 1 2 3 4 5 9 B13_7. Lose my taste buds 1 2 3 4 5 9 B13_8. Be unable to stop when I want to 1 2 3 4 5 9 B13_9. Get wrinkles 1 2 3 4 5 9 B13_10. Develop skin problems 1 2 3 4 5 9 B13_11 Have problems with my teeth 1 2 3 4 5 9 B13_12. Lose my teeth 1 2 3 4 5 9 B13_13. Have trouble breathing 1 2 3 4 5 9 B13_14 Shorten my life 1 2 3 4 5 9 B13_15. Develop a smoking-related disease 1 2 3 4 5 9 B13_16. Have bad breath 1 2 3 4 5 9 B13_17 Get sick more often 1 2 3 4 5 9 B13_18. Decrease my sports performance 1 2 3 4 5 9 B13_19. End up wasting money on cigarettes 1 2 3 4 5 9 B13_20. Become addicted 1 2 3 4 5 9 B13_21. Harm others with second-hand smoke 1 2 3 4 5 9 B13_22. Be a bad influence on others 1 2 3 4 5 9 B15. How much do you agree or disagree with the following statements about smoking cigarettes? 1 Strongly Disagree 2 Disagree 3 Neither Agree or Disagree (Neutral) 4 Agree 5 Strongly Agree 9 Prefer Not to Answer B15_1. Smoking can cause immediate damage to my body. 1 2 3 4 5 9 B15_2. It is safe for me to smoke for only a year or two, as long as I quit after that. 1 2 3 4 5 9 B15_3. If I started to smoke occasionally I would not become addicted. 1 2 3 4 5 9 B15_4. Smoking cigarettes helps people relieve stress. 1 2 3 4 5 9 B15_5. Cigarette ingredients are disgusting. 1 2 3 4 5 9 B15_6. Cigarette ingredients are dangerous. 1 2 3 4 5 9 B15_7. Smoking is a way to show others you’re not afraid to take risks 1 2 3 4 5 9 B15_8. Smoking cigarettes can help keep your weight down 1 2 3 4 5 9 B15_9. Menthol cigarettes are safer than non-menthol cigarettes 1 2 3 4 5 9 B17. Do you believe cigarette smoking is related to… 1 Definitely Yes 2 Probably Yes 3 Probably Not 4 Definitely Not Don’t Know 9 Prefer Not to Answer B17_1 Lung Cancer? 1 2 3 4 5 9 B17_2 Cancer of the lip, mouth, tongue or throat? 1 2 3 4 5 9 B17_3 Heart Disease? 1 2 3 4 5 9 B17_4 Diabetes? 1 2 3 4 5 9 B17_5 Emphysema? 1 2 3 4 5 9 B17_6 Stroke? 1 2 3 4 5 9 B17_7 Hole in throat (stoma or tracheotomy)? 1 2 3 4 5 9 B17_8 Buerger’s Disease? 1 2 3 4 5 9 B17_9 Removal of limbs (amputations)? 1 2 3 4 5 9 B17_10 Asthma? 1 2 3 4 5 9 B17_11 Gallstones? 1 2 3 4 5 9 B17_12 COPD or chronic bronchitis? 1 2 3 4 5 9 B19. Does cigarette smoke contain…. 1 Definitely Yes 2 Probably Yes 3 Probably Not 4 Definitely Not Don’t Know 9 Prefer Not to Answer B19_1 Ammonia, a substance found in fertilizer and household cleaners? 1 2 3 4 5 9 B19_2 Arsenic, a substance found in motor oil? 1 2 3 4 5 9 B19_3 Benzene, a chemical found in gasoline? 1 2 3 4 5 9 B19_4 Beryllium, a substance used in nuclear weapons and nuclear power reactors? 1 2 3 4 5 9 B19_5 Cadmium, a substance found in batteries? 1 2 3 4 5 9 B19_6 Carbon monoxide, a substance found in car exhaust? 1 2 3 4 5 9 B19_7 Formaldehyde, a chemical used to preserve things? 1 2 3 4 5 9 B19_8 Hydrogen cyanide, a substance used to kill insects? 1 2 3 4 5 9 B19_9 Lead, a substance found in bullets? 1 2 3 4 5 9 B19_10 Naphthalene, a chemical found in mothballs? 1 2 3 4 5 9 B19_11 2-Nitropropane, a substance found in paint and ink? 1 2 3 4 5 9 B19_12 Polonium 210, a poison? 1 2 3 4 5 9 B19_13 Uranium, a substance used in nuclear weapons and nuclear power reactors? 1 2 3 4 5 9 B21. How many of your four closest friends… 0 None 1 One 2 Two 3 Three 4 Four 9 Prefer Not to Answer B21_1. Smoke cigarettes? 0 1 2 3 4 9 B21_2. Use smokeless tobacco, such as chewing tobacco, snuff or dip? 0 1 2 3 4 9 B21_3 Smoke menthol cigarettes? 0 1 2 3 4 9 E8. How many others your age… 0 None 1 A few 2 Some 3 Most 4 All 9 Prefer Not to Answer E8_1. Smoke cigarettes every day? 0 1 2 3 4 9 E8_2. Smoke menthol cigarettes every day?? 0 1 2 3 4 9 E8_3 Use smokeless tobacco, such as chewing tobacco, snuff, or dip every day? 0 1 2 3 4 9 E8_4. Smoke cigarettes, but not every day? 0 1 2 3 4 9 E8_5. Smoke menthol cigarettes, but not every day?? 0 1 2 3 4 9 E8_6 Use smokeless tobacco, such as chewing tobacco, snuff, or dip, but not every day? 0 1 2 3 4 9 Section C: Demographic Items C1. Are you male or female? 1 Female 2 Male 9 Prefer not to answer C2. Are you Hispanic, Latino/a, or of Spanish origin? 1 No, not of Hispanic, Latino/a, or Spanish origin 2 Yes, Mexican American, Chicano/a 3 Yes, Puerto Rican 4 Yes, Cuban 5 Yes, another Hispanic, Latino/a, or Spanish origin 9 Prefer not to answer C3. What race or races do you consider yourself to be? Please select 1 or more of these categories. 1 Yes C3_1. White 1 C3_2. Black or African American 1 C3_3. American Indian or Alaska Native 1 C3_4. Asian Indian 1 C3_5. Chinese 1 C3_6. Filipino 1 C3_7. Japanese 1 C3_8. Korean 1 C3_9. Vietnamese 1 C3_10. Native Hawaiian 1 C3_11. Guamanian or Chamorro 1 C3_12. Samoan 1 C3_13. Other Asian 1 C3_14. Other Pacific Islander 1 [IF C2=2-9, GO TO C4, OTHERWISE GO TO C6] C4. How much do you watch Spanish and English television? Would you say… 1 Only Spanish 2 Spanish more than English 3 Spanish and English equally 4 English more than Spanish 5 English only 9 Prefer not to answer C5. During the past 30 days, about how much money did you have each week to spend any way you wanted to? 1 None 2 Less than $5 3 $6 to $10 4 $11 to $20 5 $21 to $35 6 $36 to $50 7 $51 to $75 8 $76 to $125 9 $126 or more 99 Prefer not to answer C6. How often do your parents let you watch movies or videos that are rated R? 1 Never 2 Once in awhile 3 Sometimes 4 All the time 9 Prefer not to answer C7. Other than you, has anyone who lives with you used any of the following during the past 30 days…? (You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER) 1 cigarettes 2 smokeless tobacco, such as chewing tobacco, snuff, snus (rhymes with goose) or dip, such as Copenhagen, Skoal, Grizzly, Kodiak, and Red Seal 3 cigars, cigarillos, or little cigars such as Swisher Sweets, Black & Mild, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s 4 tobacco out of a water pipe (also called “hookah”) 5 electronic cigarettes, such as blu, NJOY, Mistic, 21st Century Smoke 6 any other form of tobacco 7 No, no one who lives with me has used any form of tobacco during the past 30 days 9 Prefer not to answer C8. Do you have any brother(s) and/or sister(s) who have smoked cigarettes during the past 30 days? 1 Yes 2 No 3 I don’t know 4 I don’t have any brothers or sisters 9 Prefer not to answer Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statements. C9. I would like to explore strange places. Would you say you… 1 Strongly Disagree 2 Disagree 3 Neither agree nor disagree (neutral) 4 Agree 5 Strongly Agree 9 Prefer not to answer C10. I like to do frightening things. Would you say you… 1 Strongly Disagree 2 Disagree 3 Neither agree nor disagree (neutral) 4 Agree 5 Strongly Agree 9 Prefer not to answer C11. I like new and exciting experiences, even if I have to break the rules. Would you say you… 1 Strongly Disagree 2 Disagree 3 Neither agree nor disagree (neutral) 4 Agree 5 Strongly Agree 9 Prefer not to answer C12. I prefer friends who are exciting and unpredictable. Would you say you… 1 Strongly Disagree 2 Disagree 3 Neither agree nor disagree (neutral) 4 Agree 5 Strongly Agree 9 Prefer not to answer C13. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? _____ Number of days 2 None 3 Don’t know 9 Prefer not to answer C14. What is your zip code? 3 Don’t know 9 Prefer not to answer C15. What county do you live in? [DROP DOWN MENU BASED ON ZIP] 3 Don’t know 9 Prefer not to answer Thank you for taking time to complete this survey. OMB No: 0910-0753 Expiration Date: 10/31/2016 Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 30 minutes per response. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to [email protected]