Media Tracking Questionnaire
Food and Drug Administration's Research and Evaluation Survey for the Public Education Campaign on Tobacco among LGBT (RESPECT)
Attachment2_FollowUp_Instrument
Media Tracking Questionnaire
OMB: 0910-0808
Attachment 2: lgbt young adult follow-up Instrument
Form Approved
OMB No. XXXX-xxxx
Exp. Date xx/xx/xxxx
Research and Evaluation Survey for the Public Education Campaign on Tobacco among Lesbian Gay Bisexual Transgender (LGBT) (RESPECT) – Follow-Up Survey
Subjects for Questionnaire:
Section AA: Informed Consent
Section A: Demographic Items
Section B: Tobacco Use Behavior
Section C: Tobacco Use Intentions and Self-Efficacy
Section D: Cessation (Intention, Behavior, Motivation)
Section E: Attitudes, Beliefs & Risk Perceptions, Social Norm
Section F: Media Use and Awareness
Section G: Environment
Section H: LGBT Identity and Community
Notes: LGBT stands for Lesbian Gay Bisexual Transgender
The “Prefer not to answer” option will be available for all questions; however, it will not be visible on the screen. Rather respondents will have the option of continuing to the next question without answering the current question. If they do, they will be prompted to answer the question they skipped and “Prefer not to answer” will appear as an option.
Section AA: Informed consent
AA1. [THE INFORMED CONSENT TEXT WILL BE INSERTED HERE.]
Section A: Demographic Items
The first part of the survey asks you some general questions about yourself.
A1. What is your date of birth? (mm-dd-yyyy)?
A2. 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
A3. What race or races do you consider yourself to be? (You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER or YOU MAY SKIP THIS QUESTION)
-
1
Yes
2
No
9
Prefer Not to Answer
A3_1. American Indian or Alaska Native
1
2
9
A3_2. Asian
1
2
9
A3_3. Black or African American
1
2
9
A3_4. Native Hawaiian or Other Pacific Islander
1
2
9
A3_5. White
1
2
9
A3_6. Other
1
2
9
A3_7. Prefer not to answer
A4. Which best describes your current job or paid employment status?
1 Work full-time at least 35 hours per week
2 Work part-time 15 to 34 hours per week
3 Work part-time less than 15 hours per week
4 I don't currently work for pay
5 Don’t know
9 Prefer not to answer
A5. What is the highest grade or level of school you have completed?
1 Less than high school
2 Some high school, no diploma
3 GED
4 High school graduate—diploma
5 Some college but no degree
6 Associate degree—occupational/vocational
7 Associate degree—academic program
8 Bachelor’s degree (ex: BA, AB, BS)
9 Master’s degree (ex: MA, MS, MEng, Med, MSW)
10 Professional school degree (ex: MD, DDS, DVM, JD)
11 Doctorate degree (ex: PhD, EdD)
12 Don’t know
99 Prefer not to answer
A6. Are you currently enrolled in a degree program?
1 Yes
2 No
3 Don’t know
9 Prefer not to answer
A7. Which type of degree program are you currently enrolled in?
1 Technical/vocational program
2 2-year degree program
3 4-year degree program
4 Graduate/professional program
5 Other type of degree program
6 Don’t know
9 Prefer not to answer
A8. Which of the following categories best describes your total household income in the past 12 months?
This is the total income before taxes of all persons in your household combined. Please include money from jobs, relatives, pensions, dividends, interest, social security payments or retirement benefits, net income from business, farm or rent, and any other money received by household members.
1 Less than $10,000
2 $10,000 to $14,999
3 $15,000 to $24,999
4 $25,000 to $34,999
5 $35,000 to $49,999
6 $50,000 to $74,999
7 $75,000 to $99,999
8 $100,000 to $149,999
9 $150,000 to $199,999
10 $200,000 or more
11 Don’t know
99 Prefer not to answer
Section B: Tobacco Use Behavior
The next section asks about your experiences with tobacco products.
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, ASK B2. IF B1=2, ASK B13]
B2. How old were you when you first tried cigarette smoking, even one or two puffs?
|_|_| Years
[RANGE: 7-17,99]
[PN: IF RESPONDENT DOESN’T ANSWER 7-17, FILL WITH 99]
B3. During the past 30 days, on how many days did you smoke cigarettes?
|_|_| days [RANGE: 0-30, 99]
[PN: IF RESPONDENT DOESN’T ANSWER 0-30, FILL WITH 99]
[IF B3=1 to 30, ASK B4, IF B3= 0 skip to B6]
B4. During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?
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)
6 30 cigarettes (1 ½ packs)
7 40 cigarettes (2 packs)
8 More than 40 cigarettes (more than 2 packs)
9 Prefer not to answer
B5. During the past 30 days, were the cigarettes that you usually smoked menthol?
1 Yes
2 No
9 Prefer not to answer
B6. On the days that you smoke, how soon after you wake up do you have your first cigarette? Would you say…
1 Within 5 minutes
2 6-30 minutes
3 31-60 minutes
4 After 60 minutes
9 Prefer not to answer
B7. Do you smoke:
1 Only when you are alone
2 Mainly when you are alone
3 As often alone as with others
4 Mainly when you are with others
5 Only when you are with others
9 Prefer not to answer
B8. Do you consider yourself a smoker?
1 Yes
2 No
9 Prefer not to answer
B9. Do you consider yourself a social smoker?
1 Yes
2 No
9 Prefer not to answer
B10. About how many cigarettes have you smoked in your entire life? Your best guess is fine.
1 1 or more puffs but never a whole cigarette
2 1 cigarette
3 2 to 5 cigarettes
4 6 to 15 cigarettes (about 1/2 a pack total)
5 16 to 25 cigarettes (about 1 pack total)
6 26 to 99 cigarettes (more than 1 pack, but less than 5 packs)
7 100 or more cigarettes (5 or more packs)
9 Prefer not to answer
B11. About how long has it been since you last smoked cigarettes?
1 More than 30 days ago but within the past 3 months
2 More than 3 months ago but within the past 12 months
3 More than 12 months ago but within the past 3 years
4 More than 3 years ago
9 Prefer not to answer
B12. The last time you bought cigarettes for yourself, did you buy them by the carton, pack, loose out of the pack, or did you roll your own?
1 Carton
2 Pack
3 Loose
4 Roll your own
5 Don’t know
9 Prefer not to answer
[IF B12=1, GO TO B12_1; IF B12=2 GO TO B12_2; IF B12= 3 GO TO B12_3 ELSE GO TO B13]
B12_1. What price did you pay?
Per Carton $ ___________ [Range $5.00 to $175.00]
B12_2. What price did you pay?
Per Pack $ ___________ [Range $1.50 to $25.00]
B12_3. What price did you pay?
Per Cigarette $ _________ [Range $0.10 to $2.00]
Other Tobacco and Substance Use
B13. 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 B13=1, ASK B14]
B14. During the past 30 days, on how many days did you use chewing tobacco, snuff, snus 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
B15. Have you ever smoked cigars, cigarillos, or little cigars such as Swisher Sweets, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s, even one or two puffs?
1 Yes
2 No
9 Prefer not to answer
[IF B15=1, ASK B16]
B16. During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars such as Swisher Sweets, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s?
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
B17. Have you ever tried smoking tobacco out of a water pipe (also called “hookah”)?
1 Yes
2 No
9 Prefer not to answer
[IF B17=1, ASK B18]
B18. During the past 30 days, on how many days did you smoke tobacco out of a water pipe (also called “hookah”)?
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
B19. These are examples of electronic cigarettes, also called “e-cigarettes”, “e-cigs”, “vapor pens”, or “e-hookahs”. Electronic cigarettes sometimes look like regular cigarettes, but run on a battery and produce vapor instead of smoke. Have you ever tried electronic cigarettes, even one or two puffs?
1 Yes
2 No
9 Prefer not to answer
[IF B19=1, ASK B20]
B20. During the past 30 days, on how many days did you use electronic cigarettes, also called “e-cigarettes”, “e-cigs”, “vapor pens”, or “e-hookahs”?
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
B21. Have you ever tried marijuana, even one time?
1 Yes
2 No
9 Prefer not to answer
[IF B21=1, ASK B22]
B22. During the past 30 days, on how many days did you use marijuana?
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
B23. During the past 30 days, on how many days did you drink one or more drinks of an alcoholic beverage?
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
B24. On the days that you drank during the past week, how many drinks did you usually have each day?
Sunday # OF DRINKS _____________ [RANGE: 1 - 90]
Monday # OF DRINKS _____________ [RANGE: 1 - 90]
Tuesday # OF DRINKS _____________ [RANGE: 1 - 90]
Wednesday # OF DRINKS _____________ [RANGE: 1 - 90]
Thursday # OF DRINKS _____________ [RANGE: 1 - 90]
Friday # OF DRINKS _____________ [RANGE: 1 - 90]
Saturday # OF DRINKS _____________ [RANGE: 1 - 90]
9 Prefer not to answer
[Display Section C only if B1= 2 (never smokers)]
Section C: Tobacco Use Intentions and Self-Efficacy
C1. Thinking about the future…
|
|
1 Definitely Yes |
2 Probably Yes |
3 Probably Not |
4 Definitely Not |
9 Prefer Not to Answer |
C1_1. |
Do you think that you will try a cigarette soon? |
1 |
2 |
3 |
4 |
9 |
C1_2. |
Do you think you will smoke a cigarette at any time in the next year? |
1 |
2 |
3 |
4 |
9 |
C1_3. |
If one of your best friends were to offer you a cigarette, would you smoke it? |
1 |
2 |
3 |
4 |
9 |
C2. Thinking about the future…
|
|
1 Definitely Yes |
2 Probably Yes |
3 Probably Not |
4 Definitely Not |
9 Prefer Not to Answer |
C2_1. |
Do you think that you might experiment with cigarettes in the future? |
1 |
2 |
3 |
4 |
9 |
C2_2. |
Have you ever been curious about smoking a cigarette? |
1 |
2 |
3 |
4 |
9 |
C3. How sure are you that, if you really wanted to, you could avoid smoking cigarettes if…
[RANDOMIZE C3_1-C3_4]
-
1
Not at all sure
2
Slightly sure
3
Somewhat sure
4
Mostly sure
5
Completely sure
9
Prefer Not to Answer
C3_1. You are at a party, bar or club?
1
2
3
4
5
9
C3_2. You are in a place where most people are smoking?
1
2
3
4
5
9
C3_2. Someone you know offers it?
1
2
3
4
5
9
C3_3. Someone you want to get to know offers it?
1
2
3
4
5
9
C3_4. Someone offers it to take a break?
1
2
3
4
5
9
Section D: Cessation (Intention, Behavior, Motivation)
Cigarette Use [Ask if B3=1 to 30]
D1. How much do you want to stop smoking for good? Would you say…?
1 Not at all
2 A little
3 Somewhat
4 A lot
9 Prefer not to answer
D2. I plan to stop smoking cigarettes for good within the next…
1 7 days
2 30 days
3 6 months
4 12 months
5 I do not plan to stop smoking cigarettes within the next year
9 Prefer not to answer
D3. If you decided to give up smoking altogether in the next 12 months, how likely do you think you would be to succeed? Would you say…?
1 Very unlikely
2 Somewhat unlikely
3 Somewhat likely
4 Very likely
9 Prefer not to answer
D4. How much do you think your health would improve if you were to stop smoking for good?
1 Not at all
2 A little
3 Somewhat
4 A lot
9 Prefer not to answer
D5. How worried are you that smoking will damage your health in the future?
1 Not at all worried
2 A little worried
3 Somewhat worried
4 Very worried
9 Prefer not to answer
D6. How worried are you that smoking will damage your physical appearance or attractiveness?
1 Not at all worried
2 A little worried
3 Somewhat worried
4 Very worried
9 Prefer not to answer
[Ask ALL]
Section E: Attitudes, Beliefs & Risk Perceptions, Social Norms
The next set of questions asks for your opinions on cigarette use and other tobacco products.
Attitude
E1. How much do you agree or disagree with the following statements about people who are tobacco-free?
[RANDOMIZE ALL ROWS]
|
|
1 Strongly Disagree |
2 Disagree |
3 Neither Agree or Disagree (Neutral) |
4 Agree |
5 Strongly Agree |
9 Prefer Not to Answer |
E1_1. |
People who are tobacco-free are confident. |
1 |
2 |
3 |
4 |
5 |
9 |
E1_2. |
People who are tobacco-free are powerful. |
1 |
2 |
3 |
4 |
5 |
9 |
E1_3. |
People who are tobacco-free are happy. |
1 |
2 |
3 |
4 |
5 |
9 |
E1_4. |
People who are tobacco-free are social. |
1 |
2 |
3 |
4 |
5 |
9 |
E1_5. |
People who are tobacco-free are attractive. |
1 |
2 |
3 |
4 |
5 |
9 |
E1_6. |
People who are tobacco-free are passé. |
1 |
2 |
3 |
4 |
5 |
9 |
E1_7. |
People who are tobacco-free are unsure of themselves. |
1 |
2 |
3 |
4 |
5 |
9 |
E1_8. |
People who are tobacco-free are boring. |
1 |
2 |
3 |
4 |
5 |
9 |
E1_9. |
People who are tobacco-free are basic. |
1 |
2 |
3 |
4 |
5 |
9 |
E1_10. |
People who are tobacco-free are predictable. |
1 |
2 |
3 |
4 |
5 |
9 |
E1_11. |
People who are tobacco-free are followers. |
1 |
2 |
3 |
4 |
5 |
9 |
E1_12. |
People who are tobacco-free are trendsetters. |
1 |
2 |
3 |
4 |
5 |
9 |
E2. Smoking cigarettes is… (pick one)
[RANDOMIZE E2_1-E2_2]
E2_1. |
Bad |
|
|
|
|
|
|
|
Good |
E2_2. |
Unenjoyable |
|
|
|
|
|
|
|
Enjoyable |
E3A. How much do you agree or disagree with the following statements?
[ASK E3A ONLY if B1= 2 (never smokers) OR B3= 0 (current non-smokers)
AND B13=2 (never smokeless users) OR B14= 0 (current non-smokeless users)
AND B15= 2 (never cigarillo users) OR B16= 0 (current non-cigarillo users)
AND B17= 2 (never hookah users) OR B18= 0 (current non-hookah users)
AND B19= 2 (never e-cigarette users) OR B20= 0 (current non-ecigarette users]
ELSE SKIP to E3B (current tobacco users)]
[RANDOMIZE E3A_1-E3A_7]
|
|
1 Strongly Disagree |
2 Disagree |
3 Neither Agree or Disagree (Neutral) |
4 Agree |
5 Strongly Agree |
9 Prefer Not to Answer |
E3A_1. |
I am proud to live tobacco-free. |
1 |
2 |
3 |
4 |
5 |
9 |
E3A_2. |
Living tobacco-free is important to me. |
1 |
2 |
3 |
4 |
5 |
9 |
E3A_3. |
I am proud to tell other people I live tobacco-free. |
1 |
2 |
3 |
4 |
5 |
9 |
E3A_4. |
Using tobacco will interfere with my life. |
1 |
2 |
3 |
4 |
5 |
9 |
E3A_5. |
Tobacco use is harmful to the LGBT community. |
1 |
2 |
3 |
4 |
5 |
9 |
E3A_6. |
Being tobacco free when I go out makes me feel excluded. |
1 |
2 |
3 |
4 |
5 |
9 |
E3A_7. |
Using tobacco makes life harder. |
1 |
2 |
3 |
4 |
5 |
9 |
E3B. How much do you agree or disagree with the following statements?
[RANDOMIZE E3B_1-E3B_7]
|
|
1 Strongly Disagree |
2 Disagree |
3 Neither Agree or Disagree (Neutral) |
4 Agree |
5 Strongly Agree |
9 Prefer Not to Answer |
E3B_1. |
I would be proud to live tobacco-free. |
1 |
2 |
3 |
4 |
5 |
9 |
E3B_2. |
Living tobacco-free is important to me. |
1 |
2 |
3 |
4 |
5 |
9 |
E3B_3. |
If I lived tobacco-free I would be proud to tell other people. |
1 |
2 |
3 |
4 |
5 |
9 |
E3B_4. |
Using tobacco interferes with my life. |
1 |
2 |
3 |
4 |
5 |
9 |
E3B_5. |
Tobacco use is harmful to the LGBT community. |
1 |
2 |
3 |
4 |
5 |
9 |
E3B_6. |
If I was tobacco free I would feel excluded when I go out. |
1 |
2 |
3 |
4 |
5 |
9 |
E3_7. |
Using tobacco makes life harder. |
1 |
2 |
3 |
4 |
5 |
9 |
E4. How much do you agree or disagree with the following statements? If I smoke cigarettes every day, I will…
[RANDOMIZE ROWS]
|
|
1 Strongly Disagree |
2 Disagree |
3 Neither Agree or Disagree (Neutral) |
4 Agree |
5 Strongly Agree |
9 Prefer Not to Answer |
E4_1. |
Damage my body |
1 |
2 |
3 |
4 |
5 |
9 |
E4_2. |
Shorten my life |
1 |
2 |
3 |
4 |
5 |
9 |
E4_3. |
Be able to stop smoking when I want to |
1 |
2 |
3 |
4 |
5 |
9 |
E4_4. |
Become addicted to smoking |
1 |
2 |
3 |
4 |
5 |
9 |
E4_5. |
Be more attractive |
1 |
2 |
3 |
4 |
5 |
9 |
E4_6. |
Have bad breath |
1 |
2 |
3 |
4 |
5 |
9 |
E4_7. |
Damage my immune system |
1 |
2 |
3 |
4 |
5 |
9 |
E4_8. |
Turn off potential partners |
1 |
2 |
3 |
4 |
5 |
9 |
E4_9. |
Get sick more easily |
1 |
2 |
3 |
4 |
5 |
9 |
E4_10. |
Damage my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E4_11. |
Damage my skin |
1 |
2 |
3 |
4 |
5 |
9 |
E4_12. |
Develop lung cancer |
1 |
2 |
3 |
4 |
5 |
9 |
Social Norms
E5. How many of your four closest friends…
|
|
0 None |
1 One |
2 Two |
3 Three |
4 Four |
9 Prefer Not to Answer |
E5_1. |
Smoke cigarettes? |
0 |
1 |
2 |
3 |
4 |
9 |
E5_2. |
Smoke menthol cigarettes? |
0 |
1 |
2 |
3 |
4 |
9 |
E5_3. |
Use a hookah or water pipe to smoke tobacco? |
0 |
1 |
2 |
3 |
4 |
9 |
E5_4. |
Use electronic cigarettes, also called “e-cigarettes”, “e-cigs”, “vapor pens”, or “e-hookahs”,
Common brands are Blu, Njoy, Logic, Fin, Swisher, 21st Century Smoke, Vuse, Markten, V2 Ecigs, Nicotek or Vapin Plus. |
0 |
1 |
2 |
3 |
4 |
9 |
E5_5. |
Smoke cigars, cigarillos, or little cigars without added marijuana?
Common brands are Swisher Sweets, Black & Mild, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s. |
0 |
1 |
2 |
3 |
4 |
9 |
E6. How many LGBT people who are your age...
|
|
0 None |
1 A few |
2 Some |
3 Most |
4 All |
9 Prefer Not to Answer |
E6_1. |
Smoke cigarettes? |
0 |
1 |
2 |
3 |
4 |
9 |
E6_2. |
Smoke menthol cigarettes? |
0 |
1 |
2 |
3 |
4 |
9 |
E6_3. |
Use a hookah or water pipe to smoke tobacco? |
0 |
1 |
2 |
3 |
4 |
9 |
E6_4. |
Use electronic cigarettes, also called “e-cigarettes”, “e-cigs”, “vapor pens”, or “e-hookahs”?
Common brands are Blu, Njoy, Logic, Fin, Swisher, 21st Century Smoke, Vuse, Markten, V2 Ecigs, Nicotek or Vapin Plus. |
0 |
1 |
2 |
3 |
4 |
9 |
E6_5. |
Smoke cigars, cigarillos, or little cigars without added marijuana?
Common brands are Swisher Sweets, Black & Mild, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s. |
0 |
1 |
2 |
3 |
4 |
9 |
E7. Thinking about LGBT people your age, do you think cigarette smoking is…
1 Increasing
2 Decreasing
3 Staying the same
4 Not sure
9 Prefer not to answer
E8. How do LGBT people your age feel about cigarette smoking? Would YOU say most LGBT people your age...
2 Strongly disapprove
3 Somewhat disapprove
4 Neither approve nor disapprove
4 Somewhat approve
4 Strongly approve
9 Prefer not to answer
E9. Compared to 3 months ago, people my age at LGBT bars, clubs and events are smoking...
1 More often
2 Less often
3 About the same
4 Not sure
9 Prefer not to answer
Perceived Approval
E10. How much do you agree or disagree with the following statements?
[RANDOMIZE E10_1-E10_4]
|
|
1 Strongly Disagree |
2 Disagree |
3 Neither Agree or Disagree (Neutral) |
4 Agree |
5 Strongly Agree |
9 Prefer Not to Answer |
E10_1. |
According to my friends, it is very important for me to not smoke cigarettes. |
1 |
2 |
3 |
4 |
5 |
9 |
E10_2. |
According to most people my age, it is very important for me to not smoke cigarettes. |
1 |
2 |
3 |
4 |
5 |
9 |
E10_3. |
According to most people who hang out where I hang out, it is very important for me to not smoke cigarettes. |
1 |
2 |
3 |
4 |
5 |
9 |
E10_4. |
According to people my age in LGBT communities it is very important for me to not smoke cigarettes. |
1 |
2 |
3 |
4 |
5 |
9 |
E11. How much do you agree or disagree with the following statements? If I only smoke cigarettes on some days (for example, smoking only when I go out), I will…
[RANDOMIZE ROWS]
|
|
1 Strongly Disagree |
2 Disagree |
3 Neither Agree or Disagree (Neutral) |
4 Agree |
5 Strongly Agree |
9 Prefer Not to Answer |
E11_1. |
Damage my body |
1 |
2 |
3 |
4 |
5 |
9 |
E11_2. |
Shorten my life |
1 |
2 |
3 |
4 |
5 |
9 |
E11_3. |
Be able to stop smoking when I want to |
1 |
2 |
3 |
4 |
5 |
9 |
E11_4. |
Become addicted to smoking |
1 |
2 |
3 |
4 |
5 |
9 |
E11_5. |
Be more attractive |
1 |
2 |
3 |
4 |
5 |
9 |
E11_6. |
Have bad breath |
1 |
2 |
3 |
4 |
5 |
9 |
E11_7. |
Damage my immune system |
1 |
2 |
3 |
4 |
5 |
9 |
E11_8. |
Turn off potential partners |
1 |
2 |
3 |
4 |
5 |
9 |
E11_9. |
Get sick more easily |
1 |
2 |
3 |
4 |
5 |
9 |
E11_10. |
Damage my teeth |
1 |
2 |
3 |
4 |
5 |
9 |
E11_11. |
Damage my skin |
1 |
2 |
3 |
4 |
5 |
9 |
E11_12. |
Develop lung cancer |
1 |
2 |
3 |
4 |
5 |
9 |
APPROVAL OF SMOKING
E12. This next set of questions asks about how willing or unwilling you are to do things with people who smoke cigarettes. Would you:
|
|
1 Definitely Yes |
2 Probably Yes |
3 Probably Not |
4 Definitely Not |
9 Prefer Not to Answer |
E12_1. |
Go to a bar, club, party, concert or event where people are smoking cigarettes? |
1 |
2 |
3 |
4 |
9 |
E12_2. |
Hang out with someone who smokes cigarettes? |
1 |
2 |
3 |
4 |
9 |
E12_3. |
Dance with someone who smokes cigarettes? |
1 |
2 |
3 |
4 |
9 |
E12_4. |
Kiss someone who smokes cigarettes? |
1 |
2 |
3 |
4 |
9 |
E12_5. |
Date someone who smokes cigarettes? |
1 |
2 |
3 |
4 |
9 |
E13. 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 |
E13_1. |
Smoking can cause immediate damage to my body. |
1 |
2 |
3 |
4 |
5 |
9 |
E13_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 |
E13_3. |
If I started to smoke occasionally I would not become addicted. |
1 |
2 |
3 |
4 |
5 |
9 |
E13_4. |
Smoking cigarettes helps people relieve stress. |
1 |
2 |
3 |
4 |
5 |
9 |
E13_5. |
Cigarette ingredients are disgusting. |
1 |
2 |
3 |
4 |
5 |
9 |
E13_6. |
Cigarette ingredients are dangerous. |
1 |
2 |
3 |
4 |
5 |
9 |
E13_7. |
Smoking is a way to show my identity to others. |
1 |
2 |
3 |
4 |
5 |
9 |
E13_8. |
Smoking cigarettes can help keep your weight down. |
1 |
2 |
3 |
4 |
5 |
9 |
E13_9. |
Smoking can cause damage to every part of your body. |
1 |
2 |
3 |
4 |
5 |
9 |
E13_10. |
Smoking weakens your immune system. |
1 |
2 |
3 |
4 |
5 |
9 |
Section F: Media Use and Awareness
Next, we’d like to ask you about your use of TV and other media.
F1. How often do you…
|
1 Several times a day |
2 About Once a Day |
3 3-5 days a week |
4 1-2 days a week |
5 Every few weeks |
6 Less often |
7 Never |
9 Prefer Not to Answer |
F1_1. Watch TV shows or movies on any platform including a TV set, a computer, laptop or tablet, a smartphone or an iPod or MP3 player? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F1_2. Watch videos on YouTube? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F1_3. Listen to streaming radio? |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2. Thinking about the social networking sites you use... About how often do you visit or use the following…
[RANDOMIZE ALL]
|
1 Several times a day |
2 About Once a Day |
3 3-5 days a week |
4 1-2 days a week |
5 Every few weeks |
6 Less often |
7 Never |
9 Prefer Not to Answer |
F2_1. Facebook |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2_2. Instagram |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2_3. Twitter |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2_4. Tumblr |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F2_5. Snapchat |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3. Thinking about the following websites... About how often do you visit or use the following…
[RANDOMIZE ALL]
|
1 Several times a day |
2 About Once a Day |
3 3-5 days a week |
4 1-2 days a week |
5 Every few weeks |
6 Less often |
7 Never |
9 Prefer Not to Answer |
F3_1. Queerty http://www.queerty.com/ |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3_2. Edge Media Network http://www.edgemedianetwork.com/ |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3_3. Logo TV http://www.logotv.com/ |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3_4. Out http://www.out.com/ |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3_5. Autostraddle http://www.autostraddle.com/ |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3_6. After Ellen http://www.afterellen.com/ |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3_7. Towleroad http://www.towleroad.com/ |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3_8. Homorazzi http://www.homorazzi.com/ |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3_9. Advocate http://www.advocate.com/ |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F3_10. Gay.com http://www.gay.com/ |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
9 |
F4. How often do you go to concerts, live shows, or other events at a store, local stage, community center, or music venue?
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 attend concerts, live shows, or other events
9 Prefer not to answer
F5. In the past 30 days, on how many days did you go to an LGBT party, night, bar, club, or event?
1 0 days
2 1-3 days
3 4-6 days
4 7 or more days
5 Don’t remember how many days
9 Prefer not to answer
F6. How many LGBT celebrities, athletes, musicians, or artists do you follow on social media (e.g. Laverne Cox, Tegan & Sara, Ruby Rose, Angel Haze)?
1 0
2 1-2
3 3-4
4 5 or more
9 Prefer not to answer
BRAND AWARENESS
F7. We want to ask you about some brands that might or might not have appeared in the media around here, as part of ads or videos about tobacco or at concerts, live shows, or other events.
F7_1. In the past 3 months, that is since [FILL DATE], have you seen or heard the following brand?
COMMUNE
[DISPLAY CAMPAIGN LOGO]
1 Yes
2 No
3 Not Sure
9 Prefer not to answer
F7_2. In the past 3 months, that is since [FILL DATE], have you seen or heard the following brand?
The Real Cost
[DISPLAY CAMPAIGN LOGO]
1 Yes
2 No
3 Not Sure
9 Prefer not to answer
F7_3. In the past 3 months, that is since [FILL DATE], have you seen or heard the following brand?
[LGBT CAMPAIGN NAME]
[DISPLAY CAMPAIGN LOGO]
1 Yes
2 No
3 Not Sure
9 Prefer not to answer
AD AWARENESS OTHER TC CAMPAIGNS (TO USE AS CONTROLS)
F8. The next set of questions asks whether or not you’ve seen any of the following ads.
[RANDOMIZE F8_1-F8_3]
F8_1. In the past 3 months, that is since [FILL DATE], have you seen a Tips from Former Smokers (Tips) ad? Examples of some Tips from Former Smokers ads are shown below.
[DISPLAY Tips from Former Smokers PHOTO COLLAGE]
1 Yes
2 No
3 Not Sure
9 Prefer not to answer
F8_2. In the past 3 months, that is since [FILL DATE], have you seen a truth® campaign ad? Examples of some truth® campaign ads are shown below.
[DISPLAY truth® PHOTO COLLAGE]
1 Yes
2 No
3 Not Sure
9 Prefer not to answer
F8_3. In the past 3 months, that is since [FILL DATE], have you seen a The Real Cost campaign ad? Examples of some The Real Cost campaign ads are shown below.
[DISPLAY The Real Cost PHOTO COLLAGE]
1 Yes
2 No
3 Not Sure
9 Prefer not to answer
CHANNELS OF [LGBT CAMPAIGN NAME] AWARENESS
[IF F7_3= 1 or 3, Ask F9]
F9. Where have you seen or heard about [LGBT CAMPAIGN NAME] ? Check all that apply
[RANDOMIZE; ALL APPEAR ON SCREEN AT ONCE (IF NOT ABLE TO DISPLAY ALL, MAKE ITEM SKIPPABLE AND REMOVE F9_h)]
F9_a. On TV
F9_b. On the Internet or anywhere online
F9_c. Billboards or other outdoor ads
F9_d. At an event
F9_e. [INSERT PLACEHOLDER FOR CHANNEL OF EXPOSURE]
F9_f. [INSERT PLACEHOLDER FOR CHANNEL OF EXPOSURE]
F9_g. Some other place (please specify____________)
F9_h. Prefer not to answer
F10. The [LGBT CAMPAIGN NAME] campaign is online. Have you ever seen [LGBT CAMPAIGN NAME] or [DISPLAY LGBT CAMPAIGN LOGO] on… Check all that apply
[RANDOMIZE; ALL APPEAR ON SCREEN AT ONCE (IF NOT ABLE TO DISPLAY ALL, MAKE ITEM SKIPPABLE AND REMOVE F10_9)]
F10_1. Twitter?
F10_2. Instagram?
F10_3. Facebook?
F10_4. YouTube?
F10_5. Streaming radio?
F10_6. Tumblr?
F10_7. Snapchat?
F10_8. Other (please specify____________)
F10_9. Prefer not to answer
EVENTS AWARENESS, CHANNEL OF AWARENESS
F11_1. In the past 3 months, that is since [FILL DATE], have you heard of an event in your area sponsored by, or associated with, [LGBT CAMPAIGN NAME]? (DISPLAY LOGO)
1 Yes
2 No
3 Not Sure
9 Prefer not to answer
[IF F11_1=1,3, or 9 ASK F12]
F12_1. How frequently have you heard of an event in your area sponsored by, or associated with [LGBT CAMPAIGN NAME] , in the past 3 months, that is since [FILL DATE]?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very Often
9 Prefer not to answer
F12_2. How did you hear about the [LGBT CAMPAIGN NAME] event?
1__ Poster
2__ Flyer or promotional materials
3__ Streaming Radio ad
4__ Online Video ad
5__ Friend
6__ [INSERT PLACEHOLDER FOR OTHER EVENT PROMOTION]
7__ [INSERT PLACEHOLDER FOR OTHER EVENT PROMOTION]
8__ Other (please specify_______________)
9__ Not sure
99__ Prefer not to answer
EVENT ATTENDANCE AND REACTIONS
F13. Have you ever attended an event sponsored by, or associated with [LGBT CAMPAIGN NAME] ?
1 Yes
2 No
9 Prefer not to answer
[IF F13=2 GO TO VIDEO AWARENESS (F11_2)]
F14. How would you describe the event/s? [RANDOMIZE F14_1-F14_2] [MAKE THIS ITEM SKIPPABLE]
F14_1. |
Bad |
-3 |
-2 |
-1 |
0 |
+1 |
+2 |
+3 |
Good |
F14_2. |
Not enjoyable |
-3 |
-2 |
-1 |
0 |
+1 |
+2 |
+3 |
Enjoyable |
F15. How much do you agree or 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 |
F15_1. |
The event/s was worth remembering |
1 |
2 |
3 |
4 |
5 |
9 |
F15_2. |
The event/s grabbed my attention |
1 |
2 |
3 |
4 |
5 |
9 |
F15_3. |
The event/s was powerful |
1 |
2 |
3 |
4 |
5 |
9 |
F15_4. |
The event/s was informative |
1 |
2 |
3 |
4 |
5 |
9 |
F15_5. |
The event/s was meaningful to me |
1 |
2 |
3 |
4 |
5 |
9 |
F15_6. |
The event/s was convincing |
1 |
2 |
3 |
4 |
5 |
9 |
F15_7. |
The event/s was terrible |
1 |
2 |
3 |
4 |
5 |
9 |
F15_8. |
The event/s told me things I never knew before about tobacco |
1 |
2 |
3 |
4 |
5 |
9 |
F15_9. |
The event/s gave me good reasons NOT to smoke cigarettes |
1 |
2 |
3 |
4 |
5 |
9 |
F15_10. |
The event/s gave me good reasons NOT to use tobacco |
1 |
2 |
3 |
4 |
5 |
9 |
F16_a. On a scale of 1 to 5, indicate whether the event/s made smoking cigarettes seem like something you would or wouldn’t want to do.
1 The event/s makes me want to smoke cigarettes
2
3
4
5 The event/s makes me want to NOT smoke cigarettes
9 Prefer not to answer
F16_b. On a scale of 1 to 5, indicate whether the event/s made using tobacco seem like something you would or wouldn’t want to do.
1 The event/s makes me want to use tobacco
2
3
4
5 The event/s makes me want to NOT use tobacco
9 Prefer not to answer
VIDEO AWARENESS
F11_2. In the past 3 months, that is since [FILL DATE], have you seen a [LGBT CAMPAIGN NAME] video online? (DISPLAY LOGO)
1 Yes
2 No
3 Not Sure
9 Prefer not to answer
F17. Now we would like to show you some videos that have been shown in the U.S. Once you have viewed the video, please click on the forward arrow below to continue with the survey.
[DISPLAY VIDEOS OR SCREENSHOTS IN RANDOM ORDER. Use VIDEO for [LGBT CAMPAIGN NAME] ads and fake ad if relevant. Use SCREENSHOTS for truth® and Tips from Former Smokers ads if relevant. Each participant will view the video or screenshot then answer F18-F23, then watch the next video and answer the same questions for that video and so on until all videos/screenshots have been viewed]
[RANDOMIZE]
F18_x. Apart from this survey, how frequently have you seen this video [SCREENSHOT LANGUAGE: these ads] in the past 3 months, that is since [FILL DATE]?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very Often
9 Prefer not to answer
REACTIONS TO VIDEOS
[Ask all items for each video]
F19_x. What is the main message of this video?
[RANDOMIZE ORDER OF CHECKBOX LIST]
1 Live tobacco-free for the love of your family
2 Addiction to cigarettes is expensive
3 Smoking can damage nearly every party of your body
4 Smelling like cigarettes is gross
5 Smoking weakens your immune system and makes you more likely to get sick
6 Choose to live tobacco-free because secondhand smoke causes death and disease
7 Every year 10s of 1000s of LGBT lives are cut short by tobacco
8 Being with friends is more important than smoking
9 Tobacco gets in the way of your health and happiness
10 Live tobacco-free for the love of your friends
11 Tobacco is addictive
12 Cigarettes cause 1,300 people to die every day
13 Smoking tobacco can make your breath and hair stink
14 Tobacco smokers are found to be less attractive
15 Secondhand smoke causes an estimated 41,300 deaths per year
16 Smoking tobacco gives you smelly hair, yellow nails, wrinkled skin and a busted smile
17 [INSERT MAIN MESSAGE OF NEW CAMPAIGN VIDEOS OR DIGITAL CONTENT]
98 Not sure
99 Prefer not to answer
F20_x. How would you describe this video? [RANDOMIZE F20_1-F20_2] [MAKE THIS ITEM SKIPPABLE]
F20_1. |
Bad |
-3 |
-2 |
-1 |
0 |
+1 |
+2 |
+3 |
Good |
F20_2. |
Not enjoyable |
-3 |
-2 |
-1 |
0 |
+1 |
+2 |
+3 |
Enjoyable |
F21_x. How much do you agree or 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 |
F21_1. |
This video is worth remembering |
1 |
2 |
3 |
4 |
5 |
9 |
F21_2. |
This video grabbed my attention |
1 |
2 |
3 |
4 |
5 |
9 |
F21_3. |
This video is powerful |
1 |
2 |
3 |
4 |
5 |
9 |
F21_4. |
This video is informative |
1 |
2 |
3 |
4 |
5 |
9 |
F21_5. |
This video is meaningful to me |
1 |
2 |
3 |
4 |
5 |
9 |
F21_6. |
This video is convincing |
1 |
2 |
3 |
4 |
5 |
9 |
F21_7. |
This video is terrible |
1 |
2 |
3 |
4 |
5 |
9 |
F21_8. |
This video told me things I never knew before about tobacco |
1 |
2 |
3 |
4 |
5 |
9 |
F21_9 |
This video gave me good reasons NOT to smoke cigarettes |
|
|
|
|
|
|
F21_10. |
This video gave me good reasons NOT to use tobacco |
1 |
2 |
3 |
4 |
5 |
9 |
F22_x_a. On a scale of 1 to 5, indicate whether the video made using tobacco look like something you would or wouldn’t want to do.
1 The video makes me want to use tobacco
2
3
4
5 The video makes me want to NOT use tobacco
9 Prefer not to answer
F22_x_b. On a scale of 1 to 5, indicate whether the video made using tobacco look like something you would or wouldn’t want to do.
1 The video makes me want to use tobacco
2
3
4
5 The video makes me want to NOT use tobacco
9 Prefer not to answer
F23_x. On scale of 1 to 5, where 1 means “not at all” and 5 means “very”, please indicate how much this video made you feel…
1 2 3 4 5
Not at all Very
[RANDOMIZE ORDER, THIS ITEM MUST BE SKIPPABLE]
F23_a. Afraid
F23_b. Hopeful
F23_c. Motivated
F23_d. Worried
F23_e. Understood
F23_f. Surprised
F23_g. INSERT OTHER EMOTION HERE if necessary based on new campaign content
F23_h. INSERT OTHER EMOTION HERE if necessary based on new campaign content
LOOP BACK TO PLAY THEN ASK ALL QUESTIONS ABOUT NEXT VIDEO HERE. SHOW ALL VIDEOS.
STREAMING RADIO AWARENESS
F24. In the past 3 months, that is since [FILL DATE], have you heard about [LGBT CAMPAIGN NAME] on streaming radio? (DISPLAY LOGO)
1 Yes
2 No
3 Not Sure
9 Prefer not to answer
Now we would like to play you some radio clips that have aired in the U.S. Once you have listened the clip, please click on the forward arrow below to continue with the survey.
[RANDOMIZE]
F25_x. Apart from this survey, how frequently have you heard this on the radio in the past 3 months, that is since [FILL DATE]?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very Often
9 Prefer not to answer
LOOP BACK TO ASK ABOUT NEXT RADIO CLIP HERE. PRESENT ALL CLIPS BEFORE ASKING ANY RECEPTIVITY QUESTIONS.
DIGITAL CONTENT AWARENESS
Now we would like to show you some digital content that you may have seen online.
[DISPLAY SCREENSHOT OF MATERIALS]
F26a. Apart from this survey, have you seen this content online in the past 3 months, that is since [FILL DATE]?
1 Yes
2 No
3 Not Sure
9 Prefer not to answer
IF F26a=1,3, or 9 ASK F27b
F27b. How frequently have you seen this content online in the past 3 months, that is since [FILL DATE]?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very Often
9 Prefer not to answer
PROMOTIONAL MATERIALS AWARENESS
Now we would like to show you some materials that have been circulating in some cities in the U.S.
[DISPLAY SCREENSHOT OF MATERIALS]
F28a. Apart from this survey, have you seen promotional materials like this in the past 3 months, that is since [FILL DATE]?
1 Yes
2 No
3 Not Sure
9 Prefer not to answer
IF F28a=1,3, or 9 ASK F28b
F28b. How frequently have you seen promotional materials like this in the past 3 months, that is since [FILL DATE]?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very Often
9 Prefer not to answer
[ASK F28a and F28b UNTIL ALL MATERIALS HAVE BEEN SEEN]
BRAND EQUITY
F29. How much do you agree or disagree with the following statements about [LGBT CAMPAIGN NAME] ?
[RANDOMIZE F29_1- F29_3]
|
|
1 Strongly Disagree |
2 Disagree |
3 Neither Agree or Disagree (Neutral) |
4 Agree |
5 Strongly Agree |
9 Prefer Not to Answer |
F29_1. |
I want to help promote [LGBT CAMPAIGN NAME] |
1 |
2 |
3 |
4 |
5 |
9 |
F29_2. |
I’d defend [LGBT CAMPAIGN NAME] if someone was making fun of it |
1 |
2 |
3 |
4 |
5 |
9 |
F29_3. |
I’d wear a [LGBT CAMPAIGN NAME] T-shirt |
1 |
2 |
3 |
4 |
5 |
9 |
[RANDOMIZE ITEMS BELOW WITH F29_5/ F29_6 ASKED TOGETHER IN THAT ORDER]
F29_4. |
I talk to my friends about [LGBT CAMPAIGN NAME] |
1 |
2 |
3 |
4 |
5 |
9 |
F29_5. |
If I had the chance, I would tell people I know to watch [LGBT CAMPAIGN NAME] videos |
1 |
2 |
3 |
4 |
5 |
9 |
F29_6. |
If I had the chance, I would tell people I know to check out [LGBT CAMPAIGN NAME] at events |
1 |
2 |
3 |
4 |
5 |
9 |
F29_7. |
If I see anything from [LGBT CAMPAIGN NAME] , I check it out |
1 |
2 |
3 |
4 |
5 |
9 |
[RANDOMIZE ITEMS BELOW WITH F29_10/ F29_11 AND F29_12/ F29_13 ASKED TOGETHER IN THAT ORDER]
F29_8. |
[LGBT CAMPAIGN NAME] is popular with people like me |
1 |
2 |
3 |
4 |
5 |
9 |
F29_9. |
People are talking about [LGBT CAMPAIGN NAME] |
1 |
2 |
3 |
4 |
5 |
9 |
F29_10. |
[LGBT CAMPAIGN NAME] videos are becoming more popular with the people who hang out where I hang out |
1 |
2 |
3 |
4 |
5 |
9 |
F29_11. |
Checking out [LGBT CAMPAIGN NAME] at events is becoming more popular with the people who hang out where I hang out |
1 |
2 |
3 |
4 |
5 |
9 |
F29_12. |
[LGBT CAMPAIGN NAME] videos are for people like me |
1 |
2 |
3 |
4 |
5 |
9 |
F29_13. |
[LGBT CAMPAIGN NAME] events are for people like me |
1 |
2 |
3 |
4 |
5 |
9 |
F30. To what extent do you agree that each of the traits or statements listed below describe [LGBT CAMPAIGN NAME] ?
|
|
1 Strongly Disagree |
2 Disagree |
3 Neither Agree or Disagree (Neutral) |
4 Agree |
5 Strongly Agree |
9 Prefer Not to Answer |
F30_1. |
Trendsetting |
1 |
2 |
3 |
4 |
5 |
9 |
F30_2. |
Motivating |
1 |
2 |
3 |
4 |
5 |
9 |
F30_3. |
Confident |
1 |
2 |
3 |
4 |
5 |
9 |
F30_4. |
Outgoing |
1 |
2 |
3 |
4 |
5 |
9 |
F30_5. |
Hosts the best parties |
1 |
2 |
3 |
4 |
5 |
9 |
F30_6. |
Always looks good |
1 |
2 |
3 |
4 |
5 |
9 |
F31. How much do you agree or disagree with the following statements?
When I think of [LGBT CAMPAIGN NAME] , I think…
|
|
1 Strongly Disagree |
2 Disagree |
3 Neither Agree or Disagree (Neutral) |
4 Agree |
5 Strongly Agree |
9 Prefer Not to Answer |
F31_1. |
I have the freedom to be tobacco-free |
1 |
2 |
3 |
4 |
5 |
9 |
F31_2. |
Using tobacco can undo some of the progress I have made |
1 |
2 |
3 |
4 |
5 |
9 |
F31_3. |
Tobacco use is not attractive |
1 |
2 |
3 |
4 |
5 |
9 |
Section G: Environment
The next section asks some questions about your household and peers.
G1. 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, 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
G2. Which statement best describes the rules about smoking in your home? Would you say…
1 Smoking is not allowed anywhere inside your home
2 Smoking is allowed in some places or at some times
3 Smoking is allowed anywhere inside the home
4 There are no rules about smoking inside the home
9 Prefer not to answer
G3. How many close friends do you have? (Close friends include people whom you feel at ease with, can talk to about private matters, and can call on for help.)
__________ [MIN 0 MAX 7]
9 Prefer not to answer
G4. How often do you attend church or religious services? Would you say…
1 Never
2 Less than once a month
3 About once a month
4 About 2 or 3 times a month
5 Once a week
6 More than once a week
9 Prefer not to answer
Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statements.
G5. 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
G6. 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
G7. 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
G8. 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
G9. 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
G10. In the last month, how often have you
|
|
0 Never |
1 Almost never |
2 Sometimes |
3 Fairly often |
4 Very often |
9 Prefer Not to Answer |
G10_1. |
Felt that you were unable to control the important things in your life. |
1 |
2 |
3 |
4 |
5 |
9 |
G10_2. |
Felt confident about your ability to handle your personal problems. |
1 |
2 |
3 |
4 |
5 |
9 |
G10_3. |
Felt that things were going your way. |
1 |
2 |
3 |
4 |
5 |
9 |
G10_4. |
Felt difficulties were piling up so high that you could not overcome them. |
1 |
2 |
3 |
4 |
5 |
9 |
Section H: LGBT Identity and Community
Discrimination
H1. Have you ever experienced discrimination, been prevented from doing something, or been hassled or made to feel inferior in any of the following seven situations because of your sexual identity (lesbian, gay, bisexual, transgender)?
-
1
Yes
2
No
9
Prefer not to answer
H1_1.
In your family
1
2
9
H1_2.
At school
1
2
9
H1_3.
Getting a job
1
2
9
H1_4.
At work
1
2
9
H1_5.
At home
1
2
9
H1_6.
Getting medical care
1
2
9
H1_7
On the street or in a public setting
1
2
9
LGBT Community Involvement
H2_1. Have you ever attended a LGBT pride event?
1 Yes
2 No
9 Prefer not to answer
[IF H2_1= 1 SKIP TO H3]
H2_2. Have you attended a LGBT pride event in the past 12 months?
1 Yes
2 No
9 Prefer not to answer
LGBT Identity Development
H3. For each of the following questions, please mark the response that best indicates your current experience as an LGBT person. Please be as honest as possible: Indicate how you really feel now, not how you think you should feel. There is no need to think too much about any one question. Answer each question according to your initial reaction and then move on to the next.
|
|
1 Strongly Disagree |
2 Disagree |
3 Neither Agree or Disagree (Neutral) |
4 Agree |
5 Strongly Agree |
9 Prefer Not to Answer |
H3_1. |
I am glad to be an LGBT person. |
1 |
2 |
3 |
4 |
5 |
9 |
H3_2. |
My sexual identity is an insignificant part of who I am. |
1 |
2 |
3 |
4 |
5 |
9 |
H3_3. |
I’m proud to be part of the LGBT community. |
1 |
2 |
3 |
4 |
5 |
9 |
H3_4. |
My sexual identity is a central part of my identity. |
1 |
2 |
3 |
4 |
5 |
9 |
H3_5. |
To understand who I am as a person, you have to know that I’m LGBT. |
1 |
2 |
3 |
4 |
5 |
9 |
H3_6. |
Being an LGBT person is a very important aspect of my life. |
1 |
2 |
3 |
4 |
5 |
9 |
H3_7. |
I believe being LGBT is an important part of me. |
1 |
2 |
3 |
4 |
5 |
9 |
H3_8. |
I am proud to be LGBT. |
1 |
2 |
3 |
4 |
5 |
9 |
H3_9. |
I feel part of the LGBT community |
1 |
2 |
3 |
4 |
5 |
9 |
H3_10. |
I feel accepted by the LGBT community” |
1 |
2 |
3 |
4 |
5 |
9 |
Thank you for taking time to complete this survey.
OMB No: 0910-XXXX Expiration Date: XX/XX/XXXX
Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 40 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]
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