CATCHMy Breath

Student Assent

SCHOOL: ______

GRADE: ______

SUBJECT/CLASS: ______

YOUR TEACHER’S NAME:______

TODAY’S DATE: ______

  • In this survey you are being asked to answer questions about yourknowledge, attitudes and experience with E-Cigarettes. The data from this survey will be used to help kids your age all over the country.
  • This survey is anonymous. No one at school orat home will see your answers.
  • Taking part in this survey is up to you. Participating will not affect your grades in school or your ability to join any school activities.
  • If you do not want to answer a question, you can skip it.
  • You may stop taking part in this survey at any time.
  • By completing this survey, you agree to take part in this survey.

CATCHMy Breath

Student Pre Survey

This survey asks questions about yourknowledge and experiences with E-cigarettes. Read each question carefully and pick the answer that is most true for you. This is not a test and there are no right or wrong answers. Your answers are private and will not affect your grades in any way.

Birthdate: / /(MONTH/DAY/YEAR)

1.What is your gender?

a.Female

b.Male

2.Are you Hispanic or Latino/a?

a.No

b.Yes

3.What race or races do you consider yourself to be?

a.American Indian or Alaska Native

b.Asian

c.Black or African American

d.Native Hawaiian or Other Pacific Islander

e.White

f.More than one race

4.What grade are you in?

a.6th grade

b.7th grade

c.8th grade

d.Other: _____

The first few questions are about cigarettesmoking.

5.Have you ever smoked acigarette, or any other kind of tobacco like a cigar or pipe, even one or two puffs?

  1. Yes
  2. No

6.During the past 30 days, have you smokeda cigarette, or any other kind of tobacco?

  1. Yes
  2. No

7. Do any of your closest friends smoke cigarettes?

  1. None of them
  2. Some of them
  3. Most of them
  4. All of them

8. Do your parents smoke cigarettes?

  1. None
  2. Both
  3. Father only
  4. Mother only
  5. I don't know

The nextquestions are about E-cigarettes.

9. Have you ever usedan E- cigarette, even one or two puffs?

  1. Yes
  2. No

10. During the past 30 days, have you used an E-cigarette?

  1. Yes
  2. No

11. During the past 30 days, on how many days did you use E-cigarettes (such as Blu, 21st Century Smoke, or NJOY?)

a.0 days

b.1 or 2 days

c.3 to 5 days

d.6 to 9 days

e.10 to 19 days

f.20 to 29 days

g.all 30 days

12. Do you think you will use an E-cigarettein the next year?

a.Definitely yes

b.Probably yes

c.Probably not

d.Definitely not

13. Are you curious about what it would be like to use an E-cigarette?

  1. Definitely yes
  2. Probably yes
  3. Probably not
  4. Definitely not

14. If one of your best friends offered you a puff on an E-cigarette, would you use it?

  1. Definitely yes
  2. Probably yes
  3. Probably not
  4. Definitely not

15. How much do you agree with the following statements about E-cigarettes? Only circle one number on each line.

Strongly Agree / Agree / Disagree / Strongly Disagree
15a / I would enjoy using E-cigarettes. / 1 / 2 / 3 / 4
15b / Using E-cigarettes would help me to deal with problems or stress. / 1 / 2 / 3 / 4
15c / Using E-cigarettes will help me make new friends. / 1 / 2 / 3 / 4
15d / Using E- cigarettes would make me wake up and feel energized. / 1 / 2 / 3 / 4
15e / Using E- cigarettes would make it harder for me to play sports. / 1 / 2 / 3 / 4
15f / Kids who use E-cigarettes look older. / 1 / 2 / 3 / 4
15g / Most kids my age useE-cigarettes. / 1 / 2 / 3 / 4
15h / Most kids in high school use E-cigarettes. / 1 / 2 / 3 / 4

The remaining questions ask about your knowledge about E-cigarettes.

16. If a friend or someone you know asks you to try an E-cigarette, what kind of peer pressure is this?

  1. Indirect peer pressure
  2. Direct peer pressure
  3. Put-down peer pressure
  4. Hassle peer pressure

17. If someone is constantly pestering, nagging, begging or bullying you to try an E-cigarette, what kind of peer pressure is this?

  1. Indirect peer pressure
  2. Direct peer pressure
  3. Put-down peer pressure
  4. Hassle peer pressure
  1. How many high school studentsdo you think have used an E-cigarette in the past 30 days?
  1. 0-20%
  2. 21-40%
  3. 41-60%
  4. 61-80%
  5. 81-100%
  1. Nicotine is addictive and harmful to the body.
  1. True
  2. False
  1. When you are addicted to something, you lose control.
  1. True
  2. False
  1. E-cigarette vapor contains mostly water.
  1. True
  2. False
  1. MostE-cigarettes contain nicotine.
  1. True
  2. False
  1. Most sweet, candy and fruit flavored E-cigarettes contain nicotine.
  1. True
  2. False
  1. Which of the following is NOT a main part of E-liquid (or E-juice)?
  1. Water
  2. Flavor
  3. Nicotine
  4. Propylene Glycol
  1. It is illegal for kids my age to use E-cigarettes.
  1. True
  2. False
  1. Direct pressure is advertising that everyone knows is paid for by the tobacco or E-cigarette industry on bill boards, magazines, television, and on the internet.
  2. True
  3. False
  1. An indirect pressure hides who paid for the advertising and often doesn’t even look like advertising.

a.True

b.False

  1. Which of the following is NOT one of the 6 smart exit strategy refusal strategies?
  2. Just say no!
  3. Stand tall with nonsmoking friends
  4. Put someone down for usingE-cigarettes
  5. Add some humor

1