Maternal Smoking campaign questionnaire Maternal smoking questionnaire - about you The following survey will ask you a number of questions about what might help expectant mothers give up smoking during their pregnancy; all mandatory questions must be answered for you to be entered into the prize draw for a £50 Love to Shop voucher. Your responses are completely anonymous and will only be used to inform the approach we take to encouraging and helping pregnant women to stop smoking. The closing date for the questionnaire is Sunday 26 February 2017. Responses received after this date will not be entered into the prize draw. Question Title * 1. What is your date of birth? Question Title * 2. Are you: Pregnant, non-smoker (including recently given up) Pregnant, smoker Not pregnant Question Title * 3. If you have selected that you are a smoker, how many cigarettes do you smoke daily?(Please select non-smoker if you do not smoke) Under 10 10 - 20 21 - 40 41 - 60 60+ Non-smoker Question Title * 4. Please select the following option which relates most closely to you, since finding out you're pregnant: I have given up smoking I have unsuccessfully attempted to give up smoking I have reduced the amount I smoke I use an e-cigarette I use nicotine replacement therapy I want to give up smoking, but need further help to do so I do not want to give up smoking I have declined help to give up smoking Other (please specify) Question Title * 5. If you do not want to give up smoking and/or you have declined help to give up smoking, please explain why below: Question Title * 6. Do you know how harmful smoking during pregnancy can be to your unborn child? Yes, I know how harmful smoking during pregnancy can be I know a little bit about how harmful smoking during pregnancy can be I do not know how harmful smoking in pregnancy can be Question Title * 7. Out of the following options, please select all of the places that you would trust information from, about yours/your unborn baby's health during pregnancy. For each of these options, assume they are from trustworthy organisations like the NHS. Posters displayed at GP practice/children's centres etc Billboards displayed across the city Facebook posts Twitter posts Instagram posts Snapchat YouTube videos Radio adverts and interviews Mumsnet Hull Daily Mail NHS Choices website Other websites (please specify in comment box below) Other (please specify) Question Title * 8. Please tell us more about where you look for information about yours/your unborn baby's health during pregnancy: (For example have you joined a support group, or online forum etc.) Question Title * 9. Is there anything that would make you give up smoking, if you haven't done so already? This could be extra support, one to one mentoring, financial incentives, further information about the dangers etc. Please put your ideas in the space below: Question Title * 10. What is your postcode? Question Title * 11. And finally, where did you hear about this survey? Direct email Poster Hull Women and Children's Hospital Facebook Page Facebook (other page) Twitter NHS Hull CCG Website Other website Word of mouth Other (please specify) Please click next to submit your responses, you will then be given the option to be entered into the prize draw.Remember, if you would like support in giving up smoking, you can speak to your midwife for help or text 'steps' to 61825. Next