Smoking in pregnancy survey

We are carrying out a survey to find out more about smoking cigarettes/tobacco products during pregnancy and the support that people may need to help quit during this time. We would appreciate a couple of minutes of your time to answer some questions.

In line with data protection law, your information will remain anonymous and will only be used to inform these plans. Thank you for your time.

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* 1. Do you smoke cigarettes/tobacco products?

Yes

No, I have given up

I have never smoked

Prefer not to say

Any other comments

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* 2. Does your partner smoke?

Yes, cigarettes

Prefer not to say

Not applicable

Any other comments

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* 3. Do any other household members smoke?

Yes, cigarettes

Prefer not to say

Not applicable

Any other comments

(If you have answered NO to questions 1-3, then you do not need to continue with this survey)

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* 4. Are you pregnant or have been pregnant?

Yes

Prefer not to say

Any other comments

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* 5. Have you smoked cigarettes or tobacco while you are pregnant?

Yes

Prefer not to say

Any other comments

(If you have answered NO to questions 4-5, then you do not need to continue with this survey)

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* 6. Did you have any support to reduce or quit smoking during pregnancy?

Yes

Not applicable

Any other comments

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* 7. If you answered no, could you tell us why you did not receive support to quit smoking?

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* 8. If you did have support to stop smoking, how was this given to you and how would you rate the advice? Please tick the support that you were given and how good you thought it was.

	Not applicable	Very poor	Poor	Fair	Good	Very good
Leaflets	Leaflets Not applicable	Leaflets Very poor	Leaflets Poor	Leaflets Fair	Leaflets Good	Leaflets Very good
Online	Online Not applicable	Online Very poor	Online Poor	Online Fair	Online Good	Online Very good
Advice from a practitioner. E.g. GP, nurse, stop smoking advisor, midwife	Advice from a practitioner. E.g. GP, nurse, stop smoking advisor, midwife Not applicable	Advice from a practitioner. E.g. GP, nurse, stop smoking advisor, midwife Very poor	Advice from a practitioner. E.g. GP, nurse, stop smoking advisor, midwife Poor	Advice from a practitioner. E.g. GP, nurse, stop smoking advisor, midwife Fair	Advice from a practitioner. E.g. GP, nurse, stop smoking advisor, midwife Good	Advice from a practitioner. E.g. GP, nurse, stop smoking advisor, midwife Very good

Other: (please state)

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* 9. Did you quit smoking during pregnancy as a result of advice or support?

Yes, and I have continued to not smoke

Yes, but I returned to smoking

No, but I reduced the amount I smoked

No, I did not give up smoking

Comments:

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* 10. Do you feel any options below would help you to stop smoking? (Please tick all that you feel are relevant).

Detailed information on effects of smoking for a baby

A personal coach - this might be a person who works with you over several weeks by phone or in person

Nicotine Replacement Therapy - for example patches or inhaler type equipment

Group therapy - this would be a session where you can meet other mums who are stopping smoking

Any incentive scheme with payments through your pregnancy for staying smoke free

An incentive scheme with gifts - for example new clothes and nappies for your baby, or a bag to take into hospital

An incentive scheme which involves offering family/household members an incentive to stay smoke free

Do you have any comments about the options you have selected?

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* 11. If you received support to quit smoking along with a payment incentive, what amount of money spread over the course of your pregnancy would make this a worthwhile option for you?

£50

£100

£150

More than £200

Other/Comment

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* 12. Are there any other comments you have about smoking during and after pregnancy, or about the support that you or family/friends may need?

About you

We would like to ask some questions about you. The information you provide will be kept entirely confidential and will never be traced back to you as an individual.

We are asking these questions because we want to make sure that we have asked lots of different people for their views. These questions are optional and you do not have to answer these questions if you do not want to.

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* 13. What is the first part of your postcode? E.g. YO1

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* 14. Please state your age from the groupings below:

Under 18

18-24

25-34

35-44

Over 45

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* 15. Do you identify as?

Male

Female

Other

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* 16. What is your ethnicity?

White British

White Irish

White - Any other White background

Mixed - White & Black Caribbean

Mixed - White & Black African

Mixed - Any other mixed background

Asian or Asian British - Indian

Asian or Asian British - Pakistani

Asian or Asian British - Bangladeshi

Asian or Asian British - Any other Asian background

Black or Black British - Caribbean

Black or Black British - African

Black or Black British - Any other Black background

Chinese

Prefer not to say

Other

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* 17. What is your religion or belief?

Christian

Muslim

Jewish

Hindu

Sikh

Buddhist

Non-Religious

Prefer not to say

Other (please specify in the box below)

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* 18. Do you consider yourself to have a disability or a mental health condition? Please tick most appropriate

No disability

Physical disability such as difficulty moving arms, or mobility issues/wheelchair user

Sensory impairment such as being blind or visually impaired

Mental health condition such as depression, dementia or schizophrenia

Long standing condition such as cancer, HIV, diabetes, chronic heart disease or epilepsy

Learning difficulty or disability (such as Down's syndrome or dyslexia) or cognitive impairment (such as autistic spectrum disorder)

Prefer not to say

Other (please specify in the box below)