Focus Group about Cigarette Smoking during Pregnancy - f

FOCUS GROUPS ABOUT CIGARETTE SMOKING DURING PREGNANCY AND ADVERSE OUTCOMES, INCLUDING BIRTH DEFECTS

FOCUS GROUP GUIDES

Segment 1: Female smokers who have never been pregnant

A. Background

Hello. My name is ____ and I work with RTI International, a not for profit research company. Thank you for participating today. We are working on a project sponsored by the U.S. Centers for Disease Control and Prevention, or CDC, in Atlanta to learn about women’s views about smoking and pregnancy. Ultimately CDC would like to use this information to develop better health messages about this issue.

Before coming into the room, each of you completed the consent form and had an opportunity to ask questions. Later, you can contact the RTI’s Office of Research Protection toll-free at 1-866-214-2043 about any questions or concerns that you have related to your participating today. That number is listed on your copy of the consent form.

At this time, I want to review what will happen next. Who has participated in a focus group before? [Wait for response.] My role is to guide our discussion today and to assure that everyone has a chance to share their thoughts and ideas on the topics that I ask about. Therefore, we will follow some general rules for our discussion.

• First, please turn off your cell phones or put them on vibrate now. [Wait for them to do so.] If it is an emergency and you have to answer, please leave the room to do so.

• During our discussion, speak clearly and loudly enough so that everyone can hear you.

• Only one person speaks at a time.

• When you leave, do not discuss or repeat what others shared during the discussion.

To assure anonymity, we use only your first name. We will refer to each other by first name only during our discussion. Your full name will not be connected to any of the written notes or transcripts. Everything you say will be kept private. Information will be presented without any names and will not be linked to any specific person.

Our group discussion will take about 80 minutes. The discussion will be recorded so that I can give my full attention to what you are saying. Even though there is also a note taker in the observation room, we want to assure that we do not miss any of your comments. At the end, we will ask you to complete a short form and we will provide your incentive ($75.00). Again, your participation in this discussion is voluntary and you can end your participation and leave the group at any time. Any questions? [Wait a moment. Respond to any questions.]

Okay, let’s get started. I will turn on the recorder now. [TURN ON THE RECORDER. RECHECK TO BE SURE THAT THE RECORDER IS RECORDING!]

B. Participant Introductions and Ice Breaker

Again, I am [MODERATOR’S NAME]. Now, I would like each of you to introduce yourself—FIRST NAME ONLY PLEASE—and tell us something you like to do for fun. [Pass around name tags.] Please write your FIRST NAME ONLY on the name tag. That will help me to address you by name.

C. Discussion

We’re going to start off our discussion by talking about your thoughts on smoking during pregnancy.

I. Knowledge, Attitudes, and Beliefs

1. What have you seen, read, or heard about smoking during pregnancy?

2. What do you think about a woman smoking during pregnancy?

3. Is there any time during pregnancy when it is OK to smoke?

PROBES:

• At the beginning?

• In the middle?

• At the end?

• Why do you think that?

4. Do you think the baby is affected when the mother smokes during pregnancy? What effects do you think that smoking during pregnancy might cause for the baby?

PROBES:

• Low birthweight (baby born too small)?

• Premature birth (baby born too early)?

• Any other birth defects?

5. Do you think the mother is affected when she smokes during pregnancy? What effects do you think that smoking during pregnancy might cause for her?

PROBES:

• Lung cancer and other cancers?

• Heart disease, stroke, heart attacks?

• Problems breathing?

• Miscarriage or still birth?

6. What information have you seen, read, or heard about smoking after the baby is born?

PROBE:

• Where did you get this information?

7. This is a list of possible effects from smoking before, during, or after pregnancy. (see Appendix A) Which of these were you aware of?

PROBE:

• Which of these would make a difference in your decision to quit smoking during pregnancy? Why would it make a difference?

II. Smoking Cessation

The next questions are about issues related to quitting.

8. What are reasons why a woman might not be able to quit smoking during pregnancy?

PROBES:

• Psychological (stress, addiction)?

• Social?

• Access to a health care provider (i.e., doctor)?

• Access to cessation treatment (i.e., medicines to help you quit smoking, counseling)?

• Physical (weight loss)?

9. Would you accept nicotine replacement therapy (NRT) or other medications (e.g., gum, patches, lozenges, Bupropion, Varenicline) to help you quit smoking during pregnancy if it was offered?

PROBES:

• Why or why not?

• Do you think NRT is safe to use while pregnant?

• Would you take NRT if your doctor recommended it to you?

• Do you think the risk of using NRT is less than, equal to, or more than smoking cigarettes?

III. Social Influences

The next questions are about the acceptability of smoking during pregnancy.

10. Do you think your opinion about smoking during pregnancy is shared by your partner? Friends? Family members? Society in general?

11. Would your decision to smoke or not smoke during pregnancy change depending on your partner’s opinion? Friends’ opinions? Family’s opinion?

IV. Sources of Information

The next questions are about where you get information about health.

12. What is your main source for health information?

PROBES:

• Family?

• Internet?

• Friends?

• Health care provider?

• TV/Radio?

• Pamphlets and other literature?

13. If you wanted more information on smoking during pregnancy, where would you go?

PROBE:

• Who or what would be a trusted source of information?

14. What, if anything, has your health care provider told you about smoking during pregnancy?

15. What are the most important messages about smoking and pregnancy to communicate to someone like you?

PROBES:

• Medical info about mother (lung cancer or other cancers, heart disease, stroke, heart attacks, respiratory problems, trouble getting pregnant)?

• Aesthetic (yellow teeth and nails, premature wrinkles, loose skin, bad breath, clothes and hair smell like smoke)?

• Medical info about fetus/baby (low birthweight, premature birth, other birth defects, SIDS [crib death])?

V. Labeling (~15 minutes)

Now I would like to ask you some questions about picture warning labels on cigarette packages.

16. Other countries have added picture warning labels on cigarette packages to educate people about the effects of smoking on health and encourage them to quit smoking. This is an example of a picture warning label from Australia about smoking during pregnancy. (see Appendix B)

PROBES

• What are your first impressions after seeing this label?

• If the United States had this warning label, do you think it would encourage smokers to quit smoking before they become pregnant? Why or why not?

• Once smokers became pregnant, would this label encourage them to quit smoking? Why or why not?

17. Here is a hypothetical example of a warning label that shows a child with cleft lip as a result of the mother’s smoking during pregnancy. (see Appendix C)

PROBES

• What are your first impressions after seeing this label?

• If the United States had this warning label, do you think it would encourage smokers to quit smoking before they become pregnant? Why or why not?

• Once smokers became pregnant, would this label encourage them to quit smoking? Why or why not?

18. Now that you have seen some warning labels and we have talked about some possible birth defects, what do you think are the most important kinds of pictures or information to put on warning labels to communicate to someone like you?

VI. Wrap Up

19. I want you to reflect on the questions I have asked and the things you have heard from others. [PAUSE]. What recommendations do you have for preventing smoking during pregnancy?

That is the all of the questions that we have for you. Now we ask that you complete a short survey to provide some basic demographic information. Please remember that your answers will be anonymous. You can choose not to answer a question if it makes you feel uncomfortable.

[MODERATOR DISTRIBUTES SURVEYS AND PENS]

[MODERATOR COLLECTS SURVEYS IN AN ENVELOPE CODED WITH FOCUS GROUP NUMBER]

Thank you for completing the short survey. This is a fact sheet (see Appendix D) which provides information on smoking during pregnancy and referral services. Please let me know if you have any questions.

[MODERATOR DISTRIBUTES FACT SHEET]

Thank you for participating in the discussion. Please check at the front desk to get your incentive.

FOCUS GROUPS ABOUT CIGARETTE SMOKING DURING PREGNANCY AND ADVERSE OUTCOMES, INCLUDING BIRTH DEFECTS

FOCUS GROUP GUIDES

Segment 2: Female smokers who have been pregnant in the past 2 years

A. Background

Hello. My name is ____ and I work with RTI International, a not for profit research company. Thank you for participating today. We are working on a project sponsored by the U.S. Centers for Disease Control and Prevention, or CDC, in Atlanta to learn about women’s views about smoking and pregnancy. Ultimately CDC would like to use this information to develop better health messages about this issue.

Before coming into the room, each of you completed the consent form and had an opportunity to ask questions. Later, you can contact the RTI’s Office of Research Protection toll-free at 1-866-214-2043 about any questions or concerns that you have related to your participating today. That number is listed on your copy of the consent form.

At this time, I want to review what will happen next. Who has participated in a focus group before? [Wait for response.] My role is to guide our discussion today and to assure that everyone has a chance to share their thoughts and ideas on the topics that I ask about. Therefore, we will follow some general rules for our discussion.

• First, please turn off your cell phones or put them on vibrate now. [Wait for them to do so.] If it is an emergency and you have to answer, please leave the room to do so.

• During our discussion, speak clearly and loudly enough so that everyone can hear you.

• Only one person speaks at a time.

• When you leave, do not discuss or repeat what others shared during the discussion.

To assure anonymity, we use only your first name. We will refer to each other by first name only during our discussion. Your full name will not be connected to any of the written notes or transcripts. Everything you say will be kept private. Information will be presented without any names and will not be linked to any specific person.

Our group discussion will take about 75 minutes. The discussion will be recorded so that I can give my full attention to what you are saying. Even though there is also a note taker in the observation room, we want to assure that we do not miss any of your comments. At the end, we will ask you to complete a short form and we will provide your incentive ($75.00). Again, your participation in this discussion is voluntary and you can end your participation and leave the group at any time. Any questions? [Wait a moment. Respond to any questions.]

Okay, let’s get started. I will turn on the recorder now. [TURN ON THE RECORDER. RECHECK TO BE SURE THAT THE RECORDER IS RECORDING!]

B. Participant Introductions and Ice Breaker

Again, I am [MODERATOR’S NAME]. Now, I would like each of you to introduce yourself—FIRST NAME ONLY PLEASE—and tell us something you like to do for fun. [Pass around name tags.] Please write your FIRST NAME ONLY on the name tag. That will help me to address you by name.

C. Discussion

We’re going to start off our discussion by talking about your thoughts on smoking during pregnancy.

I. Knowledge, Attitudes, and Beliefs

1. What have you seen, read, or heard about smoking during pregnancy?

2. What do you think about a woman smoking during pregnancy?

3. Is there any time during pregnancy when it is OK to smoke?

PROBES:

• At the beginning?

• In the middle?

• At the end?

• Why do you think that?

4. Do you think the baby is affected when the mother smokes during pregnancy? What effects do you think that smoking during pregnancy might cause for the baby?

PROBES:

• Low birthweight (baby born too small)?

• Premature birth (baby born too early)?

• Any other birth defects?

5. Do you think the mother is affected when she smokes during pregnancy? What effects do you think that smoking during pregnancy might cause for her?

PROBES:

• Lung cancer and other cancers?

• Heart disease, stroke, heart attacks?

• Problems breathing?

• Miscarriage or still birth?

6. What information have you seen, read, or heard about smoking after the baby is born?

PROBE:

• Where did you get this information?

7. This is a list of possible effects from smoking before, during, or after pregnancy. (see Appendix A) Which of these were you aware of?

PROBE:

• Which of these would make a difference in your decision to quit smoking during pregnancy? Why would it make a difference?

II. Smoking Cessation

The next questions are about issues related to quitting.

8. What are reasons why a woman might not be able to quit smoking during pregnancy?

PROBES:

• Psychological (stress, addiction)?

• Social?

• Access to a health care provider (i.e., doctor)?

• Access to cessation treatment (i.e., medicines to help you quit smoking, counseling)?

• Physical (weight loss)?

9. Talk about your attempts to quit smoking during pregnancy, if any.

PROBES:

• When during the pregnancy did you attempt to quit?

• What motivated you to quit?

• What made it difficult for you to quit?

• Was there one important thing that helped you quit?

10. If you quit smoking during pregnancy, did you experience any relapses (i.e., smoking again after quitting)? When?

PROBES:

• During pregnancy?

• After pregnancy?

• How long did you quit?

• Why did you start smoking again?

11. Would you accept nicotine replacement therapy (NRT) or other medications (e.g., gum, patches, lozenges, Bupropion, Varenicline) to help you quit smoking during pregnancy if it was offered?

PROBES:

• Why or why not?

• Do you think NRT is safe to use while pregnant?

• Would you take NRT if your doctor recommended it to you?

• Do you think the risk of using NRT is less than, equal to, or more than smoking cigarettes?

III. Social Influences

The next questions are about the acceptability of smoking during pregnancy.

12. Do you think your opinion about smoking during pregnancy is shared by your partner? Friends? Family members? Society in general?

13. Would your decision to smoke or not smoke during pregnancy change depending on your partner’s opinion? Friends’ opinions? Family’s opinion?

IV. Sources of Information

The next questions are about where you get information about health.

14. What is your main source for health information?

PROBES:

• Family?

• Internet?

• Friends?

• Health care provider?

• TV/Radio?

• Pamphlets and other literature?

15. If you wanted more information on smoking during pregnancy, where would you go?

PROBE:

• Who or what would be a trusted source of information?

16. What, if anything, has your health care provider told you about smoking during pregnancy?

17. What are the most important messages about smoking and pregnancy to communicate to someone like you?

PROBES:

• Medical info about mother (lung cancer or other cancers, heart disease, stroke, heart attacks, respiratory problems, trouble getting pregnant)?

• Aesthetic (yellow teeth and nails, premature wrinkles, loose skin, bad breath, clothes and hair smell like smoke)?

• Medical info about fetus/baby (low birthweight, premature birth, other birth defects, SIDS [crib death])?

V. Labeling (~15 minutes)

Now I would like to ask you some questions about picture warning labels on cigarette packages.

18. Other countries have added picture warning labels on cigarette packages to educate people about the effects of smoking on health and encourage them to quit smoking. This is an example of a picture warning label from Australia about smoking during pregnancy. (see Appendix B)

PROBES

• What are your first impressions after seeing this label?

• If the United States had this warning label, do you think it would encourage smokers to quit smoking before they become pregnant? Why or why not?

• Once smokers became pregnant, would this label encourage them to quit smoking? Why or why not?

19. Here is a hypothetical example of a warning label that shows a child with cleft lip as a result of the mother’s smoking during pregnancy. (see Appendix C)

PROBES

• What are your first impressions after seeing this label?

• If the United States had this warning label, do you think it would encourage smokers to quit smoking before they become pregnant? Why or why not?

• Once smokers became pregnant, would this label encourage them to quit smoking? Why or why not?

20. Now that you have seen some warning labels and we have talked about some possible birth defects, what do you think are the most important kinds of pictures or information to put on warning labels to communicate to someone like you?

VI. Wrap Up

21. I want you to reflect on the questions I have asked and the things you have heard from others. [PAUSE]. What recommendations do you have for preventing smoking during pregnancy?

That is the all of the questions that we have for you. Now we ask that you complete a short survey to provide some basic demographic information. Please remember that your answers will be anonymous. You can choose not to answer a question if it makes you feel uncomfortable.

[MODERATOR DISTRIBUTES SURVEYS AND PENS]

[MODERATOR COLLECTS SURVEYS IN AN ENVELOPE CODED WITH FOCUS GROUP NUMBER]

Thank you for completing the short survey. This is a fact sheet (see Appendix D) which provides information on smoking during pregnancy and referral services. Please let me know if you have any questions.

[MODERATOR DISTRIBUTES FACT SHEET]

Thank you for participating in the discussion. Please check at the front desk to get your incentive.

FOCUS GROUPS ABOUT CIGARETTE SMOKING DURING PREGNANCY AND ADVERSE OUTCOMES, INCLUDING BIRTH DEFECTS

FOCUS GROUP GUIDES

Segment 3: Women who quit smoking during pregnancy

A. Background

Hello. My name is ____ and I work with RTI International, a not for profit research company. Thank you for participating today. We are working on a project sponsored by the U.S. Centers for Disease Control and Prevention, or CDC, in Atlanta to learn about women’s views about smoking and pregnancy. Ultimately CDC would like to use this information to develop better health messages about this issue.

Before coming into the room, each of you completed the consent form and had an opportunity to ask questions. Later, you can contact the RTI’s Office of Research Protection toll-free at 1-866-214-2043 about any questions or concerns that you have related to your participating today. That number is listed on your copy of the consent form.

At this time, I want to review what will happen next. Who has participated in a focus group before? [Wait for response.] My role is to guide our discussion today and to assure that everyone has a chance to share their thoughts and ideas on the topics that I ask about. Therefore, we will follow some general rules for our discussion.

• First, please turn off your cell phones or put them on vibrate now. [Wait for them to do so.] If it is an emergency and you have to answer, please leave the room to do so.

• During our discussion, speak clearly and loudly enough so that everyone can hear you.

• Only one person speaks at a time.

• When you leave, do not discuss or repeat what others shared during the discussion.

To assure anonymity, we use only your first name. We will refer to each other by first name only during our discussion. Your full name will not be connected to any of the written notes or transcripts. Everything you say will be kept private. Information will be presented without any names and will not be linked to any specific person.

Our group discussion will take about 75 minutes. The discussion will be recorded so that I can give my full attention to what you are saying. Even though there is also a note taker in the observation room, we want to assure that we do not miss any of your comments. At the end, we will ask you to complete a short form and we will provide your incentive ($75.00). Again, your participation in this discussion is voluntary and you can end your participation and leave the group at any time. Any questions? [Wait a moment. Respond to any questions.]

Okay, let’s get started. I will turn on the recorder now. [TURN ON THE RECORDER. RECHECK TO BE SURE THAT THE RECORDER IS RECORDING!]

B. Participant Introductions and Ice Breaker

Again, I am [MODERATOR’S NAME]. Now, I would like each of you to introduce yourself—FIRST NAME ONLY PLEASE—and tell us something you like to do for fun. [Pass around name tags.] Please write your FIRST NAME ONLY on the name tag. That will help me to address you by name.

C. Discussion

We’re going to start off our discussion by talking about your thoughts on smoking during pregnancy.

I. Knowledge, Attitudes, and Beliefs

1. What have you seen, read, or heard about smoking during pregnancy?

2. What do you think about a woman smoking during pregnancy?

3. Is there any time during pregnancy when it is OK to smoke?

PROBES:

• At the beginning?

• In the middle?

• At the end?

• Why do you think that?

4. Do you think the baby is affected when the mother smokes during pregnancy? What effects do you think that smoking during pregnancy might cause for the baby?

PROBES:

• Low birthweight (baby born too small)?

• Premature birth (baby born too early)?

• Any other birth defects?

5. Do you think the mother is affected when she smokes during pregnancy? What effects do you think that smoking during pregnancy might cause for her?

PROBES:

• Lung cancer and other cancers?

• Heart disease, stroke, heart attacks?

• Problems breathing?

• Miscarriage or still birth?

6. What information have you seen, read, or heard about smoking after the baby is born?

PROBE:

• Where did you get this information?

7. This is a list of possible effects from smoking before, during, or after pregnancy. (see Appendix A) Which of these were you aware of?

II. Smoking Cessation

The next questions are about issues related to quitting.

8. What are reasons why a woman might not be able to quit smoking during pregnancy?

PROBES:

• Psychological (stress, addiction)?

• Social?

• Access to a health care provider (i.e., doctor)?

• Access to cessation treatment (i.e., medicines to help you quit smoking, counseling)?

• Physical (weight loss)?

9. Talk about your attempts to quit smoking during pregnancy, if any.

PROBES:

• When during the pregnancy did you attempt to quit?

• What motivated you to quit?

• What made it difficult for you to quit?

• Was there one important thing that helped you quit?

10. If you quit smoking during pregnancy, did you experience any relapses (i.e., smoking again after quitting)? When?

PROBES:

• During pregnancy?

• After pregnancy?

• How long did you quit?

• Why did you start smoking again?

11. Would you accept nicotine replacement therapy (NRT) or other medications (e.g., gum, patches, lozenges, Bupropion, Varenicline) to help you quit smoking during pregnancy if it was offered?

PROBES:

• Why or why not?

• Do you think NRT is safe to use while pregnant?

• Would you take NRT if your doctor recommended it to you?

• Do you think the risk of using NRT is less than, equal to, or more than smoking cigarettes?

III. Social Influences

The next questions are about the acceptability of smoking during pregnancy.

12. Do you think your opinion about smoking during pregnancy is shared by your partner? Friends? Family members? Society in general?

13. Would your decision to smoke or not smoke during pregnancy change depending on your partner’s opinion? Friends’ opinions? Family’s opinion?

IV. Sources of Information

The next questions are about where you get information about health.

14. What is your main source for health information?

PROBES:

• Family?

• Internet?

• Friends?

• Health care provider?

• TV/Radio?

• Pamphlets and other literature?

15. If you wanted more information on smoking during pregnancy, where would you go?

PROBE:

• Who or what would be a trusted source of information?

16. What, if anything, has your health care provider told you about smoking during pregnancy?

17. What are the most important messages about smoking and pregnancy to communicate to someone like you?

PROBES:

• Medical info about mother (lung cancer or other cancers, heart disease, stroke, heart attacks, respiratory problems, trouble getting pregnant)?

• Aesthetic (yellow teeth and nails, premature wrinkles, loose skin, bad breath, clothes and hair smell like smoke)?

• Medical info about fetus/baby (low birthweight, premature birth, other birth defects, SIDS [crib death])?

V. Labeling (~15 minutes)

Now I would like to ask you some questions about picture warning labels on cigarette packages.

18. Other countries have added picture warning labels on cigarette packages to educate people about the effects of smoking on health and encourage them to quit smoking. This is an example of a picture warning label from Australia about smoking during pregnancy. (see Appendix B)

PROBES

• What are your first impressions after seeing this label?

• If the United States had this warning label, do you think it would encourage smokers to quit smoking before they become pregnant? Why or why not?

• Once smokers became pregnant, would this label encourage them to quit smoking? Why or why not?

19. Here is a hypothetical example of a warning label that shows a child with cleft lip as a result of the mother’s smoking during pregnancy. (see Appendix C)

PROBES

• What are your first impressions after seeing this label?

• If the United States had this warning label, do you think it would encourage smokers to quit smoking before they become pregnant? Why or why not?

• Once smokers became pregnant, would this label encourage them to quit smoking? Why or why not?

20. Now that you have seen some warning labels and we have talked about some possible birth defects, what do you think are the most important kinds of pictures or information to put on warning labels to communicate to someone like you?

VI. Wrap Up

21. I want you to reflect on the questions I have asked and the things you have heard from others. [PAUSE]. What recommendations do you have for preventing smoking during pregnancy?

That is the all of the questions that we have for you. Now we ask that you complete a short survey to provide some basic demographic information. Please remember that your answers will be anonymous. You can choose not to answer a question if it makes you feel uncomfortable.

[MODERATOR DISTRIBUTES SURVEYS AND PENS]

[MODERATOR COLLECTS SURVEYS IN AN ENVELOPE CODED WITH FOCUS GROUP NUMBER]

Thank you for completing the short survey. This is a fact sheet (see Appendix D) which provides information on smoking during pregnancy and referral services. Please let me know if you have any questions.

[MODERATOR DISTRIBUTES FACT SHEET]

Thank you for participating in the discussion. Please check at the front desk to get your incentive.

FOCUS GROUPS ABOUT CIGARETTE SMOKING DURING PREGNANCY AND ADVERSE OUTCOMES, INCLUDING BIRTH DEFECTS

FOCUS GROUP GUIDES

Segment 4: Women who did not quit smoking during pregnancy

A. Background

Hello. My name is ____ and I work with RTI International, a not for profit research company. Thank you for participating today. We are working on a project sponsored by the U.S. Centers for Disease Control and Prevention, or CDC, in Atlanta to learn about women’s views about smoking and pregnancy. Ultimately CDC would like to use this information to develop better health messages about this issue.

Before coming into the room, each of you completed the consent form and had an opportunity to ask questions. Later, you can contact the RTI’s Office of Research Protection toll-free at 1-866-214-2043 about any questions or concerns that you have related to your participating today. That number is listed on your copy of the consent form.

At this time, I want to review what will happen next. Who has participated in a focus group before? [Wait for response.] My role is to guide our discussion today and to assure that everyone has a chance to share their thoughts and ideas on the topics that I ask about. Therefore, we will follow some general rules for our discussion.

• First, please turn off your cell phones or put them on vibrate now. [Wait for them to do so.] If it is an emergency and you have to answer, please leave the room to do so.

• During our discussion, speak clearly and loudly enough so that everyone can hear you.

• Only one person speaks at a time.

• When you leave, do not discuss or repeat what others shared during the discussion.

To assure anonymity, we use only your first name. We will refer to each other by first name only during our discussion. Your full name will not be connected to any of the written notes or transcripts. Everything you say will be kept private. Information will be presented without any names and will not be linked to any specific person.

Our group discussion will take about 75 minutes. The discussion will be recorded so that I can give my full attention to what you are saying. Even though there is also a note taker in the observation room, we want to assure that we do not miss any of your comments. At the end, we will ask you to complete a short form and we will provide your incentive ($75.00). Again, your participation in this discussion is voluntary and you can end your participation and leave the group at any time. Any questions? [Wait a moment. Respond to any questions.]

Okay, let’s get started. I will turn on the recorder now. [TURN ON THE RECORDER. RECHECK TO BE SURE THAT THE RECORDER IS RECORDING!]

B. Participant Introductions and Ice Breaker

Again, I am [MODERATOR’S NAME]. Now, I would like each of you to introduce yourself—FIRST NAME ONLY PLEASE—and tell us something you like to do for fun. [Pass around name tags.] Please write your FIRST NAME ONLY on the name tag. That will help me to address you by name.

C. Discussion

We’re going to start off our discussion by talking about your thoughts on smoking during pregnancy.

I. Knowledge, Attitudes, and Beliefs

1. What have you seen, read, or heard about smoking during pregnancy?

2. What do you think about a woman smoking during pregnancy?

3. Is there any time during pregnancy when it is OK to smoke?

PROBES:

• At the beginning?

• In the middle?

• At the end?

• Why do you think that?

4. Do you think the baby is affected when the mother smokes during pregnancy? What effects do you think that smoking during pregnancy might cause for the baby?

PROBES:

• Low birthweight (baby born too small)?

• Premature birth (baby born too early)?

• Any other birth defects?

5. Do you think the mother is affected when she smokes during pregnancy? What effects do you think that smoking during pregnancy might cause for her?

PROBES:

• Lung cancer and other cancers?

• Heart disease, stroke, heart attacks?

• Problems breathing?

• Miscarriage or still birth?

6. What information have you seen, read, or heard about smoking after the baby is born?

PROBE:

• Where did you get this information?

7. This is a list of possible effects from smoking before, during, or after pregnancy. (see Appendix A) Which of these were you aware of?

PROBE:

• Which of these would make a difference in your decision to quit smoking during pregnancy? Why would it make a difference?

II. Smoking Cessation

The next questions are about issues related to quitting.

8. What are reasons why a woman might not be able to quit smoking during pregnancy?

PROBES:

• Psychological (stress, addiction)?

• Social?

• Access to a health care provider (i.e., doctor)?

• Access to cessation treatment (i.e., medicines to help you quit smoking, counseling)?

• Physical (weight loss)?

9. Talk about your attempts to quit smoking during pregnancy, if any.

PROBES:

• When during the pregnancy did you attempt to quit?

• What motivated you to quit?

• What made it difficult for you to quit?

• Was there one important thing that helped you quit?

10. If you quit smoking during pregnancy, did you experience any relapses (i.e., smoking again after quitting)? When?

PROBES:

• During pregnancy?

• After pregnancy?

• How long did you quit?

• Why did you start smoking again?

11. Would you accept nicotine replacement therapy (NRT) or other medications (e.g., gum, patches, lozenges, Bupropion, Varenicline) to help you quit smoking during pregnancy if it was offered?

PROBES:

• Why or why not?

• Do you think NRT is safe to use while pregnant?

• Would you take NRT if your doctor recommended it to you?

• Do you think the risk of using NRT is less than, equal to, or more than smoking cigarettes?

III. Social Influences

The next questions are about the acceptability of smoking during pregnancy.

12. Do you think your opinion about smoking during pregnancy is shared by your partner? Friends? Family members? Society in general?

13. Would your decision to smoke or not smoke during pregnancy change depending on your partner’s opinion? Friends’ opinions? Family’s opinion?

IV. Sources of Information

The next questions are about where you get information about health.

14. What is your main source for health information?

PROBES:

• Family?

• Internet?

• Friends?

• Health care provider?

• TV/Radio?

• Pamphlets and other literature?

15. If you wanted more information on smoking during pregnancy, where would you go?

PROBE:

• Who or what would be a trusted source of information?

16. What, if anything, has your health care provider told you about smoking during pregnancy?

17. What are the most important messages about smoking and pregnancy to communicate to someone like you?

PROBES:

• Medical info about mother (lung cancer or other cancers, heart disease, stroke, heart attacks, respiratory problems, trouble getting pregnant)?

• Aesthetic (yellow teeth and nails, premature wrinkles, loose skin, bad breath, clothes and hair smell like smoke)?

• Medical info about fetus/baby (low birthweight, premature birth, other birth defects, SIDS [crib death])?

V. Labeling (~15 minutes)

Now I would like to ask you some questions about picture warning labels on cigarette packages.

18. Other countries have added picture warning labels on cigarette packages to educate people about the effects of smoking on health and encourage them to quit smoking. This is an example of a picture warning label from Australia about smoking during pregnancy. (see Appendix B)

PROBES

• What are your first impressions after seeing this label?

• If the United States had this warning label, do you think it would encourage smokers to quit smoking before they become pregnant? Why or why not?

• Once smokers became pregnant, would this label encourage them to quit smoking? Why or why not?

19. Here is a hypothetical example of a warning label that shows a child with cleft lip as a result of the mother’s smoking during pregnancy. (see Appendix C)

PROBES

• What are your first impressions after seeing this label?

• If the United States had this warning label, do you think it would encourage smokers to quit smoking before they become pregnant? Why or why not?

• Once smokers became pregnant, would this label encourage them to quit smoking? Why or why not?

20. Now that you have seen some warning labels and we have talked about some possible birth defects, what do you think are the most important kinds of pictures or information to put on warning labels to communicate to someone like you?

VI. Wrap Up

21. I want you to reflect on the questions I have asked and the things you have heard from others. [PAUSE]. What recommendations do you have for preventing smoking during pregnancy?

That is the all of the questions that we have for you. Now we ask that you complete a short survey to provide some basic demographic information. Please remember that your answers will be anonymous. You can choose not to answer a question if it makes you feel uncomfortable.

[MODERATOR DISTRIBUTES SURVEYS AND PENS]

[MODERATOR COLLECTS SURVEYS IN AN ENVELOPE CODED WITH FOCUS GROUP NUMBER]

Thank you for completing the short survey. This is a fact sheet (see Appendix D) which provides information on smoking during pregnancy and referral services. Please let me know if you have any questions.

[MODERATOR DISTRIBUTES FACT SHEET]

Thank you for participating in the discussion. Please check at the front desk to get your incentive.

APPENDIX A

OUTCOMES OF SMOKING BEFORE AND DURING PREGNANCY

1. Premature birth (born too early)

2. Having a baby that is of low birthweight (born weighing less than 5 pounds, 8 ounces)

3. Miscarriage or stillbirth

4. Cleft lip and cleft palate, types of birth defects

5. Sudden Infant Death Syndrome (SIDS or crib death)

6. Problems with the placenta, the source of the baby's nutrition and oxygen during pregnancy

7. Trouble getting pregnant

APPENDIX B

GRAPHIC WARNING LABEL, AUSTRALIA

APPENDIX C

GRAPHIC WARNING LABEL, CLEFT LIP

APPENDIX D

FACT SHEET ABOUT SMOKING AND PREGNANCY