Focus Group about Cigarette Smoking during Pregnancy - p

ATTACHMENT 3

FOCUS GROUP PARTICIPANT QUESTIONNAIRE

Thank you for agreeing to complete this questionnaire. The questions you answer will only be used to describe the types of women who participated in the focus group discussions. Your answers are anonymous. Please do not put your name anywhere on the questionnaire. Completing this questionnaire is completely voluntary. Please skip any question that you do not feel comfortable answering.

1. How old are you?

 18-22

 23-30

2. Which one of these groups would you say best represents your race?

 White

 Black or African American

 Asian

 Native Hawaiian or other Pacific Islander

 American Indian or Alaska Native

3. Do you identify yourself as Hispanic or Latino?

 No

 Yes

4. At what age did you start smoking? ________years old

5. Does your partner or another household member smoke?

 No

 Yes

6. During the past 7 days, how many cigarettes or packs of cigarettes did you smoke on an average day? (A pack has 20 cigarettes)

 _____ cigarettes or ____ packs

 Less than 1 cigarette per day

 Didn’t smoke

 Don’t know

7. At what point in your last pregnancy did you quit smoking?
    I have never been pregnant

 I did NOT quit smoking when I was pregnant

 I quit before I got pregnant

 I quit as soon as I learned that I was pregnant

 I quit later in the first trimester

 I quit in the second trimester

 I quit in the third trimester

 I do not recall