Protocol - Pregnancy Status and Tobacco Use

The next questions are about your pregnancy history.

1. Have you ever been pregnant? Please include current pregnancy, live births, miscarriages, abortions, ectopic or tubal pregnancies and stillbirths.

1[ ]Yes

2[ ]No

-8[ ]DON’T KNOW

-7[ ]REFUSED

2. How many of your pregnancies have resulted in a live birth?

1[ ]|___|___|

-8[ ]DON’T KNOW

-7[ ]REFUSED

3. For [that birth those FILL## births], did any of the following occur? Choose all that apply.

1[ ]Preterm birth (birth of baby less than 37 weeks gestational age)

2[ ]Baby with low birth weight (less than 5 pounds 8 ounces)

3[ ]Baby with birth defects

4[ ]Placenta Previa

5[ ]Placenta Abruption

6[ ]Pre-eclampsia

7[ ]None of the above

-8[ ]DON’T KNOW

-7[ ]REFUSED

4. Are you pregnant now?

1[ ]Yes

2[ ]No

-8[ ]DON’T KNOW

-7[ ]REFUSED

5. How many months or weeks pregnant are you? Please enter the number of months or weeks.

1[ ]|___|___| Months

2[ ]|___|___| Weeks

-8[ ]DON’T KNOW

-7[ ]REFUSED

6. During your [most recent / current] pregnancy, [did you smoke / have you smoked] any cigarettes?

1[ ]Yes

2[ ]No

-8[ ]DON’T KNOW

-7[ ]REFUSED

7. During your [most recent / current] pregnancy, how many cigarettes [did you smoke/have you smoked] on an average day? A pack usually has 20 cigarettes in it.

1[ ]Less than 1 cigarette a day

2[ ]1 to 5 cigarettes a day

3[ ]6 to 10 cigarettes a day

4[ ]11 to 20 cigarettes a day

5[ ]21 to 40 cigarettes a day

6[ ]41 cigarettes or more a day

-8[ ]DON’T KNOW

-7[ ]REFUSED

8. During your [most recent/current] pregnancy, [did/have] you [use/used] [TOBACCO PRODUCT LIST]?

1[ ]Yes

2[ ]No

-8[ ]DON’T KNOW

-7[ ]REFUSED

PROGRAM: [TOBACCO PRODUCT LIST] = A list of all tobacco products the respondent has ever used, excluding cigarettes.