Survey Questions: Perinatal Substance Abuse

These questions are asking about your feelings about tobacco, alcohol and drug use during pregnancy. You can fill out this survey even if you are not pregnant. Please read the instructions and skip those questions that do not apply to you. We are hoping to understand, based on the answers to these questions, what members of our community think about tobacco, alcohol and drug use during pregnancy- whether they think it is a problem and if our community provides enough services for pregnant women who have problems with alcohol and drugs.

Your participation in this survey is totally voluntary. If you are willing to fill out this survey, we want you to understand that all answers to these questions will be kept confidential. Your name will not be attached to this survey, and you will not be able to be identified based on the answers you provide. Please answer the questions as honestly as you can. If you do not feel comfortable answering a question, you can skip it and move on to the next one.

Thank you for completing this survey.

FHOP 12/19/031

1. When a woman is pregnant, how much alcohol do you think is safe for her to drink during her pregnancy? (For the purposes of this survey, a “drink” is one can/bottle 12 oz beer, 5 oz (one glass) of wine, 1 oz (shot, or mixed drink) of liquor such as whiskey or vodka)

1 One or two drinks each day
2 One or two drinks each week
3 One or two drinks each weekend
4 A total of one or two drinks each month
5 No alcoholic drinks

2. Have you ever known someone who you felt might need help with a drug or alcohol problem during her pregnancy?

1 Yes, a family member
2 Yes, a friend
3 Yes, but someone I did not know well
4 Yes, to more than one of the above
5 No, not anyone

3. Do you know of resources or places to go within your community where a woman who needed help with an alcohol or drug problem during pregnancy could get the help she needs?

1 Yes, a drug and alcohol treatment program
2 Yes, a hotline or referral service
3 Yes, a health care provider or counselor
4 Yes, a support group
5 Yes, other (please specify)
6 No, I do not know of any resources in my community to help someone with an alcohol or drug problem

4. Have you ever received treatment or counseling for the use of alcohol or any drug, not counting cigarettes?

1 Yes / 2 No / 3 Not Sure

5. Are you (check one):

1 Male / 2 Female

If you are male, please skip to Question #32.

6. Have you had or do you feel you may have trouble staying off cigarettes during a pregnancy?

1 Yes / 2 No / 3 Don’t know/not sure

7. Which statement best describes the smoking behaviors of you, your family, and friends when in your home or car? Choose one answer.

1 No one smokes at all in the house or car (smokers have to go outside to smoke)
2 Smoking is restricted to one room of the house (basement, etc.)
3 No one smokes when my child is in the room or car
4 Smoking is allowed anytime in the house or car
5 Other, Please describe:

8. Have you had or do you feel you may have trouble staying off alcohol during a pregnancy?

1 Yes / 2 No / 3 Don’t know/not sure

9. Have you had or do you feel you may have trouble staying off illegal drugs during a pregnancy?

1 Yes / 2 No / 3 Don’t know/not sure

Thinking about yourself, would you be more likely to drink alcohol, less likely to drink alcohol, or would it make no difference to your alcohol use in the following situations:

10. If your spouse or partner continued to drink alcohol during your pregnancy

1 I would be more likely to drink alcohol
2 I would be less likely to drink alcohol
3 It would not make a difference
4 I don’t drink alcohol
5 Don’t know/not sure
6 Don’t have a spouse or partner

11. If your spouse or partner encouraged you to stop or cut back your alcohol use during your pregnancy

12. If your spouse or partner were to offer you alcohol during your pregnancy

13. If your spouse or partner stopped drinking alcohol during your pregnancy

Thinking about yourself, would you be more likely to smoke cigarettes, less likely to smoke cigarettes, or would it make no difference to your cigarette smoking in the following situations:

14. If your spouse or partner continued to smoke during your pregnancy

1 I would be more likely to smoke cigarettes
2 I would be less likely to smoke cigarettes
3 It would not make a difference
4 I don’t smoke
5 Don’t know/not sure
6 Don’t have a spouse or partner

15. If your spouse or partner encouraged you to stop or cut back your smoking during your pregnancy

1 I would be more likely to smoke cigarettes
2 I would be less likely to smoke cigarettes
3 It would not make a difference
4 I don’t smoke
5 Don’t know/not sure
6 Don’t have a spouse or partner

16. If your spouse or partner were to offer you cigarettes during your pregnancy

1 I would be more likely to smoke cigarettes
2 I would be less likely to smoke cigarettes
3 It would not make a difference
4 I don’t smoke
5 Don’t know/not sure
6 Don’t have a spouse or partner

17. If your spouse or partner stopped smoking during your pregnancy

1 I would be more likely to smoke cigarettes
2 I would be less likely to smoke cigarettes
3 It would not make a difference
4 I don’t smoke
5 Don’t know/not sure
6 Don’t have a spouse or partner

If you are now pregnant or have been pregnant during the past three years answer the following questions, otherwise, you have completed this survey.

During your pregnancy, how often are you or did you….

18. Smoke marijuana or hash (grass, pot) / 1 Daily / 2 Weekly / 3 Monthly / 4 Rarely / 5 Never
19. Use heroin (smack, junk) / 1 Daily / 2 Weekly / 3 Monthly / 4 Rarely / 5 Never
20. Smoke cigarettes/ tobacco / 1 Daily / 2 Weekly / 3 Monthly / 4 Rarely / 5 Never
21. Use cocaine or crack / 1 Daily / 2 Weekly / 3 Monthly / 4 Rarely / 5 Never
22. Take amphetamines (speed, crystal, ice, meth, crank) / 1 Daily / 2 Weekly / 3 Monthly / 4 Rarely / 5 Never
23. Take tranquilizers or sedatives / 1 Daily / 2 Weekly / 3 Monthly / 4 Rarely / 5 Never
24. Use ecstasy / 1 Daily / 2 Weekly / 3 Monthly / 4 Rarely / 5 Never
25. Sniff inhalants / 1 Daily / 2 Weekly / 3 Monthly / 4 Rarely / 5 Never
26. Use vicodin or oxycontin without a prescription / 1 Daily / 2 Weekly / 3 Monthly / 4 Rarely / 5 Never
27. Use Ritalin without a prescription / 1 Daily / 2 Weekly / 3 Monthly / 4 Rarely / 5 Never
28. Use opiates (such as morphine or codeine) without a prescription / 1 Daily / 2 Weekly / 3 Monthly / 4 Rarely / 5 Never
29. Take hallucinogens (LSD, acid) / 1 Daily / 2 Weekly / 3 Monthly / 4 Rarely / 5 Never

30. During the last 3 months of your pregnancy, how many alcoholic drinks did you have in an average week?

1 I didn’t drink then
2 Less than one drink per week
3 1 to 3 drinks
4 4 to 6 drinks
5 7 to 13 drinks
6 14 or more drinks per week
7 Don’t know/not sure

31. During the last 3 months of your pregnancy, how many times did you drink 5 or more alcoholic drinks in one sitting?

1 ______times / 2 Didn’t drink then / 3 I don’t know

For men:

32. Do you currently have a spouse or partner who is pregnant, or whom you think might become pregnant within the next two years?

1 Yes / 2 No / 3 Don’t know/Not sure

Thinking about yourself, if your spouse or partner were to become pregnant, would you be very likely, somewhat likely, not very likely, or not at all likely to do each of the following:

33. Encourage her to stop or cut back on her alcohol use during the pregnancy

1 Very likely
2 Somewhat likely
3 Not very likely
4 Not at all likely
5 Spouse does not drink now
6 Don’t know/not sure

34. Stop drinking alcohol yourself during her pregnancy

1 Very likely
2 Somewhat likely
3 Not very likely
4 Not at all likely
5 Spouse does not drink now
6 Don’t know/not sure

35. Encourage her to stop or cut back on her tobacco use during the pregnancy

1 Very likely
2 Somewhat likely
3 Not very likely
4 Not at all likely
5 Spouse does not use tobacco now
6 Don’t know/not sure

36. Stop using tobacco yourself during her pregnancy

1 Very likely
2 Somewhat likely
3 Not very likely
4 Not at all likely
5 Spouse does not use tobacco now
6 Don’t know/not sure

Thank you for completing this survey.

FHOP 12/19/031