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Smoking in pregnancy

Introduction

The national Tobacco Control Plan for England (Healthy Lives, Healthy People March 2011) set Public Health Outcomes Frameworks which provides key sources of information around tobacco use.  It set three national ambitions around tobacco control and one of these relates to smoking in pregnancy.

“To reduce rates of smoking throughout pregnancy to 11 per cent                                                 

or less by the end of 2015.”

Stopping Smoking in Pregnancy is the single most effective step a woman can take to improve her health and the health of her baby.

 

Smoking in Pregnancy has substantial adverse effects on the foetus. Many of the 4000 chemicals in tobacco smoke can cross the placental barrier and have a direct toxic effect on the foetus.

 

Maternal smoking is a potential cause of major morbidity and mortality to the foetus and new born baby:

 

  • 32% increased risk of miscarriage (death before the 20th week of pregnancy)
  • 26% increased risk of perinatal death (death between 20 weeks of  pregnancy and first week of life)
  • Women who smoke are 1.5 to 2.5 times more likely to have low birth weight babies (intrauterine growth retardation)
  • 27% increased risk or a preterm birth (birth before the 37th week of pregnancy). Preterm birth is a major cause of infant mortality and can affect physical and mental development during childhood. (RCP Passive Smoking and Children report 2010)

 

Until March 2013, the data for this chapter has been collected at primary care level only. From 1st April 2013 data will be collected at local authority level by the public health intelligence team and the chapter refreshed annually.

 

Facts, Figures, Trends

Smoking in pregnancy data is monitored locally by collection of rates of mothers smoking at time of delivery (SATOD). Bedford hosts one core hospital and six local feeder hospitals that report smoking at time of delivery statistics on a quarterly basis. Figure 1 shows data provided by maternity departments delivering babies to residents across Bedfordshire the two main hospitals Bedford Hospital NHS Trust and Luton and Dunstable Hospital.

 

Bedford Hospital delivers approximately 60% of maternities and Luton and Dunstable Hospital delivers approximately 20% of maternities in Bedfordshire).

 

In 2012/13 the percentage of mothers smoking at time of delivery in Bedfordshire was 13% (679 smokers out of 5210 total maternities) which represents a decrease in the percentage of mothers smoking at the time of delivery compared to 2011/12.This has been further reduced in 2013/14 is down to 12.6% of mothers smoking at time of delivery.

 

Figure 1:  Smoking at time of Delivery

SIP1 2015

Source:  Health & Social Care Information Centre - Statistics on Women's Smoking Status at Time of Delivery

 

Adult smoking prevalence from the Local Tobacco Control Profiles for England suggests that general adult smoking prevalence in Bedford Borough 17.4% (2012/13) which has increased slightly by 1.1 % from 2011/12 (16.3%). This is this is lower than 2010/11 (19.6%) and 2.6% lower than the current England average prevalence (20%), .

 

Although smoking status at discharge (SATOD) is no longer submitted by Acute Trusts, historical data shows (Figure 2) the Bedford Borough wards for 2009-2010 for smoking status at discharge. The chart shows that the majority of births, regardless of smoking status, were in Queens Park, Cauldwell, Kingsbrook, Castle, Goldington and Harpur with the number of smoking at time of delivery being higher in the same areas. These wards contain some of the LSOAs with the highest overall deprivation in Bedford Borough

 

Figure 2: Mothers'smoking status at discharge by ward

 

Smoking in pregnancy

Source: Public Health Intelligence

 

Socio-demographic factors associated with smoking in pregnancy mirrors many factors of those classed as a generic smoker.  These include:

Routine and manual occupations - pregnant women in routine and manual occupations are more than five times as likely as those in managerial and professional occupations to have smoked throughout pregnancy ((ASH (2013): Smoking Cessation In Pregnancy: A call to action)

 

Location -  local data taken from the East of England lifestyle survey suggests that there is a considerable variation between the 20% most deprived MSOA’s in Bedfordshire and the 80% least deprived MSOA’s:

 

  • Smoking prevalence 20% most deprived MSOA’s: 22.4%
  • Smoking prevalence 80% least deprived MSOA’s: 17.0%

 

Ethnicity - there is a wide ethnic variation in smoking in pregnancy with low rates reported in some population groups especially south Asian (Department of Health, 2011).

 

Age - rates of smoking in pregnancy are higher among teenagers who are more than six times as likely to smoke before or during pregnancy as mothers aged 35 or over, young women are less likely to quit smoking during pregnancy. (,  (ASH (2013): Smoking Cessation In Pregnancy: A call to action Locally 99 women in Bedford (2012/13) set a quit date with only 5 of these are from under 18 year of age.

Social factors - pregnant women with complex social factors like poverty, under 20, domestic abuse and substance misuse are more likely not to access healthcare services and will usually require tailored support  (NICE, 2010)

 

Secondhand smoke

 

Exposure to secondhand smoke is harmful to health, especially in the unborn child and children. Evidence in the Scientific Committee on Tobacco and Health report found that passive smoking is a cause of respiratory disease, cot death, middle ear infections and asthma in children. In pregnancy, second-hand smoke can reduce foetal growth and increase the risk of a preterm baby (Department of Health, 2004). Infants and children are particularly vulnerable to the health effects of secondhand smoke with most of their exposure coming from within the home.

 

Prenatal exposure to tobacco smoke has significant adverse impacts on the health of the foetus including low birth weight, premature birth, spontaneous abortion and still birth. (ASH, 2011)

 

Babies born to women who smoke weigh around 200 grams less than non-smokers. There is a small adverse effect on the baby’s weight of non-smoking mothers who themselves have been exposed to secondhand smoke during their pregnancy (IARC, 2004). Smoking also impacts on IVF and fertility rates. It has been found that exposure to secondhand smoke is as damaging as active smoking in terms of successful pregnancy outcomes for people using IVF. (Neal. M, et al, 2005)

 

Health effects of exposure to secondhand smoke in pregnant women

Research published in 2011 combined data from 19 studies investigating the impact of exposure to secondhand smoke on pregnant women. When the data from all nineteen studies were combined and analyzed together, they found that women exposed to secondhand smoke were 23% more likely to have a stillbirth and 13% more likely to give birth to a child with congenital heart defects .(Alberson. CJ et al, 2005)

 

A 2010 review of studies examining the impact of secondhand smoke exposure on non-smoking pregnant women found that there was a small risk of them having lighter weight babies and of the babies having congenital abnormalities. It concluded that for most women the risks were small but that for active smokers or those in poor health the added risk of exposure to secondhand may be more significant. (Salmasi. G et al, 2010)

 

The 2003 Scottish Health Survey estimated that four out of every 10 children (40%) live in homes where at least one person regularly smokes inside the home, this is in line with previous estimates for England. (The Scottish Government, 2005)

 

Although no comparable data is available, we know that within Bedford Borough 23.3% (2013/14) of new born babies are living in a home with at least one smoker. This is an increase of 1% from  2012/13 which was 22.3% [Systm 1 – 2014]..

 

Current activity and services

  • The Bedford Smoking in Pregnancy (SIP) Specialist Advisor has been working closely with maternity units to ensure maternity staff understand the importance of raising the issue of smoking and to ensure best recommended practice (as per NICE guidelines) is implemented.
  • The SIP specialist advisor is piloting home visits as a means of increasing access to pregnant mothers to be
  • Clinics are offered to pregnant women and their partners in the community at a range of different locations as well as from a variety of support services including GP practices and referrals from pharmacy outlets.                                          
  • Smoke Free baby and me programme supports pregnant women from referral (whilst pregnant) until 1 month postpartum.. It uses an incentive scheme to engage with smokers and to sustain a quit attempt.
  • The stop smoking service maintains links with stop smoking services in neighbouring counties as many Bedford mothers deliver at our feeder hospitals.
  • Working with local partners to achieve Smoke free homes and cars 
  • Midwives will receive training in smokeless tobacco

 

Local views

The stop smoking service aims to continuously improve and develop the service according to local need. An evaluation form is sent to all who access the service, including pregnant women. However, no questions are currently asked that relate specifically to the issue of pregnancy, this needs to be asked and recorded.

 

Informal consultation groups were held in 2010 to identify obstacles and barriers women might have in attending services and as a result the ‘smoke-free baby and me’ programme was developed.

 

Focus groups were also held in 2011, with the aim of identifying what level of written information regarding the risks of smoking in pregnancy women would like to receive and what images would engage women more. As a result, new resources were produced in collaboration with other East of England PCT’s.

 

Other views include:

 

Fantastic support by my midwife and by Sandra, the stop smoking advisor. I stopped for baby and have never felt better” Bedford 2010

 

National and local strategies

  • The national Tobacco Control Plan for England (Healthy Lives, Healthy People March 2011) set Public Health Outcomes Frameworks which will provide key sources of information around tobacco use.  It sets three national ambitions around tobacco control and one of these relates to smoking in pregnancy:

 

                                    “To reduce rates of smoking throughout pregnancy to 11 per cent or less by the end of 2015.”

 

  • Promotion of health and wellbeing is incorporated in the Healthy Child Programme (Department of Health 2009). The document sets out universal standards to support local delivery encompassing smoking status of either parent. It advises that families who smoke should be referred into specialist services and offered smoke free environments.

 

  • Locally, Bedford Borough’s vision statement says ‘All children and young people are able to lead healthy and safe lives…’ Smoking in pregnancy comes under Bedford Boroughs Health and Wellbeing strategy (Priority 4a – Healthy Lifestyles). It also states “Children who grow up with parents who smoke are more likely to smoke themselves, and are 3 times more likely to get lung cancer than children of non-smokers” The Health and Wellbeing Board seek to: ‘Further reduce smoking prevalence by preventing people from starting to smoke and helping people to stop smoking’.

 

  • The National Institute for Health and Clinical Excellence (NICE PH26 2010) released updated guidance on “Quitting smoking in pregnancy and following childbirth.” Some of the recommendations include:

 

  • Identifying pregnant women who smoke and referring them to LA Stop Smoking Services. This is aimed at midwifery and includes biomechanically measuring levels of carbon monoxide in all pregnant women and referring those who smoke to services.
  • All other health and social care professionals, such as GPs, health visitors, sonographers, youth workers, etc., should be identifying pregnant women who smoke and refer to LA Stop Smoking Services.
  • Stop Smoking Services to contact all women by phone and attempting to see those whose contact was not possible at key maternity appointments. It also recommends offering appointments at other venues, including home visits. There are also recommendations on how to relay information to pregnant women on the phone.
  • Provide initial on-going support including the provision of interventions throughout pregnancy and after delivery. It recommends the use of Carbon monoxide testing and the provision of support to women who recently quit, including the use of Nicotine Replacement Therapy when needed
  • Ensure services meet the needs of disadvantaged pregnant women who smoke, including collaboration with agencies who support women with complex needs, such as substance misuse services, teenage pregnancy support and mental health services.
  • Ensure partners and others, related to pregnant women, who smoke, are offered stop smoking support and advice on passive smoking.
  • Training should be provided to relevant professionals on delivering stop smoking interventions to pregnant women, namely midwives. All other relevant professionals should be trained on how to deliver brief interventions to initiate a referral to stop smoking services

 

Cost effectiveness

 

  • The total annual cost to the NHS of smoking during pregnancy is estimated to be as high as £64 million for treating the resulting problems for mothers and as high as £23.5 million for treating infants (aged 0-12 months). (Godfrey. C, et al, 201
  •  Estimates have also placed the costs of a complicated delivery by a woman who smokes at 66% higher than that of a woman who does not smoke. (NHS Yorkshire and Humber, 2007
  • Cost estimates are limited to NHS costs during pregnancy and the first year of life, but smoking in pregnancy has long-term effects on health and may therefore have wider costs to education, social work and judicial systems. The real costs to society could be much higher.
  • Stopping smoking during pregnancy is a cost effective health tool as it improves health and wellbeing of current and future adults and contributes to a reduction in health inequalities
  • In terms of hospital inpatient cost for children born to a smoking mother over the first 5 years of life, the cost difference was estimated at £462 when infants born to women who smoked at least 20 cigarettes per day were compared to infants of non-smoking mothers. The cost difference was £ 307 when infants born to women who smoked 10-19 cigarettes per day were compared to infants of non-smoking mothers. (Stavros, 2005)
  • The service is cost effective as the current cost (2010-2011) for treating a smoker is £146 which is below the national average of £249 for the same period (NHS Information Centre).

 

The Smoke free Baby and Meprogramme costs £135.00 per women going through the full programme, however the costs will vary depending on the length of support requested.  This equates to £32.00 more than the national average to treat a generic smoker.

 

Recommendations

  • Midwives to continue assessment and reporting of smoking status by contact with pregnant smokers within clinics and home visits. This also supports NICE recommendation that services should offer appointments at home, if needed, to increase access.
  • Continue support and training to midwives in Bedford Hospital to enable them to better advise and support pregnant smokers to stop smoking.
  • Explore closer work with teenage pregnant smokers to increase uptake of service
  • Meet regularly with the midwives to encourage good communication.
  • To follow and sustain a shared care model with the Hospital Trusts to provide a collective approach of support women and their families
  • Work closely with Bedford Borough services which incorporate pregnant women
  • Work with LPC and pharmacies in Bedford Borough, delivering a tailored Stop Smoking services to pregnant smokers, normalising access to the service and encouraging women who do not access mainstream health services.
  • Work with other feeder hospitals to ensure all Bedfordshire mothers are offered consistent support
  • Explore partnership working to encompass smoking in pregnancy and second-hand smoke.
  • Ensure L3 advisors who support pregnant women, accurately record ethnicity so we get a better guide as to Eastern European and other groups accessing the service.
  • Work closely with local children’s centres and explore whether rolling group advice can be offered within the children’s centres. This may be particularly effective for those women who feel uncomfortable accessing mainstream services.
  • Continue encouraging pregnant women to utilise the Smoke free Baby and Me scheme as motivational support to quit.

 

This chapter links to the following chapters in the JSNA:

 

References:

Coleman, T. Thornton J, Britton J, Lewis S, Watts, K, Coughtrie MW (2007, Protocol for the smoking, nicotine and pregnancy (SNAP trial, BMC Health Services Research 7:2

Department of Health (2011) Service delivery and monitoring guidance

Department of Health (2005) You’re Welcome Quality Criteria: Making health services young people friendly

NICE (2010) NICE Clinical Guideline 110: Pregnancy and Complex Social Factors

Department of Health, Scientific Committee on Tobacco and Health (2004) Secondhand Smoke: Review of the evidence since 1998

Action on Smoking and Health, 2011, Secondhand Smoke: the impact on children.  Available at:  http://www.ash.org.uk/files/documents/ASH_596.pdf.  Last accessed 19 August 2013

International Agency for Research on Cancer (IARC).(2004) IARC Monographs on the evaluation of carcinogenic risks to humans Volume 83 Tobacco smoke and involuntary smoking. IARC. France

Neal M. Hughes E. Holloway A et al. (2005) Sidestream smoking is equally as damaging as mainstream smoking on IVF outcomes. Human Reproduction; 20 (9): 2531-2535. 

Alberson CJ, Strickland MJ, Gilboa SM, Correa (2011) A Maternal smoking and congenital heart defects in the Baltimore-Washington infant study. Pediatrics 2011. 127. 3:e647-e653 (doi:10.1542/peds.2010-1399) Published online 28 February 2011. 

Salmasi G, Grady R, Jones J et al. (2010) Environmental tobacco smoke exposure and perinatal outcomes: a systematic review and meta-analyses. Acta Obstet Gynecol Scand.

 (2005), Scottish Health Survey 2003, The Scottish Government, (2005) Available at: http://www.scotland.gov.uk/Resource/Doc/924/0019811.pdf (last accessed 19 August 2013)

Local Tobacco Profiles for England, Public Health England, 2013, available at:  http://www.tobaccoprofiles.info/. (last accessed 19 August 2013)

Godfrey C, Pickett K, Parrot S et al. (2010) Estimating the costs of smoking in pregnancy for pregnant women and infants. York: Department of health sciences, The University of York

NHS Yorkshire and the Humber (2007) Reducing smoking pre-conception, during pregnancy and postpartum. Integrating high impact actions into routine healthcare practice

Stavros P. (2005) The association between smoking during pregnancy and hospital inpatient costs in childhood. Social Science & Med, 60;5:1071-108

NICE (2010) NICE Clinical Guideline 110: Pregnancy and Complex Social Factors

ASH (2013) Smoking In pregnancy: A call to action

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