Dundee Smoking and Pregnancy Project

Background

The project aimed to develop and pilot a mainstream care pathway which would encourage and support pregnant women in Dundee not to smoke and help them to remain smoke free following the birth of their child.

What is the problem you are trying to solve?

The project addressed the prevalence of smoking in pregnant women in Dundee. Since 1998, there have been approximately 1500 births each year in Dundee City, while the proportion of pregnant women who smoke has changed little since 1995. In terms of local authority areas, Dundee City has one of the highest proportions of pregnant women smokers in Scotland, for instance, 37.6% of pregnant women in Dundee were smokers in 2001-2. This compares with an overall figure of around 26% for Scotland as a whole and 27.6% for the surrounding Tayside Health Board area. Dundee also has one of the highest rates of teenage pregnancy in Scotland and a significantly higher rate of low birth weight babies than elsewhere in Tayside.

What local organisations are involved?

The project worked closely with hospital and community midwives, health visitors and other local smoking cessation services and projects. A local GP and pharmacist helped to develop a Patient Group Direction (PGD) for provision of Nicotine Replacement Therapy (NRT), although approval by the local PGD Committee was not achieved.

How many people are running this project and who are they?

An experienced health visitor was appointed at the beginning of August 2003 as project coordinator with responsibility for the day to day running of the project. A project steering group was also established consisting of the women’s and reproductive health senior manager, community nursing service manager, a practising midwife, the project coordinator, a health promotion specialist with expertise in smoking cessation and a representative from specialist public health to advise on monitoring and evaluation. Other professionals were invited to attend the group as appropriate.

What local population are you targeting?

Between June 2004 and July 2005, the project targeted all pregnant women in Dundee who were current smokers or who had stopped smoking during the previous year.

How many people are you targeting?

We targeted approximately 600 women.

Interventions

What interventions are you using to address the problem?

The project aimed to:

• Review and revise the existing smoking cessation in pregnancy care pathway in Dundee;
• Raise and maintain levels of awareness of the importance of smoking cessation during pregnancy, through training and encouraging health professionals to question women about their smoking at every visit and to provide appropriate information and advice;
• Increase professionals’ knowledge and skills in providing cessation support;
• Research and liaise with similar projects elsewhere to identify emerging evidence of effective/best practice;
• Investigate the feasibility of NRT provision through a PGD for pregnant women who smoke, and implement such provision if possible;
• Provide appropriate information and advice regarding smoking to all pregnant women in Dundee and one-to-one cessation support to those who wish it; and
• Develop an appropriate monitoring system in line with the Scottish National Minimum Dataset (MDS) for smoking cessation projects.

Following a revision of the care pathway and training in motivational interviewing for midwives and health visitors, it was intended that ongoing one to one support for pregnant women wishing to stop smoking would be provided by their own health visitor. However, a pilot phase demonstrated that due to existing workloads this was not feasible. Thereafter, one to one support was provided by the project coordinator at a time and place of the woman’s choice. A draft PGD to enable trained project staff to prescribe NRT was developed, but approval was not obtained. Women wishing NRT were directed to their local GP services.

Is the project design based on evidence? If so, please state reference.

A recent review suggests that cessation interventions including written materials, advice and bio-feedback (such as saliva cotinine, carbon monoxide levels) can be effective during pregnancy ¹ .

Research also suggests that smokers are more likely to stop if seen by professionals trained in cessation techniques, and that professionals who are trained are more likely to intervene ² .

Motivational interviewing, a technique developed to encourage drug users to stop, has been suggested as an alternative to direct persuasion for pregnant smokers ³ .

Although NRT has been shown to increase the effectiveness of cessation advice in the general population ⁴ , it was for some time not recommended during pregnancy because of fears of potential harm to the foetus. However, guidelines now suggest that NRT may be considered for pregnant women in the UK, who cannot stop smoking without it ³ .

Outcome

What outcomes or planned outcomes are you measuring?

The project was monitored in line with the requirements of the MDS for NHS smoking cessation projects. The MDS was developed by Partnership Action on Tobacco and Health (PATH) for the Scottish Executive and Health Scotland during 2004 and sets out mandatory information that NHS smoking cessation services must collect for each client setting a quit date.

We measured the proportion of participants who had successfully stopped smoking at four follow-up points: one and three months following their initial quit date, shortly after delivery of their infant and approximately eight weeks following delivery. Participants’ smoking status was ascertained (by carbon monoxide testing when possible) by the project coordinator at the one and three month points, from routine recording at their health visitor’s first visit post-delivery, and by a questionnaire at the eight week post-delivery Child Health Surveillance Programme Clinic. Women lost to follow-up were assumed to be smoking. However, not all participating women could be followed up post-delivery due to the time limits of the project.

For comparison, non-participating pregnant smokers booking for delivery during the period of the project were followed up at their health visitor’s first post delivery visit, and at the Child Health Surveillance Programme Clinic, where their self-reported smoking status was ascertained.

Do you have any outcomes or results yet? If so, what are they?

Between June 2004 and July 2005 the following data was collected from all women in Dundee at their first or "booking in" antenatal appointment:

• 530 (35.3%) pregnant women reported being current smokers;
• 130 women (19.7% of smokers and recent smokers) reported having stopped smoking in the previous year;
• The average age of smokers was 26.2 years, and ranged 15-43 years;
• The majority of smokers (68.2%) resided in postcode sectors categorised as more deprived, according to Carstairs and Morris Deprivation Categories. Carstairs and Morris scores ⁵ are derived from census variables and provide a means of quantifying levels of relative deprivation in different geographic localities, and range from 1 (least deprived) to 7 (most deprived);
• A total of 393 (59.5%) of expected project data abstraction forms, some not fully completed, were received from midwives;
• 254 smokers (69% of those asked) reported living with at least one other smoker;
• 214 smokers (62% of those asked) reported being entitled to free prescriptions;
• 306 smokers (85.5% of those asked) said they would like to stop smoking;
• 52 (9.8% of all) smokers were willing to set a future quit date; and
• 246 (37.3% of all) smokers/recent ex-smokers agreed to be referred for cessation support.

Over 40% of those agreeing to referral did not respond to attempts to contact them to arrange an appointment and another 22% withdrew at first contact or did not attend appointments. A further 7% were not included in the study due to miscarriage or other trauma. Over the one year data collection period, 76 women (31% of referrals) received some one to one cessation support.

In the short term, the project had little evident success in tackling smoking during pregnancy, as only 6 (7.8%) participants reported remaining a non-smoker at the end of the data collection period. However, around a third of participants reported they had cut down the amount of cigarettes smoked. Since most smokers make several attempts to quit before finally succeeding, it is to be hoped that the personal encouragement participants received will help motivate them to a successful next attempt. The project has also raised the profile of smoking cessation with midwifery and health visiting staff and encouraged staff to ask and provide brief advice to all smokers at every appointment.

Information regarding smoking status at the health visitor’s first visit following delivery was available for 299 smokers/recent smokers who had booked for delivery during the project, but had not participated. A total of 222 (74.2%) women were recorded as smoking, a reduction of around 6% since first booking. Since their first booking appointment, 35 smokers reported they had stopped smoking. However, 19 recent smokers at first booking reported having relapsed.

A total of 336 women recorded as smokers/recent smokers during the project were recorded as attending an eight week post-delivery baby clinic. Around 36% (121 women) completed project questionnaires. A total of 92 (76%) respondents reported currently smoking, slightly lower than the proportion at first booking. Nine smokers reported they had stopped smoking since first booking. However, 14 recent smokers at first booking had relapsed, eight of these since their health visitor’s first visit following delivery.

Results published at: http://www.ashscotland.org.uk/ash/files/Dundee_pregnancy_Final_ReportJan06.pdf

Is your project relevant to a government target or guideline?

Yes, targets set by the Scottish Executive for reducing the proportion of women smoking during pregnancy in Scotland were 23% by 2005 and 20% by 2010 ⁶ .

Feedback

What obstacles did you have to overcome to set up this project?

None – the project received external funding and had strategic and managerial support.

What have you learned about the project so far?

Evidence suggests ⁷ that many women who continue to smoke during pregnancy are those who are highly dependent on nicotine, have multiple and complex psychosocial problems, including poverty, debt problems, depression, illicit drug abuse and low self-esteem. Such women require non-judgmental, holistic and integrated support to help them deal with their difficulties, alongside their smoking.

Women in Dundee registered with General Practices with enthusiastic smoking cessation staff were more likely to participate in the project than others.

What would you do differently?

Although nearly half of pregnant women admitting to smoking agreed to referral for one to one support, few actually participated or set a quit date. Some women may have agreed to the offer of support simply to avoid further discussion or pressure to stop smoking. Considerable specialist time was taken up trying to contact women who subsequently showed little or no interest in participating. Targeting only those women highly motivated to quit with one to one support, while continuing to offer opportunistic brief advice to all smokers, may be a more cost effective use of specialist resources.

Midwives and health visitors expressed concerns about their capacity to comply with the care pathway within current staff resources. Some midwives also expressed concerns that discussing smoking could compromise the trusting relationship required between themselves and their patients. These concerns need to be addressed if "mainstream" staff are to contribute effectively to smoking cessation work.

Since use of NRT has been shown to improve the chances of smokers successfully quitting, the project’s inability to provide NRT on prescription was disappointing and may have affected both the numbers of women willing to participate and the success of individual quit attempts. The position regarding prescribing of NRT during pregnancy requires clarity to ensure that GPs will prescribe, while development of appropriate PGDs to enable other professionals supporting women in cessation attempts would be helpful.

It may be that cessation advice given as soon as pregnancy is confirmed is more effective than later in pregnancy. General Practice staff need to be aware of the key role they can play in encouraging women to quit both before and during pregnancy.

References:

1. Lumley J, Oliver SS, Chamberlain C, Oakley L. Interventions for promoting smoking cessation during pregnancy. The Cochrane Database of Systematic Reviews. 2004; Issue 3. Art. No.: CD001055.pub2. DOI: 10.1002/14651858.CD001055.pub2.
2. Lancaster T, Silagy C, Fowler G. Training health professionals in smoking cessation. Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No. CD000214. DOI: 10.1002/14651858.CD000214.
3. West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update. Thorax. 2000; 55:987-999.
4. Fiore MC, Bailey WC, Cohen S J. Smoking cessation. Clinical Practice Guideline No 18. Rockville, MD: US AHCPR Publication No.96-0692: Department of Health and Human Services, Pubic Health Service, Agency for Health Care Policy and Research. 1998.
5. Carstairs V, Morris R. Deprivation and Health in Scotland. Aberdeen University Press. 1991.
6. The Scottish Office. Towards a Healthier Scotland: a white paper on health. The Stationery Office: Edinburgh. 1999.
7. DiClemente CC, Dolan-Mullen P, Windsor RA. The process of pregnancy smoking cessation: implications for interventions. Tob Cont. 2000;9(3):iii16-iii21.