Smoking Cessation Support in Pregnancy: Service Provision in Scotland

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Smoking Cessation Support in PregnancyService
Provision in Scotland

• Susan MacAskill, Douglas Eadie
• CTCR, University of Stirling and OU
• Linda Bauld, University of Bath
• David Tappin, University of Glasgow
• Funded by NHS Health Scotland

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Study Background

• Reducing smoking in pregnancy
• Improves health of baby and mother
• Improves population health, reduce inequalities
• Pregnancy is a key trigger to quitting
• Challenges
• Identifying smokers
• Encouraging engagement
• Best practice in tailoring approaches.
• Known that practice was developing but varying
• stages

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Overall Aims

• Map smoking cessation support activities in
  pregnancy in Scotland
• Identify good practice in Scotland and UK
• Review in relation to Guidelines and NICE
  guidance

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Approach

• 1. Broad level information (n16)
• 2. Information on specific services (n20)
• 3. Six case studies (n28)
• 4. Audit using routinely collected data
• Review in relation to
• Scottish Guidelines NICE Guidance

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Case Studies
Elements of promising practice
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What Did we Find?
Identification and recruitmentService
provisionTrainingMonitoring and Audit of
Routine Data
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Identification and Recruitment

• Important that smokers reach support
• Identify smokers (booking any contacts)
• Ask them
• Early (and frequently)
• Testing eg. CO monitors, blood test (purpose?)
• Explain the issues, brief advice
• Refer/signpost to specialist support
• All smokers and opt-out OR selective
• Motivate/support eg. incentives

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Additional Awareness Raising

• Information in Booking Pack
• At visit or pre-posted
• Posters, service leaflets and cards
• Local media

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Additional Targets

• Variable reach
• Partners
• Family members and friends
• Disadvantaged populations
• Teen mothers
• Substance misusers

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Support Provision

• Specialist provision, but variable and many areas
  without
• Staff providing specialist smoking cessation
  advice varied from 0.5 to 2.3 per maternity unit
  (not linked to numbers)
• Additional support approaches apparent

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Support Provision
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Specialist Support

• One-to-one
• Face-to-face and telephone options
• Behavioural support
• Location
• Home
• Clinic and telephone / community pharmacy
• Flexible contact timings
• Length, frequency
• NRT support (around 80)
• Risk-benefit analysis, avoid 24 hour patch
• Staffing midwives, nurses

13
Intermediate Support

• Time allocated as part of role
• (Midwives, Community Pharmacists)
• Behavioural support
• Clinics, community settings, pharmacy
• NRT

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Generic Community Services

• Pregnant women accessing community
• services (also family)
• Uptake appears low (MDS)
• Perceived as not meeting needs
• Potential to build links and skills
• Increasing skills and referrals among MWs
• Training community cessation workers
• Proactive links with Units

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All in Contact with Pregnant Women

• Support role among all in contact
• MWs, MCAs, obstetricians
• HVs, Family Centres, pre-pregnancy etc
• Brief advice, referral, sign-posting
• Broader capacity building approach
• General climate of quitting

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Training
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Training Specialists

• Specialist / Intermediary services
• Midwifery or community nursing background
• Cessation training mixed
• PATH accredited training Maudsley Pip Mason
• On-going development
• Community Pharmacists general training
• Also Community cessation specialists

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Training Frontline Staff

• Raises service profile, contributes to climate
• supporting quitting, and enhances referrals
• Range of relevant staff
• Midwives - those undertaking booking a priority
• Obstetricians, MCAs etc
• Others in contact, eg. HVs, Family centres,
  family planning
• Broad content (training / awareness raising)
• Service provision and referral routes
• Importance and benefits of quitting
• Brief advice
• NRT
• Enhance confidence

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Training Frontline Staff

• Challenges
• Time to attend training, resources for back-fill
• Competing training priorities
• Management priorities
• Flexible scheduling and locations
• Fitting with shifts
• 30 mins to 1 day

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Monitoring Analysis of Routine Data
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Routine Data Smokers (SMR02)

• Essential for assessment of progress feedback
• Requirement re. all mothers, eg. SWHMR records
• Asking about smoking behaviour
• Recording
• Analysis of SMR02 data valuable
• Baseline of all smokers
• Basis for achievement of national target
• Analysis variations in completeness
• Overall 7 unknown
• Varied from 30 to under 1 unknown

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Routine Data Service Users (MDS)

• Requirement re. cessation service users
• (MDS has a pregnancy code)
• Who referred
• Who sets quit date
• Who quits
• Analysis (data not always available)
• Referral rates 16-93 of smokers
• 8-22 of smokers engaged with service
• 1-17 of smokers set a quit date
• 0.4-5.4 quit at 4 weeks (self-report)

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Summary and Conclusions
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What Seems to Work

• Important elements identified
• Getting people through the door
• Identifying and motivating / referring (testing?)
• Specialist service elements
• 1-1
• Flexible and responsive to womens needs
• Home based and clinic
• MW and other staff
• NRT support
• Broader approaches in support of quitting
• STCA Cessation in Pregnancy group

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Areas for Development

• Enhance identification and recruitment
• Booking and beyond
• Opt out or opt in?
• Use of testing tools (clarify purpose)
• Wider targets?
• Increase availability of specialist support
• Capacity, resources
• Admin support
• Continue brief advice and encouragement at all
  stages and contacts with mothers
• Training front line professionals and community
  cessation staff
• Encouraging management support
• Enhance recording, data entry and monitoring /
  audit

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Conclusions

• Pregnant smokers can be helped to quit
• BUT a variable picture across the country
• Appropriate services not available to all
  pregnant smokers
• Substantial public health challenge
• Significant progress
• More needs to be done

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Support Provision Pregnant Smokers
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Analysis of Routine Data

• National data (SMR02) recorded smoking status as
  unknown for 6 of pregnant women (variations)
• NB source of national target information
• Potential for routine testing
• Referral rates of identified smokers to
  specialist cessation services varied between
  maternity units from 16-93
• Self-report quit rates at 4 weeks varied from
  0.4 to 5 (using all identified pregnant smokers
  as the denominator)
• MDS includes pregnancy code