For some time, government policy has backed the need to tackle smoking in pregnancy, especially among teenagers and those who are less well off. England’s current target is to reduce the prevalence of smoking at delivery to 15 per cent by 2010.
This target has been met early. The current smoking prevalence at delivery is 14.4 per cent, according to the latest DH statistics published in July 2009. However, this still equates to 92,000 pregnant women in England smoking.
Blackpool has the highest prevalence, and at a staggering 33.3 per cent is over double the national average. In the last two years the smoking prevalence has increased in 41 per cent of primary care trusts (62 of out 152), by between 0.1 per cent and 4.9 per cent.
Recent evidence shows that smoking cessation interventions are effective in reducing smoking throughout pregnancy, as shown in the latest Cochrane review of interventions for promoting smoking cessation during pregnancy published in July 2009.
Since 1999 NHS stop smoking services have helped pregnant women to stop smoking. Over 111,000 pregnant women have received help to set a quit date, representing huge progress. A total of 18,928 set a quit date last year, compared with a modest 4,037 in 2001-02.
However success at four weeks is limited.
Last year 18,928 set a quit date but less than half (46 per cent) managed to quit smoking at four weeks. Only 24 per cent were confirmed by carbon monoxide validation.
Compared with last year, there was a 12 per cent fall in the number quitting according to figures published by the NHS Information Centre in August 2009. The Care Quality Commission judges success through a decreasing number of smokers at delivery.
While services are clearly reaching large numbers of smokers, this still only represents a fraction of the overall number of women smoking in pregnancy. Recently the pressure group ASH highlighted the need for greater investment to improve the referral process to specialist services, to ensure that access is universal, to target partners who smoke and to develop and evaluate new services.
Professor Linda Bauld at Bath University emphasises the need for improved identification (carbon monoxide/cotinine testing), referral, engagement and treatment of smokers to improve the contribution of stop smoking services to reducing smoking in pregnancy.
Recent evidence shows that the social stigma around pregnant women smoking can have a negative impact on their willingness to seek help, with more than a quarter admitting they are worried about being judged. Criticising or stigmatising pregnant women who smoke is counterproductive.
Many pregnant women find it hard to stop smoking despite knowing the benefits of doing so. Tobacco delivered nicotine is highly addictive. Smoking in pregnancy is also strongly associated with poverty, low levels of education, poor social support, depression and psychological illness. Evidence shows that many smokers are too stressed by the hard economic times to attempt to stop smoking.
Smoking in pregnancy is relatively common, although reported data shows a down ward trend over time.
Despite evidence of considerable under-reporting of smoking in pregnancy, data is obtained using self report, which does not reliably indicate prevalence or its rate of decline. National guidance recommends the use of biochemical methods such as cotinine testing to validate results.
There have been remarkable achievements in tobacco control in England in the past decade, including prohibiting most tobacco advertising and establishing the NHS stop smoking services.
The smoking ban created a new context for this work and a drive for further action. Smoking rooms in hospitals are now consigned to history, which may help prevent former smokers relapsing back to smoking after the baby’s birth.
Although these interventions largely target the population as a whole, the government has invested heavily in the smoke free pregnancy agenda.
Recently smoking and pregnancy has gained a wider platform and the momentum for change has developed. Improvements are easily overlooked. Previously a barrier to quitting was the lack of nicotine replacement therapy support, formerly contraindicated in pregnancy. Usage in pregnancy received a vote of confidence by the Medicines for Health Regulatory Agency in 2006 and the National Institute for Health and Clinical Excellence in 2008.
Increasingly the CO monitor has a place in the midwife’s toolkit when used as a motivational tool. An effective intervention is providing financial incentives; voucher reward schemes are increasingly being piloted by primary care trusts. Many are also exploring social marketing approaches to engage pregnant women with support services.
Smoking and pregnancy is high on the UK’s annual smoking cessation conference agenda. A welcome development is support from the national support teams for tobacco control and infant mortality. Local services should be developed in line with NST recommendations for good practice.
Looking to the future, the government’s next tobacco control strategy is likely to include an ambitious new target. ASH recommends setting the target only after an independent measure of smoking in this population has been established. NICE will publish new guidance on smoking and pregnancy next year.
In May the DH recommended the development of new programmes to support cessation before and during pregnancy, and which are specifically focused on the less well off. The author recommends that the government appoint/identify a national lead to drive forward the smoke free pregnancy agenda.
Carmel O’Gorman is midwifery lead for smoking cessation in pregnancy at Heart of England Foundation Trust and NHS Birmingham East and North.