Key learning points:
– Smoking during pregnancy presents numerous serious negative consequences for both mother and baby, which extend from birth through to childhood
– There is evidence that many pregnant women want to quit and would like support to do so
– Every contact with a pregnant woman counts as a valuable opportunity to intervene with pregnant smokers and encourage them to quit
The fact that smoking is dangerous is no longer headline news. Cigarettes are laden with thousands of hazardous chemicals, from arsenic to formaldehyde. It is well established that smoking significantly increases the risk of cardiovascular disease, chronic obstructive pulmonary disease and several forms of cancer, from lung to bladder.
Smoking remains one of the leading causes of avoidable death, and treating smoking related illnesses places a tremendous financial burden on the NHS (estimated £1.5 billion annually).1 Despite these widely recognised risks, approximately 20% of the current UK population continue to smoke.2 Even greater concern is that approximately 26% of pregnant women continue to smoke immediately before or during pregnancy, with 13% smoking through to the point of delivery.3 The true prevalence of maternal smoking during pregnancy is likely to be even higher, as pregnant women may under report their smoking due to stigmas associated to smoking during pregnancy. Not only are these women at increased risk of the general harms associated with smoking, but also several additional pregnancy specific risks. Smoking during pregnancy presents numerous serious, negative consequences for both the mother and her baby. Women who smoke during their pregnancy are at increased risk of: complications during labour, miscarriage, premature and still births, low birth weight and sudden infant death syndrome (SIDS).4 The negative consequences associated with fetal exposure to tobacco smoke into childhood, and include increased risk of respiratory infections, asthma, obesity, early onset adult diabetes, and high blood pressure. The detrimental effects are not only physiological, but also include negative consequences on behavioural and educational performance, such as attention and hyperactivity issues.5 It is important that healthcare professionals understand the serious toll associated with smoking during pregnancy. Women are more likely to smoke during pregnancy if they are younger (i.e. less than 20 years of age), less educated, and work in routine and manual occupations.
Pregnant women are also more likely to smoke if they live in a household where at least one other person smokes, particularly their partner.6 Furthermore, having a partner who smokes has been shown to make it harder for pregnant women to quit, and increases the likelihood of relapse in mothers to be who do manage to quit.7 Partner smoking also magnifies the potential risk to the fetus or newborn baby of the harms associated with smoking by increasing exposure to second hand smoke. There is evidence that compared to non-smoking households, babies are at an increased risk of dying from SIDS from paternal, rather than maternal smoking.8 Therefore, it is critical that healthcare professionals consider the smoking behaviour of the whole household, not just the mother-to-be.
Communicating these risks
The National Institute for Health and Care Excellence (NICE) has published guidelines on quitting smoking in pregnancy and following childbirth.9 The guideline states that every contact with a pregnant woman, including all pre-conceptual care meetings, routine antenatal appointments, and chance encounters count are a valuable opportunity to intervene with pregnant smokers and encourage them to quit.
There are two types of support available to help smokers quit: pharmacological (i.e. nicotine replacement therapy (NRT), varenicline, zyban) and behavioural support interventions. There is limited, good evidence supporting the use of smoking cessation medications in pregnancy.10 However, many of these medications are contraindicated in pregnancy, with the exception of NRT, which should only be used with pregnant smokers if the advantages outweigh the disadvantages, and in those who have a failed unaided quit attempt.9 In contrast, there is evidence that behavioural support interventions can help pregnant smokers to successfully quit.5 Behavioural support can be either intensive or brief and aims to maximise a smokers motivation to quit, facilitate relapse prevention and coping. In the UK, intensive behavioural support is widely available via the NHS stop smoking services, which offer free weekly one-to-one or group support sessions with trained, specialist advisors. Many of these services also provide specialist behavioural support services tailored to the needs of pregnant smokers. Brief behavioural support interventions, also known as very brief advice (VBA), are often delivered by a range of healthcare professionals, over a few minutes, and typically involve three simple steps:
1.Asking whether someone smokes.
2.Advising them of the risks and the importance of quitting.
3.Offering assistance to quit.
VBA interventions have also been shown to be highly effective when delivered by a range of healthcare professionals, including nurses and midwives.11
NICE guidance recognises nurses and midwives have an important role in supporting pregnant smokers to quit by delivering VBA and initial support, given their wider role in health counselling and education for the woman, family and community. The guidance specifically recommends healthcare professionals routinely coming into contact with pregnant smokers:
– Ask: Identify pregnant smokers by assessing/documenting/discussing exposure to tobacco smoke and conducting an expired-air carbon monoxide test.
– Advise: Provide brief opportunistic smoking cessation advice, including information on risks to the unborn child while pregnant, and hazards of second-hand smoke.
– Assist: Offer/arrange a referral to an NHS stop smoking service, at subsequent appointments, check whether the woman took up her referral and progress with quitting.9
However smoking and pregnancy is a sensitive issue, which is not always easy to raise or discuss. Studies have shown that many professionals worry about the negative impact discussing smoking might have on the relationship they have with their clients, and some feel that it is not their role to make women feel potentially more anxious or guilty.12 This is a valid concern, however, it is important to note that there are also studies demonstrating that many pregnant smokers actually want to quit and want more advice and support on smoking cessation than they currently receive.13 Furthermore, the recommendations set out in the NICE guidelines do not involve making a woman feel guilty or pressured. Rather, delivering VBA should be viewed similarly to providing advice on diet, alcohol or place of birth. The aim is to educate and provide information that enables a woman to make an informed choice, but not to coerce or make decisions on her behalf. Without such knowledge, pregnant women may be unwittingly causing severe harm to themselves or their babies.
Another common concern is the additional time taken to deliver such VBA interventions alongside other clinical responsibilities in a time constrained consultation. VBA interventions only take a few minutes to deliver, arguably less time than required for other routine procedures. Given the serious negative consequences of smoking in pregnancy, arguably time should be dedicated to discussing smoking cessation. It is important to note that VBA, as outlined in NICE recommendations, does not require the nurse or midwife to actually provide the intensive smoking cessation support, but rather, to raise the issue and refer onto dedicated services. This ‘assist’ component of VBA interventions is arguably the most important, as there is evidence that smokers are much more likely to quit with an offer of support (e.g. a referral) compared to those who are just advised to quit.11 More positive results have been achieved with an opt-out referral approach rather than an opt-in approach.10 An opt-out approach ensures all pregnant smokers will receive an offer of additional support, which they would otherwise not receive if they were not referred. Clients are always free to decline the support when contacted.
Therefore, the question remains as to how to effectively deliver VBA without taking up too much time or causing awkwardness? The National Centre for Smoking Cessation and Training (NCSCT) provides an easy to access training and accreditation package for all healthcare professionals wishing to improve their knowledge and confidence in delivering smoking cessation support. It also provides specialist training modules for smoking cessation in pregnancy and VBA (see Resources section for more information). In summary, the VBA training recommends that:
– If the woman’s smoking status is unknown, a simple question such as, “do you smoke at all?” can establish their status. If the smoking status is already documented, it can be asked: ‘I see from your notes that you’re a smoker, are you still smoking?’ If they are recorded as ex-smokers, it is vital to re-check as approximately 70% of ex-smokers will eventually relapse
within a few years, further questions that can be used are: “According to your records you quit smoking, how are you getting on with that?”
– When ‘advising’ it is important to take the perspective of educating not judging or coercing, for example: “Ok, I am not sure whether you are aware, but there are several negative consequences to you and your baby of smoking during pregnancy, and it is entirely your choice, but we know that the best way to stop is with extra support, which is available in the NHS. This makes it much more likely for you to succeed.”
– When ‘acting’ if the client is interested in further support you can say: “That is great, here is the number for your local stop smoking service. All you need to do is call this number and they’ll put you in touch with someone who can arrange treatment and support”
– Some women simply won’t be ready to stop. Therefore, if
gentle persuasion doesn’t work, it’s important to remain positive and reassure that “help will always be available if they change their mind.”
– Lastly, raising the issue of smoking cessation might prompt the woman to talk extensively about their smoking. Given time constraints, it might not be possible to fully support the woman at the time. It is acceptable to cut this discussion short, by highlighting that smoking is important and should be discussed in a dedicated consultation, ideally with a stop smoking advisor, and providing the necessary contact details for the local stop smoking service.
Smoking in pregnancy has a potentially devastating toll on a mother and her baby. Spending a few minutes asking, advising, and assisting on smoking cessation in a sensitive manner can make a significant difference in pregnancy, birth, and childhood.
Resources
National Centre For Smoking Cessation and Training: online training: elearning.ncsct.co.uk
National Centre For Smoking Cessation and Training: ncsct.co.uk
References
1. Twigg L, Moon G, Walker S. The smoking epidemic in England. Health Development Agency, 2004.
2. Smoking in England. Cigarette smoking prevalence 2015. smokinginengland.info/ (accessed 20 August 2015).
3. The NHS Information Centre. Infant Feeding Survey 2010: Early Results. Health and Social Care Information Centre. Report number: 1, 2011.
4. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking Health. The health consequences of smoking: A report of the Surgeon General. U.S. Dept of Health and Human Services, 2004.
5. Lumley J, Chamberlain C, Dowswell T, Oliver S, Oakley L, Watson L. Interventions for promoting smoking cessation during pregnancy 2009. DOI: 10.1002/14651858.CD001055.pub3 (accessed 24 August 2015).
6. Penn G, Owen L. Factors associated with continued smoking during pregnancy: analysis of socio-demographic, pregnancy and smoking-related factors. Drug and Alcohol Review 2002;21(1):17-25. DOI: 10.1080/09595230220119291 (accessed 24 August 2015).
7. Fang W L, Goldstein AO, Butzen AY, Hartsock SA, Hartmann KE, Helton M, Lohr JA. Smoking cessation in pregnancy: a review of postpartum relapse prevention strategies. The Journal of the American Board of Family Practice 2004;17(4):264-275. DOI: 10.3122/jabfm.17.4.264 (accessed 24 August 2015).
8. Klonoff-Cohen HS, Edelstein SL, Lefkowitz ES, Srinivasan IP, Kaegi D, Chang JC, Wiley KJ. The effect of passive smoking and tobacco exposure through breast milk on sudden infant death syndrome. The Journal of the American Medical Association 1995;273(10):795-798. DOI: 10.1001/jama.1995.03520340051035 (accessed 24 August 2015).
9. National Institute for Health and Clinical Excellence. Quitting smoking in pregnancy and following childbirth 2010. nice.org.uk/guidance/ph26 (accessed 20 August 2015).
10. Brose LS. Helping pregnant smokers to quit. British Medical Journal 2014;348:g1808. DOI: http://dx.doi.org/10.1136/bmj.g1808 (accessed 20 August 2015).
11. Aveyard P, Begh R, Parsons A, West R. Brief opportunistic smoking cessation interventions: a systematic review and meta-analysis to compare advice to quit and offer of assistance. Addiction 2012;107(6):1066-1073. DOI: 10.1111/j.1360-0443.2011.03770.x (accessed 20 August 2015).
12. McLeod D, Benn C, Pullon S, Viccars A, White S, Cookson T, Dowell A. The midwife’s role in facilitating smoking behaviour change during pregnancy. Midwifery 2003;19(4):285-297. DOI: 10.1016/S0266-6138(03)00038-x (accessed 24 August 2015).
13. Ussher M, West R, Hibbs N. A survey of pregnant smokers’ interest in different types of smoking cessation support. Patient Education Counselling 2004;54:67-72. DOI: 10.1016/S0738-3991(03)00197-6 (accessed 24 August 2015).
