SMOKING IN PREGNANCY

Transcription

1 ESSEX COUNTY COUNCIL SMOKING IN PREGNANCY HEALTH NEEDS ASSESSMENT 2017 A health needs assessment of women who smoke during pregnancy in Essex. It includes an epidemiological profile, the current service provision, local and national policy, views of stakeholders and recommendations for improving outcomes.

2 2 Smoking in Pregnancy: Health Needs Assessment 2017 DOCUMENT CONTROL Date Version Amendments Name 20 October Document set up Molly Thomas-Meyer 17 February First draft complete Molly Thomas-Meyer 22 February PAH addition Molly Thomas-Meyer 23 February Edited following Molly Thomas-Meyer commissioner review 9 March Edited following Molly Thomas-Meyer consultant review 16 March Amendment Molly Thomas-Meyer 8 June Ready to be published Molly Thomas-Meyer ACKNOWLEDGEMENTS Many thanks to those who contributed advice, data, information and perspectives to this needs assessment. Particular thanks go to the following: Petra Lastivkova, Provide Hannah Taylor, ECC Chris French, ECC Danny Showell, ECC The Public Health team, ECC Clare Bailey, Smoking Specialist Midwife, CHUFT Thanks to all those who took part. Smoking in Pregnancy health needs assessment, ECC June 2017 Any questions from this report, please contact: Molly Thomas-Meyer, Public Health Specialty Registrar Molly.thomas-meyer@essex.gov.uk

3 Smoking in Pregnancy: Health Needs Assessment CONTENTS CONTENTS... 3 EXECUTIVE SUMMARY... 5 THE PROBLEM... 9 METHODOLOGY DEFINITIONS SECTION ONE: WHY DOES THIS MATTER? Evidence of Harm Poor birth outcomes in Essex Who smokes and why? The benefits of giving up? Evidence for giving up: what works? SECTION TWO: POLICY AND RECOMMENDATIONS Policy: National and Local Initiatives Guidelines and Recommendations SECTION THREE: FACTS AND FIGURES How many women smoke during pregnancy in Essex? Where are the smokers? How has this changed over time? Who are the pregnant smokers in Essex? How many women stop smoking in pregnancy in Essex? Data Summary SECTION FOUR: WHAT SERVICES ARE AVAILABLE? Current situation Smoking cessation provider: Provide Other cessation services for Southend and Thurrock UA residents The NHS Acute Trust referral pathways SECTION FIVE: PERSPECTIVES Stakeholders views Pregnant women Midwives and acute trust staff Smoking cessation staff at Provide SECTION SEVEN: REPORT RECOMMENDATIONS APPENDIX ONE EXAMPLE OF PAPER FORM INCLUDED IN BOOKING NOTES APPENDIX TWO... 58

4 4 Smoking in Pregnancy: Health Needs Assessment 2017 EXAMPLE OF INFORMATION LEAFLET PUBLICISED BY REGIONAL GROUP APPENDIX THREE SATOD DATA FOR INDIVIDUAL PCT/CCG AREAS BY QUARTER, APPENDIX FOUR QUESTIONS SUBMITTED TO SENIOR MIDWIVES AT EACH NHS ACUTE TRUST APPENDIX FIVE DATA COLLECTION METHODS SURVEY, SUPPLIED BY PROVIDE. COMPLETED SUMMER REFERENCES... 70

5 Smoking in Pregnancy: Health Needs Assessment EXECUTIVE SUMMARY SITUATION In 2015/16, about one in ten of all women who were pregnant in Essex were smokers at the time of delivery: 9.8% (confidence interval 9.3% to 10.3%). This was significantly below the government s target of 11%. The actual number identified as smokers at delivery during this period was just below 1500 across Essex. In the last ten years Essex has mirrored the national picture in terms of the proportion and downwards trend of women who smoke in pregnancy. There is a large difference between the proportions of pregnant women identified as smokers between the CCG areas: 6.5% in West Essex to 14.2% in North East Essex in 2015/16. These are, respectively, some of the lowest levels in the East of England region, and the second highest. In 2015/16, in Essex, of 283 pregnant women who set a quit date, 142, or 50%, successfully reported they had stopped smoking. This was similar to the national figure. A third of women reported they were unsuccessful and 17% were lost to follow up. Overall, 12% of all pregnant women who set a quit date were CO validated as having quit (35 out of 283). Since the new smoking cessation provider, Provide, was appointed in Essex in April 2016, outcomes suggest that the proportion of women who stop smoking once they have set a quit date remains stable, but the absolute numbers entering the service and agreeing to quit has declined. This decline in smokers entering traditional services is in evidence across the country. It is rather early to determine why this might be. 777 women were referred from the five NHS acute trusts to Provide over a nine month period between April and December 2016, where there is data available. Referral numbers from the five Essex NHS trusts vary widely: 21 during the nine month period from Princess Alexandra Hospital Trust in Harlow to 316 from Colchester Hospital Foundation Trust. Women who smoke in pregnancy in Essex are likely to be younger and from a lower socio-economic status than average, if they follow the pattern of the national situation. It is not possible currently to verify this from routinely available local data.

6 6 Smoking in Pregnancy: Health Needs Assessment 2017 CURRENT PROVISION All five acute NHS trusts in Essex have an identification and referral system for pregnant smokers that broadly reflect the main aspirations of the current national guidelines and recommendations. The five acute NHS trusts all use CO monitoring as the basis of their smoker identification and cessation discussions with pregnant women. The acute trusts have referral systems which vary in terms of process, efficiency and their ability to effectively refer all pregnant women who smoke. One Essex acute NHS trust has a specialist smoking midwife, who works 7.5 hours a month on this topic. She is based at Colchester Hospital. Smoking cessation advice and support is currently provided for Essex residents by Provide, a community provider based in Colchester. They have been the provider since April They are commissioned by Essex County Council. Provide run clinics throughout the county. They have a lead who acts as a liaison between the trusts and the smoking cessation service. There is no difference between the service offered to this client group as opposed to any other. Women receive on average eight weeks of support following their decision to stop smoking. They receive free NRT prescriptions if they choose to use it to aid their quit attempt. GAPS AND IDENTIFIED PROBLEMS Currently the smoker identification and cessation pathway fails a large proportion of pregnant women who smoke in Essex: There are many women who are identified as smokers by the acute NHS trusts but are not referred to the relevant smoking cessation services. Approximately five in ten women (54%) who were identified as smokers at the four trusts who submitted data during April to October 2016, were not referred onwards to smoking cessation services. Princess Alexandra Hospital NHS Trust had the lowest number of referrals as a percentage of the women identified as smokers at booking between April and August Colchester Hospital NHS Foundation Trust had the highest proportion to a single provider, Provide. Basildon & Thurrock University Hospitals NHS Foundation Trust had a similarly high proportion from its combined referrals process, to Provide and NELFT (which covered residents from both Essex County Council and Thurrock UA areas.). There is a large number of women who choose not to try and stop smoking following their referral to the smoking cessation services. Of the 777 women who were referred to Provide from April to December 2016, 84% did not set a quit date to stop smoking.

7 Smoking in Pregnancy: Health Needs Assessment It is difficult to get women successfully through the pathway. Of the 777 referrals to Provide from five acute trusts between April to December 2016, 62 (8%) reported they had quit after 4 weeks. Service provider stakeholders cite time pressures, IT complications, resource shortfalls, confidence in delivering support, lack of communication between midwives and cessation services, lack of women s knowledge of risks from smoking, overcomplicated pathways and referral processes, as contributors to the very varied referral rates across the five acute trusts in Essex, and the difficulty of encouraging those who are referred into setting a quit date. Time consuming and complicated referral systems and pathways appear to be a key issue for midwives. They also cite lack of time and resources such as training in how to approach the topic in women who are reluctant to consider stopping. Pregnant women spoken to cited general satisfaction with the referral and cessation service, but a number had not had their CO monitored. The numbers spoken to for this assessment were too small to be a reliable sample, but indicate that the use of systematic CO monitoring may need to be audited across the trusts. Very little is known about the local demographics of women who smoke while pregnant in Essex, and similarly about the reasons they have for not wanting to stop smoking or why they may be unsuccessful in quitting. This is due to limited routine data and the difficulties in engaging with this hard to reach group. Data collection processes and the quality of data about smoking status vary greatly between the five acute NHS trusts in Essex. This has affected the assessment s ability to get an accurate picture of some aspects of the needs of pregnant smokers in some areas of Essex. Measuring pathway outcomes from identification to quit attempts is currently difficult. This has recently improved with the introduction of the smoking at time of booking (SATOB) indicator and provider data. However any definitive conclusions are limited by the short period of this dataset and limited number of trusts that provided it. RECOMMENDATIONS Develop a strategy involving all relevant stakeholders to increase the awareness and priority level of smoking in pregnancy in Essex. Identify specific targets and map how to achieve them in order to bring about change. ECC to facilitate meetings with each trust and CCG to encourage engagement and, in partnership, plan how best to proceed in each area, and how best to support their efforts. Encourage trusts to prioritise stopping smoking amongst pregnant women as a goal for maternity departments and support them to do this. For example, mandating stop smoking

8 8 Smoking in Pregnancy: Health Needs Assessment 2017 training for midwives and staff, or formulating targets with performance indicators to encourage cessation efforts, consider appointing a public health midwife to work on issues such as smoking in pregnancy. Nominating a named midwife in each acute trust maternity unit to act as a point person for the community cessation provider and ECC, and with whom to discuss feedback on performance and outcomes. This person could also lead on performance of the maternity unit, and report to the Quality team/head within the trust. Each trust should ensure there is at least a paper based referral form that is readily available to all midwives. It should contain the basic data information and referral contact information. It should be opt out only. The submission process should be easy, systematic and timely to minimise time between identification, referral and follow up. The information governance should not hold up the dissemination of data to the relevant partners. Identify other opportunities to raise smoking cessation when women are attending health care appointments during pregnancy. For example, consider widening training to other staff members working in acute NHS trusts. For example, receptionists, HCAs. Data ensure that smoking at time of booking and delivery indicators (SATOB and SATOD), are collated systematically and promptly, and returned to the relevant information teams. Raise the priority of stopping smoking amongst the public in Essex: especially pregnant women and their friends, partners and families. Conduct an evidence based review to identify examples of effective and cost efficient communications strategies or tools that could be used in Essex. For example, in social marketing and new media strategies to raise awareness and encourage quitting. Research evidence for specific effective and cost efficient interventions to help increase quitting rates. Assess the costs involved and possible benefits of those that look feasible. For example, offering free NRT to partners of pregnant women. Consider carrying out a review to fill the current knowledge gap about the demographics of pregnant Essex smokers. This is needed to inform efforts for considering targeted efforts to identify and encourage women to stop. For example, quantitative methodologies could be done to assess location, age and socio-economic status of pregnant smokers in Essex, while qualitative work could be done using focus groups or interviews to assess what interventions would be most effective and utilised. Investigate the reasons for the pathway gaps identified: the difference between the numbers of smokers identified and referrals received, and the reasons why women who are referred commit in low numbers to setting a quit date. Continue pathways review from identification to smoking cessation with the various stakeholders, with a view to streamlining and improving the pathways for implementation, and working out a plan to embed them in each local area. For example: increasing links between the midwives and smoking advisors to communicate about individual patients.

9 Smoking in Pregnancy: Health Needs Assessment THE PROBLEM There is a wealth of evidence that has shown strong associations between poor birth, and development, outcomes in children born to mothers who smoke, as well as a level of increased risk for women who are exposed to smoke passively. Healthcare and public health organisations from international 1 to national and local levels 2 advocate cessation during pregnancy as a key prevention strategy in improving maternal and child health. In 2015/16 the rate of smoking in pregnancy in England fell below the government s 2011 target of 11% for the first time -- to 10.6%. However, there is wide variation across the country: from 1.5% of new mothers living in Westminster, compared to 26% of mothers in Blackpool. 3 Nationally an estimated 67,000 infants were born to women who smoked while pregnant in 2015/16: of those were resident in the Essex local authority region. That is, in 2015/16, one in ten pregnant women in Essex was identified as a smoker at the point of delivery: 9.8% (confidence interval 9.3% to 10.3%). Essex has seen a decline in smoking in pregnancy in recent years. This is in line with the long-term national picture, and in 2015/16 was also below the government-based target of 11% smoking in pregnancy. While this is encouraging it masks a large range within the county: 6.5% identified as smokers at delivery in West Essex, to 14.2% in North East Essex in the same period. This suggests there are different levels of need within Essex. Very little is known about this cohort of women in Essex and what their specific demographics are, and smoking cessation service requirements. There are also issues around data completeness and quality. In order to help women stop smoking they must, first and foremost, be identified and referred to the appropriate cessation service. However, while one in ten pregnant women in Essex smoke during pregnancy, they are not all coming to the attention of smoking cessation services. 5 It is hard to track the women who smoke during pregnancy through to referral outcomes, but barely half of women identified as smokers at four of the Essex acute trusts were referred to their relevant smoking cessation team, during the period the data is currently available. Furthermore, the process of encouraging women to quit smoking in pregnancy is difficult. Only one in every six women who was referred to the main cessation provider in Essex 1 World Health Organisation. WHO Recommendations for the prevention and management of tobacco use and secondhand smoke exposure in pregnancy Accessed at on 1 December See page 19 3 ONS Statistics on Women s Smoking Status at Time of Delivery England. Quarter 4, June Accessed 26 October 2016 at 4 Smoking in Pregnancy Challenge Group. Smoking Cessation in Pregnancy: A Review of the Challenge October Accessed at on 1 December % of maternities (count:1484) from Essex, excluding Southend and Thurrock. NHS Digital Search?productid=21116&q=smoking+in+pregnancy&sort=Relevance&size=10&page=1&area=both#top

10 10 Smoking in Pregnancy: Health Needs Assessment 2017 decided to set a quit date between April and December 2016: that is 16% of the total number of referrals. 6 Achieving a successful quit is also difficult, and this is true in Essex as it is across England. In 2015/16 about half of pregnant women in Essex managed to stop smoking after four weeks having decided to stop: similar to the national outcomes. 7 So what can be done to increase referrals and support successful outcomes? Women who are pregnant come into contact with lots clinicians and other staff across the health care system during the span of their pregnancy, providing many opportunities for identification, interventions and support for all types of health and social issues. In any routine pregnancy a woman will have at least eight appointments between the initial dating scan appointment and initial postnatal follow up. There will be more in higher risk pregnancies. Pregnancy is thus a teachable moment. 8 There are many health care professionals that can identify smokers, deliver information and support quit attempts. Midwives in particular are ideally placed to help secure these public health outcomes due to this unique contribution 9 that they make to women and babies lives, as well as to the partners and families, during this pregnancy and post natal period. However, local evidence in this assessment shows that although recommended strategies are largely in place across the county, the pathway from identification to referral and support in quitting does not happen systematically, reliably, or ultimately successfully for many women. Stakeholders cite time pressures, IT complications, resource shortfalls, confidence in delivering support, lack of women s knowledge of risks from smoking, overcomplicated pathways and referral processes, as all contributing to the very varied referral rates across the five acute trusts in Essex, and the difficulty of encouraging those who are referred into agreeing to quit. There is an opportunity right now for commissioners and service leads across the county to prioritise smoking in pregnancy, and to come together to support midwives and cessation providers carry out the evidenced and recommended guidelines. This will enable those who identify pregnant smokers to feel confident and supported in delivering information, make timely and robust referrals, and encourage women to stop smoking during every stage of 6 Data from Provide. 777 referrals and 124 setting a quit date from April to December In Essex in 2015/16: of the 283 women who set a quit date during their pregnancy in Essex during this period, 142 reported they had quit after four weeks. Carbon monoxide (CO) verification was confirmed in 12% of the original cohort who set a quit date: 35 out of the original A third who set quit dates reported they did not succeed, and about a fifth were lost to follow up. In England, for the same period 45% of pregnant women who set a quit date were self-reported quitters after 4 weeks in 2015/16, and 24% of those who set a quit date were verified by a CO reading. 31% self reported they did not succeed. NHS Digital at Accessed 25 October World Health Organisation, WHO Recommendations for the prevention and management of tobacco use and second hand smoke exposure in pregnancy Accessed at on 1 December Chief Nursing Officers of England. Midwifery 2020: Delivering Expectations Accessed at 17 November 2016

11 Smoking in Pregnancy: Health Needs Assessment pregnancy and after birth. It will allow stop smoking services to act on referrals and use their skills to inform, encourage and support women to stop for good. It has the potential to improve poor birth outcomes, reduce healthcare needs, and give children a healthier start.

12 12 Smoking in Pregnancy: Health Needs Assessment 2017 METHODOLOGY The aim of the health needs assessment was to describe the epidemiology of smoking in pregnancy in Essex in as much detail as possible, and compare it to the regional and national context; identify current recommended best practice guidelines; chart the current service pathways and provisions around identification of smokers and cessation services; identify gaps or problems with provision, and suggest specific measures which could help to increase the number of referrals and successful quits. We firstly used routine data to determine the local situation at county and CCG level, and used provider data to try and chart the path from identification to eventual outcomes. We spoke to stakeholders including: acute trust midwives and midwifery heads, CCG commissioners, pregnant women who smoke and are trying to stop, smoking cessation service advisors and LA based commissioners. This was to determine qualitative data regarding service experience, pathways, service provision and suggestions for improvements. We conducted a search of current recommendations and recent international and national strategies. We determined service provision at each acute trust, and from the smoking cessation provider, and compared it against national good practice and recommendations. We compiled a list of recommendations to all with a view to increasing the numbers of successful quit attempts in and beyond then antenatal period. DEFINITIONS SATOB smoking at time of booking. Experimental data that has been collected from NHS acute trusts since It is not currently available routinely from all trusts and for all months. SATOD smoking at time of delivery. Long established measure that records smoking status shortly after delivery CO carbon monoxide: a toxic gas that binds preferentially to haemoglobin in the blood and will prevent the transfer of adequate oxygen across the placenta to the baby. In high enough levels it is fatal. High levels detected using a screening breath test may indicate that a person has been exposed to cigarette smoke. Setting a quit date (SQD) early on in the counselling process, smoking cessation advisors encourage someone to set a date when they will commit to stop smoking. The aim is for the smoker to set a definite goal to stop, which can increase the chance of them adhering to their target. A Quit a person is classified as having successfully quit smoking at the four week follow-up if they report not having smoked at all since two weeks after the quit date. It is self reported by the participant. It can then be verified using the CO breath test. CO verification until recently smokers have self reported that they have quit smoking (usually at 4 weeks). Now this can also be verified by using a CO meter to record the carbon monoxide reading from their breath. A reading above 4 ppm (most agree this is the cut off point for referral) or 7 ppm (NICE recommended level) is considered to be unusual in a non smoker.

13 Smoking in Pregnancy: Health Needs Assessment SECTION ONE: WHY DOES THIS MATTER? Evidence of Harm Smoking is the biggest single modifiable risk factor for poor birth outcomes, and a major cause of inequality between the different socio economic groups of mothers and children. 10 Evidence from several decades strongly suggests that smoking is associated with elevated risk to the unborn child and baby, increases the risk of complications in birth and labour, and adversely affects the future of the mother and child. Smoking in pregnancy is associated with increasing the risk of specific serious problems for mother and baby, including: Complications during labour increased risk of miscarriage premature birth still birth low birth-weight sudden unexpected death in infancy 11. In 2011 a report by the Royal College of Physicians 12 used a wide range of studies, systematic reviews and meta-analyses to assess the harms from smoking. It estimated that annually smoking caused the following outcomes based on a smoking prevalence of 20% in the UK: 2,200 premature births ,000 miscarriages 300 perinatal deaths Studies differ on the level of increased risk smoking may contribute to these poor outcomes. This is partly explained by the multifactorial risks that are often responsible for these outcomes, but also the difficulty in untangling the particular contribution that any one risk factor might make. However, one large US study in 2010 looked at 3.3 million singleton maternities, and found smoking more than doubled the association between smoking and, both, low birth weight and sudden infant death syndrome (SIDS), compared to not smoking. 13 Studies have shown for some time that smoking is associated with low birth weight in newborns, and low birth weight is an important recognised factor in infant and child 10 Smoking in Pregnancy Challenge Group. Smoking Cessation in Pregnancy: A Review of the Challenge October Accessed at on 1 December Royal College of Physicians Smoking and the Young Accessed at 3 January Tobacco Advisory Group, Royal College of Physicians. Passive Smoking and Children Accessed 23 October Low birth weight: adjusted odds ratio 2.3, confidence interval , and SIDS: adjusted odds ratio 2.7, confidence interval Dietz et al. Infant Morbidity and Mortality Attributable to Prenatal Smoking in the U.S. Am J Prev Med 2010;39(1):45 52). Confidence intervals 95% unless otherwise stated.

14 14 Smoking in Pregnancy: Health Needs Assessment 2017 morbidity and mortality 14. A large well designed Swedish study from 2013 found that children born at term to mothers who smoked weighed between g less than mothers who did not smoke. They found too an apparent dose response effect: that is, mothers who smoked less than 10 cigarettes a day had babies whose weight was less affected than those whose mothers smoked more. Mothers who gave up smoking during pregnancy were shown to go on to have babies whose weight was less affected, than those who relapsed back to smoking. 15 The risk of stillbirth when women smoke has been considered in various systematic reviews and meta analyses 16. A 2015 meta-analysis by Marufu et al calculated smoking was associated with increased odds of 47% of stillbirth (confidence interval (CI) ) 17. A second meta-analysis in 2011 showed that smoking was associated with a 36% increase in the odds of a stillbirth (CI ). This study focussed on studies from high income countries including the UK. 18 An England based cohort study of 92,000 singleton births found that smoking was associated with an 80% elevated risk of stillbirth compared to non-smokers (CI ). 19 The harm smoking causes continues into childhood and beyond, since it is also associated with: respiratory conditions; attention and hyperactivity difficulties; learning difficulties; problems of the ear, nose and throat; obesity and diabetes 20 The evidence on the effects of a women experiencing smoke second hand, as a passive smoker, are often harder to pinpoint due the varied situations and proximity to the smoker. Generally the size of the effect of passive smoking is smaller than from active smoking, and therefore very large studies are needed to show a true effect. However an extensive review 21 of the evidence by the Tobacco Advisory Group of the Royal College of Physicians in 2010, found that passive smoking is likely to have the same types of risks associated with those of active smoking, albeit of a smaller magnitude. The evidence showed that passive smoking reduces birth weight by 30-40g. It may also reduce fertility, increase foetal and perinatal 14 Centers for Disease Control Accessed at 15 February And Godfrey et al. Estimating the costs to the NHS of Smoking in Pregnancy for Pregnant Women and Infants, PH Research Consortium. University of York, Juarez SP, Merlo J (2013) Revisiting the Effect of Maternal Smoking during Pregnancy on Offspring Birthweight: A Quasi-Experimental Sibling Analysis in Sweden. PLoS ONE 8(4): e doi: /journal.pone Many include a majority of cohort studies 17 Marufu et al. Maternal smoking and the risk of still birth: systematic review and meta-analysis BMC Public Health201515: Flenady V et al. Major risk factors for stillbirth in high-income countries: a systematic review and metaanalysis Lancet 2011; 377: Gardosi J et al. Maternal and fetal risk factors for stillbirth: population based study. BMJ 2013; 346:f Lowry et al, Smoking in Pregnancy Challenge Group. Smoking Cessation in Pregnancy: A Call to Action Accessed at on 15 November They used systematic reviews and meta analyses, or did their own, and used randomised control trials preferentially to minimise bias and confounders.

15 Smoking in Pregnancy: Health Needs Assessment mortality and increase the risk of some congenital abnormalities, but the evidence was not so conclusive or clear cut. 22 The costs to the NHS of the effects of smoking on maternal and infant outcomes are considerable. A study in 2010 estimated the cost of poor maternal outcomes from smoking at between 8 and 64 million for top level HRG NHS Reference costs, and million for infant outcomes chiefly those attributable to low birth weight and premature babies. 23 These costs were estimated against a smoking prevalence in pregnancy which is higher than currently, but health costs have increased in the intervening years. The wider costs to society, such as in education, social care and the judicial system, for example, will increase this total. Poor birth outcomes in Essex In England and Wales the stillbirth rate in 2015 was 4.5/1000 total births. 24 This rate has been declining in recent years, but the declines across the UK have been slower than in other high income countries, and it still remains higher than for many other high income countries In 2014 there were 55 stillbirths across the five CCG areas within Essex 27. The most recent MBRRACE-UK perinatal mortality surveillance report compared the adjusted rates for still birth and perinatal deaths, (together classed as extended perinatal deaths), in 2014 for all the local health commissioning organisations in the UK locally this was by CCG areas. By area: Basildon & Brentwood, Mid Essex, North East Essex and Thurrock s rates of stabilised and adjusted extended perinatal mortality rates were found to be 10% higher than the UK average; while Castle Point & Rochford and West Essex s rates were 10% lower, and Southend s rate was more than 10% lower. 28 Between 2011 and 2016, smoking has been a noted factor in nearly three quarters (21 out of 29) of the sudden unexpected unexplained deaths which predominantly occurred in children 22 Tobacco Advisory Group, Royal College of Physicians. Passive Smoking and Children Accessed 23 October Godfrey et al. Estimating the costs to the NHS of Smoking in Pregnancy for Pregnant Women and Infants, PH Research Consortium. University of York, ONS Accessed at marytablesenglandandwales/2015#the-number-of-stillbirths-decreased-in-2015 on 3 January acteristicsinenglandandwales/ MBRRACE-UK Perinatal Mortality Surveillance Report UK Perinatal Deaths for Births from January to December Accessed at PMS-Report-2014.pdf 3 January UK Parliamentary research briefings Accessed at on 3 January ONS. Number of all live births and stillbirths in singleton births by Clinical commissioning group in England and local health board in Wales, 2012 to Accessed at mberofbirthsinsingletonbirthsbyclinicalcommissioninggroupinenglandandlocalhealthboardinwales2012to2014 on 15 February MBRRACE-UK Perinatal Mortality Surveillance Report UK Perinatal Deaths for births from January to December Accessed at PMS-Report-2014.pdf 3 January 2017

16 16 Smoking in Pregnancy: Health Needs Assessment 2017 under one in the Southend, Essex and Thurrock area. Smoking was the most frequently identified factor in these cases, and partners, as well as mothers, who smoke during and after the pregnancy were specifically referenced. 29 In 2014 in the Essex local authority area, 1181 babies were born that were at a low birth weight (below 2500g). This is 7.2% of the total live and stillbirth maternities (CI 6.8%- 7.6%). The rate was not significantly different from the England or regional equivalent. Babies who weighed less than 1500g at full term in Essex numbered 206 during this period (1.3% CI 1.1%-1.4%); again, this is similar to the national and regional figures. 30 Who smokes and why? Smoking in pregnancy is inversely associated with age and affluence. Teenager mothers are at least five times more likely to smoke than their older counterparts, and mothers classed as being in manual occupations, or have never worked, are at least four times more likely to smoke than those from the professions NICE states that these social and environmental determinants have an effect not only on the smoking behaviours of many women, but also on their attempts to stop: Many of the women most likely to smoke during pregnancy live in circumstances that make it more difficult for them to quit. 33 A literature search found three systematic reviews of qualitative studies that have investigated the views of women towards smoking, and giving up or not giving up during pregnancy. 34 The following major themes were identified by the reviews. Women were generally aware that smoking increases the risk of harm to an unborn child, even if they did not have a full understanding. For some this did not mean the knowledge of risk would lead to change. Smoking behaviour was firmly embedded in their lives in terms of their lifestyle, behaviours and environment. For example, their own long term behaviour and those of their families and friends, and where they work and live. The influence of partners and their smoking status, and level of support they were or were not willing to give to any quit attempt, was considered important by the women in determining their own smoking behaviour. 29 Child Death Review Annual Report : Essex, Southend and Thurrock Office of National Statistics. Compendium of Population Health Indicators, Identifier P Accessed at 14 February Lowry et al, Smoking in Pregnancy Challenge Group Smoking Cessation in Pregnancy: A Call to Action Accessed at 15 November NICE Smoking: stopping in pregnancy and after childbirth PH26 (2010). Accessed at on 21 October NICE Smoking: stopping in pregnancy and after childbirth PH26 (2010). Accessed at on 21 October Ingall G et al (2010) Exploring the barriers of quitting smoking during pregnancy: A systematic review of qualitative studies. Women and Birth. 23, Flemming K et al (2014) Smoking in pregnancy; a systematic review of qualitative research of women who commence pregnancy as smokers Journal of Advanced Nursing 69(5), Graham H et al. (2014) Cutting down: insights from qualitative studies of smoking in pregnancy Health and Social Care In the Community 22(3),

17 Smoking in Pregnancy: Health Needs Assessment The influence of wider family and friends was important to how women thought of smoking and whether it would encourage or dissuade them from stopping. They often trusted personal experience over medical advice. For example women doubted smoking caused harm to babies because they knew of many examples of babies who had been born in apparent good health. Smoking was seen by some as a key way to exhibit control within their lives, and a way to control stress and anxiety. Quitting was seen as difficult and not something that was desired, because of the change in behaviour, environment and relationships they felt it would require. Pregnancy was often seen as an opportunity to cut down the number of cigarettes smoked, because quitting was considered too difficult and not desired. This was framed as harm reduction. Smoking was often associated with feelings of guilt and stigma, as there was a perceived and felt tension between the identities of mother and smoker. Enablers to quitting included having both a strong sense of identity and a stable living environment. Barriers included a belief that an individual did not have the necessary willpower to stop; a perception that stop smoking provision could be judgemental, and that quitting had high personal and environmental costs and was not unambiguously positive. For example changing a relationship with a partner if they still smoked. The benefits of giving up? Evidence differs on the amount of benefit that occurs when women stop smoking in pregnancy, but generally found better birth outcomes such as improved birth weights, and lower risk of stillbirth and premature births. A Cochrane systematic review in 2009 found that successful smoking cessation during early pregnancy lead to a significant 17% reduction in the relative risk (CI ) of low birthweight babies and 14% in preterm births (CI ) Lumley et al, Interventions for promoting smoking cessation during pregnancy Cochrane Database, PMC, Accessed at on 23 November 2016

18 18 Smoking in Pregnancy: Health Needs Assessment 2017 babyclear Newcastle and Teeside University led a recent evaluating of an intervention called babyclear which was introduced in Its purpose was to try and reduce the high SATOD figures in the North East using recommendations from the NICE guidance. The intervention was funded by the local tobacco control office and NE Strategic Health Authority. It involved training for antenatal staff, systematic identification of smokers and using an opt-out referral system ie using a total system wide approach. The study ran between 2013 and 15 and has reviewed changes in referral rates, quit rates, birthweight, and cost effectiveness from before and after the introduction. Data from 10,594 smokers within a group of 37,726 mothers was analysed. The full study has not yet been published, however interim results report that referrals were 2.5 times higher (adjusted odds ration: 2.5, CI ) four months after the baseline level. The odds of quitting were 1.8 after introduction: 80% higher (adjusted odds ratio 1.8, CI ). Babies born to women who quit during pregnancy were 6% heavier (CI %) than those who continued to smoke: that is about 200g. Thirty pregnant women need to be treated (pregnant smokers) in order to secure an additional quit. The cost is estimated at 938 per quit. Since the introduction SATOD rates have declined at a higher rate than the national figures. The study was funded by the NHS National Institute for Health Research. Evidence for giving up: what works? In 2009, a Cochrane systematic review and meta-analysis found that interventions to stop smoking in late pregnancy were associated with a further 6 in 100 women quitting smoking compared to not taking part in interventions. However there were significant differences between the studies methods being compared. 36 An update in 2013 by the same collaboration found that psychosocial interventions such as counselling, particularly in conjunction with other strategies, were significantly more likely to lead to stopping smoking in late pregnancy compared to usual care ( % CI ). 37 Incentives seem to have a positive effect on increasing quitting rates for the period the incentive is given. However this conclusion from a 2015 systematic review and meta-analysis included a majority of trials taking place in the United States. 38 Nicotine replacement therapy (NRT) is currently offered to pregnant women, although NICE recommends it is used by this group only if they cannot quit without it. It does not appear to harm the unborn child. 39 Despite this, evidence shows that quitting smoking is hard for pregnant women and evidence shows that relapse rates are high in the immediate postpartum period Lumley et al, Interventions for promoting smoking cessation during pregnancy Cochrane Database, PMC, Jul 8;(3):CD doi: / CD pub3. Accessed on 31 January Chamberlain C et al Psychosocial interventions for supporting women to stop smoking in pregnancy Cochrane Database Syst Rev Oct 23;(10):CD doi: / CD pub4.. Accessed on 31 January Cahill K et al. Incentives for smoking cessation Cochrane Database Syst Rev May 18;(5):CD doi: / CD pub5.Accessed on 31 January NICE Smoking: stopping in pregnancy and after childbirth PH26 (2010). Accessed at on 21 October Clare Meernik et al. A critical review of smoking, cessation, relapse and emerging research in pregnancy and

19 Smoking in Pregnancy: Health Needs Assessment SECTION TWO: POLICY AND RECOMMENDATIONS Policy: National and Local Initiatives In 2011, the Government s Tobacco Control Plan set a target of reducing smoking in pregnancy rates to 11%. That was achieved in 2015/16 with 10.6 % of mothers in England recorded as smokers at the time of delivery. 41 A new tobacco control policy has been expected since 2016 with a new lower target, but this has so far not been announced. In February last year, the NHS England National Maternity Review was published which set out the vision for maternity services as the partner for the Five Year Forward Plan. It noted improvements in services and outcomes, but stressed the increasing importance of preventative work particularly in smoking -- as the biggest single modifiable factor in poor birth outcomes. 42 Midwives have been identified as a key part of this objective due to the unique contribution 43 that they make to women and babies lives, as well as the partners and families, during the pregnancy and postnatal period. Public Health England is working with NHS England to achieve a 50% reduction of stillbirths by This is set out in the document: Saving Babies Lives: Stillbirth Reduction Care Bundle. A cornerstone of the care bundle is smoking cessation, carbon monoxide screening at booking and other antenatal appointments, and referring those with elevated levels for support to stop smoking. 44 In 2015, the Smoking In Pregnancy Challenge Group reported on the work that had been done since its initial review in The group was set up in 2012 to address this specific issue, and includes several Royal Colleges, the third sector and academics. The new report noted good progress, and an increased priority for this issue within the NHS and Public Health England. However it highlighted the importance of ensuring local activity is vigorous and system wide. It noted a lack of engagement of many CCGs, which posed a problem since they are key in procuring acute maternity services. It also pointed out that other groups like obstetricians, health visitors and GPs could take a stronger role in addressing smoking in pregnancy. It called for a halt to the erosion of specialist stop smoking services due to budget pressures within local authorities, and an effort to resolve post-partum. Br Med Bull (2015) 114 (1): DOI: Published: 29 April Accessed at on 31 January NHS Digital. Statistics on women s smoking status at time of delivery, England Quarter 4, Accessed at 9 November NHS England. National Maternity Review, Better Births: improving outcomes of maternity services in England, February Accessed at accessed 22 November Chief Nursing Officers of England. Midwifery 2020: Delivering Expectations Accessed at 17 November NHS England. Saving Babies Lives: stillbirth reduction care bundle Accessed at on 1 December 2016.

20 20 Smoking in Pregnancy: Health Needs Assessment 2017 possible ambiguity over roles and responsibilities of stakeholders within the cessation pathway. It suggested a new target of 6% for pregnant smokers by A Maternity Clinical Network and a Smoking in Pregnancy (SIP) Network are in place in the East of England region. The quarterly SIP meeting allows SIP leads and other stakeholders to discuss local and national progress and share knowledge and good practice. CO monitoring is seen as a key strategy, and recent discussions have centred on midwife training for delivering key messages, producing new infographics for women and pathway improvements. Since 2015, NHS trusts now contribute smoking at time of booking data (SATOB) to the established smoking at time of delivery dataset (SATOD). SATOB is part of the monthly Maternity Services Dataset to monitor and improve quality outcomes in maternity and obstetrics departments. Various NHS organisations have identified smoking cessation in pregnancy within their outcomes and indicator priorities, both directly and as part of the effort to reduce stillbirths. The NHS Outcomes Framework is a mandate where the Secretary of State holds NHS England to account for improvements: indicator 1c in Domain One of the framework prioritises reducing the numbers of neonatal mortality and stillbirths. A key way to affect this will be to reduce smoking rates in pregnancy. 46 The CCG Improvement and Assessment Framework 2016/17 lists SATOD and reducing neonatal deaths and stillbirth rates as indicators in order to improve health and save NHS costs. 47 SATOD is an indicator included in the Public Health Outcomes Framework by Public Health England because of the increased risk smoking and passive smoking contribute to poor pregnancy and birth outcomes. Budget pressures and increased demand have put mounting pressure on the finite resources of the health care system. As a result, there has been a strategic shift to increase emphasis on prevention in order to conserve finite resources. Cutting smoking rates is seen as an important part of improving health across the population and reducing future healthcare and social costs. To this end: tackling smoking is a top priority for many of the local Sustainability and Transformation Plans (STPs) and is recommended by Public Health England in its Menu of Preventative Actions for this purpose. 48 Locally, the Essex County Council ECC Corporate Plan has a clear outcome of improving public health and wellbeing. This includes encouraging health and active lifestyles and tackling the wider causes of ill health, which includes smoking. 45 Smoking Cessation in Pregnancy: A Review of the Challenge. October Accessed at on 1 February Department of Health. NHS Outcomes Framework Accessed at on 23 November NHS England. CCG Improvement and Assessment Framework 2016/17. Accessed at on 23 November Selbie, D. Blog on PHE website, 6 December Accessed at on 4 January 2017 and accessed on 1 February 2017.

21 Smoking in Pregnancy: Health Needs Assessment Guidelines and Recommendations As set out below, carbon monoxide monitoring has been adopted by many agencies as a key way to identify women who smoke during pregnancy. It also aids verification of self-reported quit attempts. The 2016, the Savings Babies Lives (NHS England) report stressed the importance of CO monitoring as a cornerstone of ascertaining smoking status. It recommended that equipment and training of midwives must be provided so they can conduct a CO test and deliver the up to date key messages. Midwives need to have enough time to carry out the CO test and deliver key messages during the appointments. Referrals to smoking cessation services must be on an opt out basis, and the pathway should include follow up processes. 49 Public Health England has recommended all STPs should consider a menu of preventative initiatives including: all pregnant women should be screened for smoking via carbon monoxide monitoring at booking and subsequent prenatal appointments, and referred for support to quit at the earliest opportunity using an opt out system. 50 In 2010 the National Institute for Health and Care Excellence (NICE) published Quitting Smoking in Pregnancy and following childbirth (PH26 Guidance). It highlighted the identification of all pregnant women who smoke, and delivery of local stop smoking support services to them. The recommendations are aimed at different groups of stakeholders. Some of the major points within the recommendations are highlighted below as well as the recommended pathway in Figure 1: Recommendation 1 51 and 2: Identify pregnant women who smoke (including those who stopped two weeks previously) and refer them to the appropriate cessation service This should be done at booking appointment and subsequent appointments Done in conjunction with CO monitoring Provide information about risk of smoking Stress it is normal to refer on to smoking cessation service Identify if partner or someone else in household smokes Refer all women who: smoke and those who have stopped in previous two weeks, who have a CO reading higher than 7ppm (although a lower reading should also be referred if woman is a light smoker). At subsequent appointments check if woman took up referral and if not, ask again WHO SHOULD DO THIS: Midwives, but also referrals should be encouraged and made by all those across the extended health care system, pharmacies, community and social services. Recommendation 3: NHS Smoking cessation services need to contact the referrals and offer encouragement, information and support to stop smoking 49 NHS England. Saving Babies Lives: stillbirth reduction care bundle Accessed at on 1 December Public Health England, Local health and care planning: menu of preventative interventions November Accessed at on 4 January See Figure 1 pathway below

22 22 Smoking in Pregnancy: Health Needs Assessment 2017 This should be done by telephone, and an attempt to see those who cannot be contacted by telephone Address any factors that are preventing taking up the cessation offer: eg lack of information or low confidence Provided structured self help material if the woman is reluctant to attend Send information to those who opt out Encourage partners to stop Provide the woman with ongoing and intensive support including the use of telephone support and on line Apps WHO SHOULD DO THIS: Smoking cessation services Recommendation 4: smoking cessation services need to provide initial and on-going support The recommendation outlines the approaches that have been shown to be effective (eg CBT) and advises the steps of an encounter between the advisor and the woman. These include: o Establishing smoking habits of the woman and who else in household smokes o Provide information about risks o Address concerns o Encourage other family members to quit if present o Provide intensive and on-going support o Use CO monitoring during the whole process o Record method used to quit and follow up 12 months later after quit date o Establish links with the antenatal and postnatal services (amongst others) to ensure they area aware of the stop smoking service and how to refer WHO SHOULD DO THIS: Smoking cessation services Recommendation 5: use of NRT and other pharmacological support States that evidence about success using NRT is mixed, and therefore it can be prescribed if advisor thinks it might help. Should be prescribed once stopped smoking. Full risks and benefits should be discussed. WHO SHOULD DO THIS: Smoking cessation services Recommendation 6: the smoking cessation service should meet the needs of the disadvantaged pregnant women who smoke. This should be done in part by ensuring services are flexible, and work in partnership with the relevant other agencies who support women with complex social and emotional needs. WHO SHOULD DO THIS: Smoking cessation services Recommendation 7: address whether partners and others in the household smoke. Provide clear information about the harms to the baby from passive smoking, and offer support and encouragement to stop WHO SHOULD DO THIS: Smoking cessation services and identification by midwives Recommendation 8: training to deliver these interventions including training for all midwives (and health care workers across the system) to approach, identify and talk to women about these issues, and cessation advisor level training for those midwives who deliver intensive stop smoking interventions. WHO SHOULD DO THIS: smoking services and maternity services amongst others.

23 Smoking in Pregnancy: Health Needs Assessment NICE Guidance PH 48 concerns Smoking Cessation in Secondary Care, Maternity and Mental Health (2013). These 16 recommendations include: o Strong leadership and management to ensure secondary care premises remain smoke free o Identifying people who smoke at the first opportunity; advising; providing support; following up o Ensuring continuity of care so that the support in secondary care continues in community based settings, and vice versa

24 24 Smoking in Pregnancy: Health Needs Assessment 2017 Figure 1: NICE recommended referral pathway from maternity services to NHS Stop Smoking services Source: NICE Guidance PH26, 2010

25 Smoking in Pregnancy: Health Needs Assessment The National Centre for Smoking Cessation Services (NCSCS) supports smoking cessation services nationally. They recommend a three step process for midwives to follow based on CO monitoring, and referring all those with readings above 4ppm (parts per million). 52 The suggested very brief advice process is shown in the figure below. They recommend the importance of recording information about smoking status, and identifying and encouraging the woman s friends and family who smoke to give up too in order to increase her motivation. The need for ongoing support is stressed as the relapse rate for this group is high, and continuing CO monitoring is a powerful tool in this process. Figure 2: NCSCS Very Brief Advice Model for midwifery staff Source: NCSCS 52 McEwen, A. National Centre for Stop Smoking Services, Smoking Cessation: a briefing for midwifery staff, Third Edition Accessed at on 1 December 2016.

26 26 Smoking in Pregnancy: Health Needs Assessment 2017 An alternative model that has gained favour with local services is shown below. This model is based on Test, Question and Refer, and places more emphasis on carbon monoxide screening as the initiator of the smoking discussion between a midwife and a woman. Figure 3: Ask, question, refer model of identifying women who smoke in pregnancy Source: East of England Smoking in Pregnancy Group A note on e-cigarettes E cigarettes are a new phenomenon and there is anecdotal evidence that pregnant women use them in preference to cigarettes if they do not wish to stop smoking completely while pregnant 53. Evidence on their safety long term in pregnancy is not available yet, but the advice currently being given is that it is preferable to smoking tobacco-based products because there are less chemicals inhaled. However even though nicotine itself is thought to be comparatively a lesser risk, it may still present an elevated risk to the foetus, and so fully quitting is always preferable 54. The Smoking in Pregnancy Challenge Group has prepared an info-graphic for pregnant women which is included in APPENDIX TWO. It was authorised for use within the East of England region in autumn Smoking in Pregnancy Challenge Group Use of electronic cigarettes in pregnancy Accessed at on 10 January National Centre for Smoking Cessation and Training. Electronic cigarettes: a briefing for stop smoking services January

27 Smoking in Pregnancy: Health Needs Assessment SECTION THREE: FACTS AND FIGURES 55 How many women smoke during pregnancy in Essex? Just under one in ten pregnant women who live in Essex were recorded as smokers in 2015/16. That is, 9.8% of women who live in the Essex local authority area were identified as smokers at the time of delivery (confidence interval 9.3% to 10.3%). In actual numbers 1484 women were recorded as smokers out of a total 15,138 maternities in this period. *56 This figure meets the government-based target set in of 11% or less by 2015, and shows that the Essex proportion is significantly lower than this target. It is slightly lower than the Midlands and East England regional average of 10%, and an English average of 10.6% during the same period. In 2015/16, the prevalence of smoking in the whole adult population was 17.6% in Essex, compared to 16.9% in England. As shown below in Figure 4. Figure 4: smoking prevalence in adults -- current smokers in Essex East of England region England Essex Southend-on-Sea Thurrock Smoking Prevalence in Adults - Current Smokers in Essex (2015) 16.6% 16.9% 17.6% 18.8% 21.3% 0% 5% 10% 15% 20% 25% Percentage smoking Source: ECC Health and Social Care Intelligence Team The latest figures (Q2 2016/17) show that the national target for women smoking in pregnancy has been maintained: 10.4% of all maternities were identified as smokers. 55 All data from this section if from NHS Digital unless otherwise stated. * However, it should be noted that 2.8% of women has a smoking status that was not known at the time of delivery. Before 2017 they were included in the denominator which may skew the findings. From April 2017 the unknown group will not be counted within the denominator. It should also be highlighted that the delivery status assumes they smoked during pregnancy. 56 NHS Digital. Statistics on Women s smoking at time of delivery 2015/16. Accessed at Search?productid=21116&q=smoking+in+pregnancy&sort=Relevance&size=10&page=1&area=both#top 57 Department of Health, HM Government Healthy Lives, Healthy People: A Tobacco Control Plan for England, March 2011

28 28 Smoking in Pregnancy: Health Needs Assessment 2017 Where are the smokers? The data across Essex shows a wide variation within the county as shown below in Figure 5. West Essex recorded 6.5% women as smokers at the time of delivery, and North East Essex was 14.2% in 2015/16. Statistically, the range of the outcomes shows that Basildon and Brentwood reported results not significantly different from the English average. However, Castle Point and Rochford, West and Mid Essex had significantly lower rates, while North East Essex showed a significantly higher result than the national figure. Figure 5: percentage of maternities recorded as smoking at time of delivery (SATOD) in Essex by CCGs Percentage of MaterniLes Recorded as Smoking at Time of Delivery in Essex Essex average NHS West Essex NHS Thurrock NHS Southend Nadonal ambidon 11% NHS North East Essex NHS Mid Essex NHS Castle Point and Rochford NHS Basildon and Brentwood NHS England Midlands and East England 0% 2% 4% 6% 8% 10% 12% 14% 16% Percentage smoking Source: NHS Digital

29 Smoking in Pregnancy: Health Needs Assessment Since early 2015 the number of women who are recorded as smoking at the time of booking (usually week 8-10 of pregnancy), has been collected by many NHS trusts and collated nationally by NHS Digital. The indicator is called SATOB. This provides national surveillance of smokers identified at the start of pregnancy, and therefore the potential referrals to smoking cessation services can now be identified and compared between NHS trusts. 58 Local SATOB data shows that there is also a level of variation in pregnant women in Essex recorded as smokers between the acute trusts that submit this data. In 2015/6, Colchester Hospital University NHS Foundation Trust and Basildon and Thurrock University Hospitals NHS Foundation Trust had the highest percentage of women identified as smokers at time of booking about 16% of the women that booked. The lowest percentage of those smoking was in Princess Alexandra Hospital NHS Trust and Southend University Hospital NHS FT about 10%. Please note Mid Essex NHS Trust did not submit SATOB data during this period, and some trusts did not submit it for every month. Figure 6: percentage of maternities smoking at time of delivery recorded by acute trusts in Essex Percentage of MaterniLes Smoking at Time of Booking in Acute Trusts in Essex * Southend University Hospital NHS Foundadon Trust The Princess Alexandra Hospital NHS Trust NHS England Midlands and East (East) Basildon and Thurrock University Hospitals NHS Foundadon Trust Colchester Hospital University NHS Foundadon Trust 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% Percentage smoking * Mid Essex NHS Trust has not submitted this data for this period. And Southend data is only available for 4 out of the 12 months Source: NHS Digital 58 It should be noted that smoking at time of booking data is experimental and has only been collected since early It is not available for all local trusts and in all months. For that reason is it classed as experimental data and should be treated with some caution.

30 30 Smoking in Pregnancy: Health Needs Assessment 2017 Regionally the East of England areas range from 3.2% women identified as smokers at delivery in Ipswich and East Suffolk CCG, to 17% in Great Yarmouth and Waveney CCG. This is illustrated in Figure 7 which includes the national target of 11%. Figure 7: percentage of maternities recorded as smoking at time of delivery in the East of England region by CCGs in Percentage of MaterniLes Recorded as Smoking at Time of Delivery in East of England Region by CCGs in % 16% 14% Percentage smoking 12% 10% 8% 6% 4% 2% 0% Source: NHS Digital The national context is illustrated in Figure 8 below. The highest proportions of smokers were identified in the North East and North West of England, and some coastal areas of Suffolk and Kent.

31 Smoking in Pregnancy: Health Needs Assessment Figure 8: proportion of women known to be smoking at time of delivery by CCGs in England Essex Source: ONS

32 32 Smoking in Pregnancy: Health Needs Assessment 2017 How has this changed over time? Over the last decade there has been a gradual decline in the number of pregnant smokers in Essex, consistent with the national trend, as shown in Figure 9 below. Figure 9: annual percentage of maternities smoking at time of delivery in Essex and England Percentage smoking 25% 20% 15% 10% 5% 0% Percentage of MaterniLes Smoking at Time of Delivery in Essex (2004/ /16) 2004/ / / / / / / / / / / /16 Essex England Source: NHS Digital Over the period of the last three years, the majority of CCG areas have each reported a largely consistent proportion of their maternities as being smokers most recorded a change no greater than 2% between 2013/4 and 2015/16. The noticeable exception to that is West Essex CCG which has shown a large drop in the percentage recorded as smokers from over 12% in 2013/14 to 6.5% in 2015/16. This is shown in Figure 10. Figure 10: percentage of maternities recorded as smoking at time of delivery in Essex by CCGs Percentage of MaterniLes Recorded as Smoking at Time of Delivery in Essex Percentage smoking 16% 14% 12% 10% 8% 6% 4% 2% 0% 2013/ / /16 Source: NHS Digital

33 Smoking in Pregnancy: Health Needs Assessment Looking in greater detail at individual areas in Essex over a longer period, Figure 11 below shows a general downwards trend in most places since records were first kept in 2004/5. Generally, the individual areas of the Essex have followed the England-average pattern of an overall lowering of smoking at delivery figures from 2004 to the present. However there is a noticeable variation between the various PCT/CCG areas. North East Essex has consistently reported the highest levels since 2006, compared to other areas in Essex. North East Essex shows a large reduction in 2012/13 from a peak of over 20% recorded as smokers in 2009/10. This coincided with the introduction of a smoking cessation midwife in 2009 for 15 hours per week, and a CQUIN to refer a target of 4000 smokers to the cessation services. Mid Essex, up until 2013/14, consistently appeared to have some of the lowest levels in the county, but in the intervening years this is now less obvious, as other areas have had even lower or broadly similar results. However it is important to note that there are missing results for many of the areas within that time frame (which is shown as gaps in the graph lines and blank squares in Figure 11). Additionally a restructuring of local health commissioning areas in 2013 means that redrawn boundaries for some of the new CCG areas may not make entirely accurate comparisons with the PCT predecessors. Individual CCG/PCT graphs by quarters are included in APPENDIX THREE.

34 34 Smoking in Pregnancy: Health Needs Assessment 2017 Figure 11: percentage of women smoking at time of delivery in Essex PCT/CCGs Smoking at Time of Delivery in Essex PCT/CCG Areas % 20% Percentage smoking 15% 10% 5% 0% 2004/ / / / / / / / / / / /16 England East of England* Mid Essex North East Essex Castle Point and Rochford** Basildon and Brentwood*** West Essex NHS Southend NHS Thurrock Source: NHS Digital Blank squares indicate data is not available for this period. East of England, included the E Midlands from 2015/16 ** Castle Point and Rochford was South East Essex PCT until 2013/14 *** Basildon and Brentwood CCG was South West Essex PCT until 2013/14

35 Smoking in Pregnancy: Health Needs Assessment Who are the pregnant smokers in Essex? Very little local data is available which describes the characteristics of the women who are recorded as smokers. This is a very clear evidence gap in this health needs assessment. National data and studies have described this cohort as tending to be younger than average, and are much more likely to be of a lower socio economic status Pregnant women who smoke are likely to be single, less educated than those who do not, more likely to live in rented accommodation and have partners who smoke. 61 Although some local trusts record person-centred variables such as age, ethnicity and deprivation status of their maternities, it is not available in the nationally collated routine data sources. It was beyond the timescale and scope of this report to request and analyse these on a trust by trust basis. This would be a useful endeavour if targeting populations for specific health services or communications was a priority in future health promotion strategies. A further unknown is the smoking status of a proportion of the women who are pregnant. An average of 2.8% (428) women did not have a smoking status recorded at delivery amongst the 5 Essex based CCG areas in 2015/16. This varied between the areas: 0.2% (6) in Basildon & Brentwood CCG, to 6.4% (219) in West Essex CCG area and 6.8% (122) in Castle Point & Rochford, as shown below in Figure 12. This affects the data quality of course and its validity, and if a significant proportion of them were smokers it potentially also affects the conclusions that can be drawn from the data. Figure 12: percentage of women whose smoking status was not known at time of delivery Percentage of women whose smoking status was not known at Lme of delivery Percentage smoking 8% 7% 6% 5% 4% 3% 2% 1% 0% England Basildon and Brentwood Castle Point and Rochford Mid Essex North East Essex Southend Thurrock West Essex Thurrock had no women with unrecorded smoking status for this period Source: NHS Digital 59 Flemming K et al (2014) Smoking in pregnancy; a systematic review of qualitative research of women who commence pregnancy as smokers Journal of Advanced Nursing 69(5), Lowry et al, Smoking Cessation in Pregnancy: A Call to Action Accessed at 15 November NICE Smoking: stopping in pregnancy and after childbirth PH26 (2010). Accessed at on 21 October NICE Smoking: stopping in pregnancy and after childbirth PH26 (2010). Accessed at on 21 October 2017.

36 36 Smoking in Pregnancy: Health Needs Assessment 2017 How many women stop smoking in pregnancy in Essex? Outcome one: smoking cessation service outcomes after setting quit dates In 2015/16 Essex CCG areas reported that of 283 pregnant women who set a quit date, 142, or 50%, had successfully stopped smoking (self reported at their 4 week follow up appointment). Overall 12% of all pregnant women who set a quit date were CO validated as having quit after 4 weeks (35 out of 283). 33% of women reported they were unsuccessful and 17% were lost to follow up. This compares to national figures of 45% of pregnant women setting a quit date reporting they had stopped after four weeks, and 28% of those setting that quit date being CO validated in the same period. 31% were not successful and 24% lost to follow up. The known outcomes are shown below in Figure 13 as proportions, and compared with the England average. In the same period (2015/16) the range of successful quits from those who set an initial quit date varied across the other LA areas in the East of England -- from 30% (Suffolk) to 76% (Peterborough). Figure 13: proportional outcomes of women who set a quit date locally and England ProporLonal outcomes of women who set a quit date in Essex, and England Essex Thurrock Southend-on-Sea Percentage of successful quiiers (self-reported) Percentage who had not quit East of England Percentage not known/lost to follow up England 0% 20% 40% 60% 80% 100% Source: NHS Digital

37 Smoking in Pregnancy: Health Needs Assessment In comparison with all smokers (men and women of all ages) in 2015/16 across England: 51% reported they were successful at their four week follow up and 36% were CO validated, while 55% successfully quit in Essex and 37% were CO validated. In April 2016 a new community provider called Provide, was commissioned by Essex County Council to deliver smoking cessation services for county s residents. Nine months of data is currently available (April to December 2016). Within that nine month period last year, the smoking cessation provider reported that 124 pregnant women set a quit date, and 62 reported that they had stopped smoking after 4 weeks. This shows a conversion rate of 50% from setting a quit date to successfully stopping, which is the same so far as the 2015/16 proportion overall. This information is shown below by CCG area in Table 1 below. Mid Essex has the highest proportion of those setting quit dates going on to quit, and Basildon & Brentwood the lowest conversion proportion. However overlapping 95% confidence intervals show these differences may not be statistically significant. Table 1: total of women who set a quit date and reported a successful quit by CCGs, April to December 2016 Apr to Dec 2016 Number setting a quit date Number reporting quitting smoking (% of those setting a quit date) Basildon & Castle Point Mid North East West Essex Total Apr to Brentwood & Rochford Essex Essex Dec (28%) 10 (56%) 19 (61%) 22 (52%) 4 (50%) 62 (50%) Source: Provide Although the data is not complete for 2016/17 the absolute numbers setting quit dates and quitting are likely to be lower than the previous year. It is hard at this point to draw conclusion as to why the absolute numbers are down or whether this is significant, but this observation is similarly reflected in data from all groups of smokers locally in the current year 62. Potential reasons may be: lower rates of referrals, less successful engagement of smokers to participate in the smoking cessation pathway (due to various reasons including harder to reach individuals), and the use of e-cigarettes. Outcome 2: pregnancy referrals from acute NHS trusts to the smoking cessation provider, Provide April to December 2016 The new provider of smoking cessation services has collected data by acute NHS trust since April of 2016 when it took over the service provision. In the nine months between April and December 2016, there have been 777 referrals from the five Essex acute NHS trusts to 62 Source: Provide 2016 data

38 38 Smoking in Pregnancy: Health Needs Assessment 2017 Provide for the residents within Essex County Council area. Princess Alexandra Hospital NHS Trust has made 21 referrals during that time, and the highest number was from Colchester Hospital NHS Foundation Trust with 316. The number of pregnant smoker referrals from each Trust is shown below in Table 2 below for 9 months between April and December 2016, and is illustrated in Figure 14. (The denominator of women identified as smokers is not available from each trust for the entirety of this period see Outcome 3 below.) Table 2: monthly pregnancy referral totals from each acute NHS trust in Essex to the local cessation provider, Provide, April to December 2016 Trust April May June July Aug Sept Oct Nov Dec Total 2016 The Princess Alexandra Hospital NHS Trust Colchester Hospital NHS Foundation Trust Mid Essex Hospital Services NHS Trust Southend University Hospital NHS Foundation Trust Basildon & Thurrock University Hospitals NHS Foundation Trust TOTAL 777 Source: Provide Figure 14: monthly pregnancy referrals from Essex NHS acute trusts to smoking cessation service, April to December 2016 Referrals from Essex NHS acute trusts to smoking cessalon service, April to December 2016 Number of referrals April May June July Aug Sept Oct Nov Dec Princess Alexandra Hospital NHS Trust Colchester Hospital University NHS Foundadon Trust Mid Essex Hospital Services NHS Trust Southend University Hospital NHS Foundadon Trust Basildon & Thurrock University Hospitals NHS Foundadon Trust Source: Provide

39 Smoking in Pregnancy: Health Needs Assessment Outcomes 3: Pathway outcomes from acute NHS trusts to smoking cessation services from identification of smokers to referrals April to October 2016 It has only been recently possible to map these referrals against a denominator of women identified as smokers at time of booking by NHS acute trusts, using the SATOB indicator. Approximately 1,220 smokers who live in Essex, Southend or Thurrock, were identified by the four acute trusts that submitted SATOB data during this seven month period, and 558 were referred either to Provide or NELFT depending on their address. (It is not known how many referrals were sent to the Southend stop smoking service. Please note Mid Essex NHS Trust did not submit SATOB data for this period so they are not included in either total above.) This means that very roughly, an estimated 46% 63 of the referrals that could potentially have been made from the four trusts were actually recorded by the relevant smoking cessation provider. Table 3 below shows the individual sources of data for this period: April to October Princess Alexandra Hospital NHS Trust had the lowest number of referrals as a percentage of the women identified as smokers at booking. Colchester Hospital NHS Foundation Trust had the highest proportion to a single provider, Provide. Basildon & Thurrock University Hospitals NHS Foundation Trust had a similar referrals proportion: to Provide and NELFT (which would have covered residents from both Essex County Council and Thurrock UA areas.). This is illustrated below in Figure 15. Both Southend and Princess Alexandra figures are statistically significantly lower than the two other trusts included, and Princess Alexandra is statistically significantly lower than Southend, suggesting these results are not simply due to random chance. Despite the incomplete data and the short time period, this percentage shows that a minority of women who smoke were effectively referred: whether this shortfall is one of inaccurate identification or data collection, or poor referral systems is unclear and beyond the scope of this present assessment. This SATOB data only been available recently, and is currently only available to match with the referral data for a seven month period April to October It should be noted that the denominator is very hard to determine due to the incomplete data return from Southend University Hospital NHS Foundation Trust and Princess Alexandra NHS Trust, general experimental nature of this SATOB data, and of course the short time period which is potentially unrepresentative. It is likely that with more experience using and submitting this dataset, it will become more reliable. Additionally, please note the proportion is likely to be higher if Southend stop smoking services had provided their referrals numbers from Southend Hospital. 63 The percentage has been calculated for the referrals received (April to October 2016) by Provide from each of the four trusts (Basildon&Thurrock, Colchester, Princess Alexandra and Southend), and includes the 115 referrals received by NELFT who provide services for those who live in Thurrock UA. Southend smoking service has not provided the referrals received from Southend Hospital.

40 40 Smoking in Pregnancy: Health Needs Assessment 2017 Table 3: Referrals made by local acute NHS trusts and referrals received by Provide, April to October 2016 April to October 2016 Women identified as smokers at booking (SATOB) Referrals received by Provide (% of SATOB) Referrals received by another provider if applicable (% of SATOB) Basildon & Thurrock University Hospitals NHS Foundation Trust Colchester Hospital NHS Foundation Trust The Princess Alexandra Hospital NHS Trust Southend University Hospital NHS Foundation Trust Mid Essex Hospital Services NHS Trust ** Not available* 115 (29%) 227 (59%) 13 (8%) 88 (33%) (29%)**** Not applicable Not applicable Not available *Mid Essex Hospitals NHS Trust did not submit SATOB data during this period. ** Southend University Hospital NHS Foundation Trust and Princess Alexandra Hospital NHS Trust did not submit SATOB data for one of the months and so this number is likely to be lower than expected *** Southend Hospital staff also refer smokers who live within the Unitary Authority area to the Stop Smoking service provided by the UA despite a request for this referral number the information was not supplied. ****Basildon and Thurrock hospital staff also refer smokers who live within the Unitary Authority area to NELFT that was 115 during this seven month period. Source: NHS Digital, Provide and NELFT Not applicable Figure 15: proportion of referrals to smoking cessation services as a percentage of the women identified by smokers at booking by NHS trust* **, April to October 2016 ProporLon of referrals to smoking cessalon services as a percentage of total women idenlfied as smokers at booking by NHS acute trust, April to October % 60% 50% 40% 30% 20% 10% 0% Basildon & Thurrock University Hospitals NHS Foundadon Trust Colchester Hospital NHS Foundadon Trust The Princess Alexandra Hospital NHS Trust Southend University Hospital NHS Foundadon Trust % of referrals made from those idendfied as smokers at booking by each trust *Mid Essex NHS Trust did not submit this data during the relevant period. **Basildon & Thurrock s total referral proportion is a total of those made to NELFT and Provide during this period. Source: NHS Digital, Provide and NELFT

41 Smoking in Pregnancy: Health Needs Assessment Outcomes 4: overall pathway from initial identification to successful quitting April to December 2016 Trying to chart the outcomes from initial identification of pregnant smokers by acute NHS trusts through to setting quit dates and successful quitting is hard to achieve, due to the gaps and incompleteness of data available. However, from April to December 2017, there were 777 pregnant women referred by the 5 Essex acute NHS trusts. During that time 124 women set a quit date with Provide, and 62 women went onto report they had successfully quit. This translates into a successful outcome in under 8% of those initially identified and referred. As mentioned before, the proportion who set a date and then go onto quit is largely in line with national figures, but this figure suggests how often attempts are unsuccessful, and raises the issue of why that might be. It is beyond the scope of this current assessment to ascertain why referrals do not translate into higher number of women setting quit dates, and whether this is a common occurrence compared to previous years or other areas. Only by further investigation would women s reasons for not entering the smoking cessation support pathway become clearer. Figure 16: outcomes from referrals to successful quits April to December 2016, and the percentages of the outcomes as a proportion of the referrals 777 referrals 124 set a quit date (16%) 62 quit (8%) Source: Provide

42 42 Smoking in Pregnancy: Health Needs Assessment 2017 Data Summary In 2015/16 one in ten pregnant women smoked at the time of delivery in Essex: that is 9.8% (confidence interval 9.3% to 10.3%). It appears from subsequent quarterly data that this is being maintained currently. In actual terms 1483 women who were residents within ECC areas were identified as smokers at the point of delivery in 2015/16. This number rises to 1899 women including Southend and Thurrock UA residents. Essex has mirrored the national picture in the last decade in terms of a gradual decline in SATOD levels. There is a wide variation in SATOD proportions across the various CCG areas: from 6.5% in West Essex to 14.2% in North East Essex. This represents some of the lowest and the highest figures within the East of England region. The lack of a recorded smoking status at time of delivery was highest for women in Castle Point & Rochford, and West Essex CCG areas in 2015/16. This will affect the overall accuracy of the data, and potentially conclusions that can be drawn from it. Little is known about the specific demographics of pregnant smokers in Essex. In 2015/16 Essex CCG areas reported that 50% of pregnant women who set a quit date had successfully stopped smoking (self reported at their 4 week follow up appointment). Overall 12% of all pregnant women who set a quit date were CO validated as having quit after 4 weeks (35 out of 283). 33% of women reported they were unsuccessful and 17% were lost to follow up. This is similar to the national average. The new Essex smoking cessation provider reports a similar conversion percentage of women setting a quit date to successful quits in the last nine months (50% between April to December 2016). The highest conversion proportion from setting a quit date to successfully quitting was in Mid Essex at 61%, while the lowest was in Basildon & Brentwood with 28%. However the absolute numbers of both categories are lower than those at a similar point last year. It is not known for sure why this is. It is also speculation before the full year of data is available. There were a total of 777 referrals from the 5 NHS Essex acute trusts to Provide between April and December Referral numbers from the five Essex NHS trusts vary widely: 21 during the nine month period from Princess Alexandra Hospital Trust in Harlow to 316 from Colchester Hospital Foundation Trust. There is a large gap between the numbers of women identified by the trusts as smokers and the referrals received by the local smoking cessation providers. The data is incomplete and covers a small period, but indicates that between April and October 2016, about 46% of pregnant women identified by four of the Essex acute NHS trusts as smokers were referred to their relevant cessation service. There is a second large gap between the women who are referred and those who then commit to setting a quit date. Between April and December 2016, 16% of women, or one in six, set a quit date from the 777 pregnancy referrals received by the smoking cessation provider. The reasons for this low conversion figure are not known, or whether this is similar to other areas, or previous years, since referral to outcome data is not nationally available.

43 Smoking in Pregnancy: Health Needs Assessment A NOTE ON THE DATA As has been stated throughout this section there are many problems with data in this area. Both in terms of completeness, and accuracy. Below are some issues to keep in mind when considering the data. Key problems with data affecting validity, and the ability to make meaningful comparisons: Variation between CCG areas in the number of women whose smoking status at delivery was not collected. Hard to compare areas with complete accuracy due to change from PCT to CCG footprints in 2013/14. Gaps in data for certain months, at certain Trusts, or data not collected for similar periods of time, for example the SATOB data. There is no standard set of questions about smoking asked of pregnant women for the five NHS trusts in Essex. There is a variable number of smoking questions asked, and number of answer options between each Trust. SATOB is experimental data only available since Only two Essex based Trust have provided relevant data for all the months since then, Mid Essex has no routine data available to date, and other Trusts have gaps. The smoking cessation provider has, only recently collected data such as referrals by trust, and therefore drawing robust conclusions from such a limited period of time is difficult. It has proved difficult to measure outcomes within the smoking referral pathway. This is partly due to the change in providers of smoking cessation service in Essex in 2016, and also due to the variable return of data by local trusts to the national collators which makes determining a denominator hard. There is no easily accessible routine data on the characteristics of pregnant women in Essex who smoke. During the compiling of this section, there were anecdotal reports that at the acute trusts there are issues with data completion: for example, paper and computer sources for collecting information and passing it on are often delayed, information is often not filled in during the time of the appointment, or that CO monitoring is not always achieved due to lack of equipment, training or time pressures. There are varied interpretations of what is the definition of a non smoker and unknown status as well as varied interpretation of the status of those who use e-cigarettes It is beyond the scope of this report to be able to verify this, and a trust by trust audit would be required.

44 44 Smoking in Pregnancy: Health Needs Assessment 2017 SECTION FOUR: WHAT SERVICES ARE AVAILABLE? Current situation Pregnant women who are Essex residents can access smoking cessation advice and support directly from the local smoking cessation service. As anyone else, they can also access cessation support from their GP surgeries and local pharmacists. However most women will be identified and referred to this service by their midwife following their booking appointment which is usually at 7-8 weeks into their pregnancy. Smoking cessation provider: Provide Since April 2016 smoking cessation services across Essex have been provided by Provide. Prior to that it was provided by ACE (North East, South West, South and West Essex) and Provide (Mid Essex). Provide is a community provider, and operates from headquarters in Colchester. Southend UA commissions its own Stop Smoking service, which jointly works with Provide for women at Southend Hospital. Thurrock UA commissions services from NELFT, who with Provide cover Basildon & Thurrock Hospital. Provide are commissioned by the Health and Wellbeing commissioner who is part of the Public Health Team at Essex County Council. Provide offer a free at the point of delivery service, which advises and supports those who want to stop smoking. Provide are contracted to focus on increasing the number of quitters from several priority target groups who experience the largest barriers to giving up smoking, including pregnant women. This means they are charged to work closely with primary, secondary and tertiary care providers to increase referrals and to reduce the numbers of pregnant women who smoke, and their partners. This can be done, for example, by offering support and resources for midwives. Targets are set to achieve the numbers of quitters in all groups including pregnant women. Provide have nine smoking cessation advisors, who conduct a mixture of individual face to face and telephone clinics based across 4 areas of Essex (North, South, East and West). The face to face clinics offer 20 minute appointments, and generally run for several hours although some may be for the whole day. They are based on a broadly Monday to Friday, 9am to 5pm schedule, although there are some clinics that run until 630p and on Saturday mornings. The clinics are located in a range of venues: libraries, community and children s centres, GP surgeries, one in a hospital (Princess Alexandra, Harlow), and the probation service. Evening sessions are done by telephone and tend to be between 6pm and 8pm, and their frequency varies from one per week in the West, to three per week in mid Essex. South and mid Essex areas have Saturday morning telephone clinics. 64 There is no specific advisor assigned to work with pregnant women, and all the advisors can support this cohort. There is one coordinator who oversees the cessation work involving pregnant women, and those with mental illness, including the liaison with the acute trusts. 64 Based on November 2016 schedule provided by Provide

45 Smoking in Pregnancy: Health Needs Assessment Once Provide receive a referral (electronically or paper based) from the hospital, the client will be telephoned within a few days by a member of the triage team. The client will be asked about their smoking behaviour, and an appointment made to see an advisor at a clinic, or by telephone. These subsequent appointments are about 20 minutes in length and take place at one of any number of locations around the county that is convenient to the client s home or workplace. An effort is made to establish a quit date early in the process. Women will have appointments up to once a week for a period of 8 weeks. NRT can be prescribed and it is free for pregnant women. Individual behavioural counselling is available and self help materials. There is one advisor who attends an all day drop in clinic for vulnerable pregnant women at the Youth Enquiry Service in Colchester in partnership with a specialist antenatal midwife from Colchester Hospital, this takes place every other week. If someone does not turn up following a referral, they should routinely receive two phone calls and a letter. Other cessation services for Southend and Thurrock UA residents Southend Unitary Authority runs its own in-house stop smoking service. It is a team of four people. There was a specialist pregnancy advisor until two years ago when she retired and was not replaced. Their referrals are almost always from Southend Hospital. Due to the size of the team these advisors tend to see only the most complex cases, which includes all pregnant women. The advisors have the discretion to continue support for as long as is deemed necessary, throughout pregnancy if required. However staff shortages mean there are few opportunities to liaise with the midwives directly, or follow up those who DNA. The advisors work with Provide to ensure the Southend Hospital referrals are dealt with by the provider which covers the woman s place of residence. The service has not been given a target currently for reducing smoking in pregnancy. Thurrock Unitary Authority commissions its stop smoking service from NELFT, a community provider. This has been the case for a number of years. NELFT tends to see about 5 pregnant women per month, with a yearly target of 40. Their referrals are from Basildon Hospital. Support usually lasts for 10 weeks, but if a woman feels she needs longer term support this can be given. There is a smoking advisor who deals specifically with pregnant clients. Additionally if they lapse they can return immediately to access the service. NELFT work with Provide for women referred from Basildon Hospital so they are contacted by the appropriate provider. The NHS Acute Trust referral pathways Table 4 below gives an overview of the staff numbers and the systems in place to identify, refer, monitor and support women and their smoking status at each of the five acute NHS trusts in Essex. The table was based on information provided by senior midwives from each trust and the smoking cessation provider pregnancy lead at Provide. The questions are included in APPENDIX FOUR, and the initial survey completed by Provide in the summer of 2016 is included in APPENDIX FIVE.

46 46 Smoking in Pregnancy: Health Needs Assessment 2017 Table 4: Overview of staff and systems at the five Essex Acute NHS trusts Number of midwives Access to computers at point of booking Basildon & Thurrock University Hospitals NHS Foundation Trust 161 midwives (WTE), 33 WTE based in the community No. Midwives complete paper referrals Colchester Hospital NHS Foundation Trust 170, with 46 community based midwives Yes, laptop generates automatic referral which is submitted in bulk to Provide nhs.net weekly through data extraction Mid Essex Hospital Services NHS Trust 24 midwives, with 17 based in the community Yes for those based at hospital. Community midwives will complete paper referrals. Currently referrals also submitted via intranet by an individual midwife upon return to the office. The Princess Alexandra Hospital NHS Trust 145 in the unit. 41 in the community (28.6 WTE) Yes, access to laptops at the point of booking. There is no formal referral pathway utilising the electronic system (Cosmic). Currently, an e-referral form is ed by each midwife to Provide via secure . Southend University Hospital NHS Foundation Trust 149 midwives (WTE), 33 in the community (WTE) Yes for Southend UA residents but not for Essex residents. Paper referral part of hand held notes Yes NA Yes to be started shortly No, via . Currently under review Provide s referral for Essex based residents are paper and part of booking pack. (Referrals for Southend residents at booking registration are electronic and opt in, but then opt out when consent requested for a referral at booking appointment) Part of booking pack. Paper referral NA NA Yes although NA separate due to change Average time A Provide The information Once a week, Not known. Referrals are

47 Smoking in Pregnancy: Health Needs Assessment between referral and receiving by Provide representative picks referrals up once a week. is taken from the IT system weekly by the IT midwife and sent to Provide when Provide pick up referrals Referrals ed adhoc. No formal referral pathway currently. picked up once a week by a Provide representative. CO readings taken routinely and recorded Opt out system for CO monitoring/ referrals Training given on CO monitoring and smoking cessation Yes at booking, then followed up at 28 weeks in hand held notes Women encouraged to take CO test whether they smoke or not. Can decline, but referral form is still submitted stating this. Women informed that referral is routine practice. Have to gain consent from the women to share the information. CO training to all midwives. Community staff who have had CO training, then teach the newer staff. General update to all community midwives given summer 2016, and RCM e- learning link. Yes at initial booking appointment, but not subsequently unless requested Yes, opt out only For community and antenatal based midwives only. Further training planned. Midwives supported by a designated smoking in pregnancy midwife. Yes recorded at booking. Yes opt out for monitoring, referrals sent but on form can put that woman does not wish to be contacted. About half of community staff have had CO training, they teach the newer staff. Smoking cessation training had not been done for a long time, however some midwives trained last year and equipment provided. Further training Yes. Women can choose not to be tested or referred. Not all midwives have been trained. Currently planning training sessions in conjunction with Provide. Yes at initial booking appointment, but not subsequently unless requested Yes. Can decline, but referral form is still submitted stating this. Have to gain consent from the women to share the information. CO training to the majority of midwives has been completed within the last year. 49 community midwives received mandatory training from Provide in March New starters have 1:1 meeting with stop smoking service

48 48 Smoking in Pregnancy: Health Needs Assessment 2017 Smoking information recorded at subsequent antenatal visits Is smoking in pregnancy information a KPI at the trust SIP specialist midwife or named midwife responsible Training session offered in Feb 2017, 8 community midwives attended. It is followed up at 28 weeks routinely. No, although SATOD recorded for maternity dashboard. It is flagged up on the IT system so is available during each visit if midwife wishes to pursue The number of women smoking at delivery No Yes. One at 7.5 hours per month. is now planned. Possibly as there is space in hand held notes, but subsequent appointments are 15mins only and need to cover other topics plus examination. No, although SATOD recorded. Occasionally it is discussed but not systematically. Hand held notes currently being reviewed to include space at future appointments. SATOB data is monitored monthly. No No No. lead. Training session offered Feb 2017, 27 community midwives attended. Not routinely. It can be but there is no space in hand held notes The number of women smoking at delivery Mid Essex Hospital Services NHS Trust There are 24 midwives who support women at Broomfield Hospital, as well as the community. The eventual aim is to have referrals done electronically, but currently this is not possible due to waiting for a new computer system (Lorenzo) to be put in place to replace the old PAS system (by Spring 2017). The electronic system currently has lead to a delay between the booking appointment and referrals being made (which lead to only 3 referrals being received by Provide in July of this year). So in the meantime an updated paper based system is to be introduced whereby a smoking status and referral form are integrated within the hand held notes. This is to be completed at the point of booking. The smoking specific referral form can be detached from the notes and sent to Provide, while the status and information is retained in the notes with some informational material on the harms of smoking for the woman to read. The hand held notes have reminders to prompt the midwives to reassess smoking cessation if relevant in subsequent hospital visits. Carbon monoxide testing is done routinely and there is equipment available in all the key areas of the hospital. However not all the community based midwives have their own

49 Smoking in Pregnancy: Health Needs Assessment monitors, and about half have received training. There are minimal information resources for midwives to give to women on harms of smoking/co Basildon & Thurrock University Hospitals NHS Foundation Trust Women are seen at Basildon Hospital and in the community. There are 141 whole time equivalent (WTE) midwives. Of those, 42 midwives are based in the community. The midwives do not have laptops available at the point of antenatal booking appointment. The hand held notes contain information on smoking harms, and there are information sheets available to hand out. There is adequate CO equipment, and each community midwife has her own monitor. The paper referral form is collected weekly from midwives office. The data collected in hand held notes are transferred onto the Evolution system by a clerk, the time frame of recording the data onto the system following the booking appointment can vary significantly. Each midwife records her own notes post-delivery directly onto the Evolution maternity system. The smoking status question is mandatory field (100 % compliance to answer the question, no option of unknown status). Colchester Hospital NHS Foundation Trust There are 170 midwives with 46 based in the community. All the midwives have laptops available at the point of booking appointment and record the data directly on the maternity electronic system Medway. The referrals are paperless, submitted to Provide weekly on an excel spread sheet extracted from Medway. The electronic system Medway prompts a mandatory smoking status question, and prompts further questions at subsequent appointments if smoking status is selected as unknown at the first appointment. The smoking status is asked by a midwife at the point of delivery and recorded directly on Medway. There has been a smoking cessation specialist midwife at Colchester Hospital since Originally she worked 15 hours a month on this issue, but is now at 7.5 hours per month. Southend University Hospital NHS Foundation Trust The midwives do not have laptops available at the point of antenatal booking appointment. The separate Provide paper referral form for Essex County Council residents is collected weekly from the midwives office by the Provide staff, while Southend UA residents will be seen by the Southend Stop Smoking Service for which there is an electronic referral form. The data collected in hand held notes are transferred onto the CSC computer system by a clerk, the time frame of recording the data onto the system following the booking appointment can vary significantly, and can be up to one month. Community midwives have

50 50 Smoking in Pregnancy: Health Needs Assessment 2017 their own CO equipment and the trust is in the midst of providing equipment to the Fetal Medicine and Women s Clinic. The introduction of the CO monitoring has been linked to a possible reduction in SATOD cases, although this is not confirmed. The midwives are provided with information and leaflets to give to pregnant women and training has been rolled out during the last year to the majority of midwives. Educating health care workers and pregnant women is seen by senior midwifery staff as a key step to support cessation efforts. The Princess Alexandra Hospital NHS Trust Princess Alexandra Hospital in Harlow has 145 midwives, with 41 in the community. CO testing is established at the booking stage, but there is currently not a systematic way to record future smoking discussions, and no space in the notes to record them. This is under review. Referrals are currently made via by individual midwives, and there is no formal process in place. A proportion of midwives have had CO training and this will soon be extended through partnership with Provide. There is adequate CO equipment, although community midwives may not have individual monitors. Midwives signpost and use website resources to direct women to GP and Provide cessation services. Midwives are keen to identify and refer women, although there has been discussion as to whether to refer all women or only those who are keen to stop. A key issue is time within the booking appointment: since there are a number of screening and health promotion issues to raise and address.

51 Smoking in Pregnancy: Health Needs Assessment SECTION FIVE: PERSPECTIVES Stakeholders views Pregnant women A total of eight women agreed to talk about their experiences using the stop smoking services for this needs assessment. All were contacted via telephone. They were referred by smoking cessation advisors, after giving their consent to be contacted for this purpose. The women were on average aged 22 and at the beginning of their second trimester, one was at 37 weeks. For half it was their first child, for half it was their second. Those four who were having a second child had struggled with quitting smoking during their first pregnancy and had returned to smoking shortly after the birth. All were long term smokers from their early teens, and all smoked a minimum of twenty cigarettes a day, and half over thirty. Six out of the eight smoked rolling tobacco exclusively. One of the women had recently quit completely with no NRT. The rest had cut down from their previous levels of smoking. Half of the women lived with family or partners who smoke. All were identified at their booking appointment and the referral was completed by their midwife to Provide. Four out of the eight had been monitored for CO at booking, all were questioned about their smoking behaviour. One had had multiple CO tests when they attended each midwife appointment. All of the women said the midwives had spoken to them about quitting: this ranged between briefly she should stop, and another who had an approximately ten minute discussion about the harms. Most of the women had the majority of the harms of smoking explained to them by the smoking cessation advisor. The general time taken to hear back from Provide after seeing the midwife was a few days to a week. Most women had seen their advisor once when they were spoken to for this assessment, and were booked in for subsequent appointments. Meetings consisted of face to face sessions and follow ups over the telephone. Generally the women felt positive about the smoking cessation pathway they had experienced, but were finding quitting completely very difficult despite their knowledge of the risks. They identified various barriers and enablers which had helped and hindered them when trying to stop smoking. Barriers to quitting: Being surrounded by people who smoke: partners, family members, friends and work colleagues. Long held habit and smoking behaviours. For example having a cigarette during a coffee break at work, or when going out in the evening Feeling it is a way to calm down in contrast to dealing with all the other chaos associated with pregnancy Feeling worried about effects of NRT if they tried to stop If get bored is very difficult to resist having a cigarette Can be awkward to get to the stop smoking locations for sessions due to work patterns

52 52 Smoking in Pregnancy: Health Needs Assessment 2017 Enablers for quitting: Reminders that you are doing this for a reason -- specifically the baby s health Feeling scared about what could happen to the baby if continue to smoke Knowledge of the risks of poor birth outcomes See the same advisor during the whole process Peer support When friends, partner or family members do not smoke Having a determined mindset to quit This report was not able to gauge the viewpoints of women who did not choose to be referred or who declined setting a quit date, which unfortunately means a significant group within the needs assessment remain unrepresented. Midwives and acute trust staff Midwifery departments from all five acute NHS trusts were contacted. Senior midwives or maternity matrons from each of the five Essex NHS acute trusts filled out a questionnaire (see APPENDIX FOUR). Face to face meetings took place at two trusts (Mid Essex and Colchester), with groups of midwives -- and some doctors at Colchester. The smoking specialist midwife at Colchester was interviewed. The biggest single problem the midwives identified when trying to encourage women to quit smoking is not having enough time to cover the topic during the booking session. Several midwives said there was little or no time in subsequent appointments. Most of the midwives spoken individually to for this assessment said they addressed the issue in the booking appointment and completed a CO reading. The CO reading was considered a helpful approach in addressing the smoking issue as it was fact driven and felt less judgmental. However a recurring theme mentioned by midwives was that they were not able to cover the specific harms and outcomes in enough detail during the appointments, particularly if a woman was reluctant to stop. Another theme identified was the frustration at the lack of feedback within the pathway. For example there are minimal links between the midwifery departments and the stop smoking advisors regarding the women who are referred. Several midwives described that taking on these issues with women was down to how confident a midwife was in these situations: some people find these kinds of potentially confrontational conversations easier. One midwife said it was easier to deal with female genital mutilation in their patients rather than the topic of smoking, as woman could be more defensive and reluctant to discuss it. A common theme expressed was not knowing how to counter women s beliefs that the risks were not that great, and counterbalancing women s personal experience of smoking with previous normal birth outcomes. Enablers for midwives to encourage quitting:

53 Smoking in Pregnancy: Health Needs Assessment Confidence to address smoking in women when they are reluctant to stop A quick and easy way to refer women A supportive partner who is also keen to stop Information to give to women and a follow up leaflet to reinforce the points. Barriers to encourage quitting: A lack of time to cover all the harms and risks associated with smoking in pregnancy Lack of follow up resources to help support women after they have been identified A lack of confidence to approach the issue when women are aggressive or reluctant to discuss smoking or refuse to consider quitting Worries about alienating women with questions about smoking Women with mental health issues struggle with quitting more, as do those from vulnerable backgrounds: stopping smoking is a very low priority for them an opinion which is hard to reverse or help even if the individual seems open to stopping. Key suggestions for improvement Training in addressing smoking issues with women: both to help educate women about the specific harms of smoking, and also how to respond to women who are reluctant to stop Training in CO monitoring and adequate equipment required at some trusts for health care workers including midwives, clinicians and ancillary staff Feedback and coordination with the smoking cessation service about outcomes Free prescriptions for partners to be considered More follow up resources needed: for example to follow up the women after their first appointments to check on quitting efforts and barriers faced. Smoking cessation staff at Provide All smoking cessation advisors staff and managers received a questionnaire that they could fill out anonymously. Six out of 12 were returned. Two of the advisors agreed to telephone interviews. These were individuals who had specific long term experience in supporting pregnant women stop smoking. One of the monthly meetings for the advisors was attended, which provided a forum for a discussion about this issue between the advisors and staff. The advisors spoken to for this assessment said they saw between two and five pregnant women per month, (one sees more as she runs a clinic for vulnerable women from Colchester Hospital regularly). They tend to see this cohort for an average of five to six follow up sessions. The advisors reported that women rarely refuse to attend, but tend to DNA when they do not engage. All the advisors who contributed to this assessment said they follow up any DNA, but the level of follow up may differ depending on workloads but would meet the minimum requirement.

54 54 Smoking in Pregnancy: Health Needs Assessment 2017 Advisors stated that women who stop tend to so because of anxiety over increased risks to the baby or to the birth. Several advisors mentioned midwives and the information they provide to women as key to the success of the process since women trust this source of advice and heed it. This was felt to help increase the significance of the message both of the risk and behaviour change required. Pregnant smokers who are reluctant to stop were considered some of the hardest to engage with by the advisors -- as it is only being pregnant that is forcing them to consider quitting. This group otherwise enjoy smoking and have done so for a long time. Advisors said women who did not want to quit often stated they saw very little evidence of harm to babies: for example, their mothers smoked, or they have had previous pregnancies without any harmful outcome occurring. Some of the women who are reluctant to stop may cut down or return to smoking as soon as the baby is born. Partners smoking status and their support was mentioned by several advisors as important to the eventual outcome of the quit attempt. Enablers to encourage quitting: NRT and advisor support over the entire period of pregnancy A supportive partner A belief that stopping smoking will harm the baby or complicate the birth The mother understanding the specific risks to the baby Support form midwives as they have a good rapport with the women already and are trusted Barriers to encourage quitting: A lack of motivation caused by a belief that smoking risks are not that great and that smoking is seen as beneficial (helps combat stress, is enjoyable) Unsupportive partners/friends/family Women with complex needs Key suggestions to improvement: Longer appointments for pregnant women who are seen for the length of their pregnancy, and more intensively if required. Free support for partners, including free prescriptions for NRT Increased partnership with the midwives at the five trusts to support women More publicity around the risks of smoking within the public domain Informing midwives of those who DNA so they can follow up at subsequent antenatal appointments

55 Smoking in Pregnancy: Health Needs Assessment SECTION SEVEN: REPORT RECOMMENDATIONS Develop a strategy involving all relevant stakeholders to increase the awareness and priority level of smoking in pregnancy in Essex. Identify specific targets and map how to achieve them in order to bring about change. ECC to facilitate meetings with each trust and CCG to encourage engagement and, in partnership, plan how best to proceed in each area, and how best to support their efforts. Encourage trusts to prioritise stopping smoking amongst pregnant women as a goal for maternity departments and support them to do this. For example, mandating stop smoking training for midwives and staff, or formulating targets with performance indicators to encourage cessation efforts, consider appointing a public health midwife to work on issues such as smoking in pregnancy. Nominating a named midwife in each acute trust maternity unit to act as a point person for the community cessation provider and ECC, and with whom to discuss feedback on performance and outcomes. This person could also lead on performance of the maternity unit, and report to the Quality team/head within the trust. Each trust should ensure there is at least a paper based referral form that is readily available to all midwives. It should contain the basic data information and referral contact information. It should be opt out only. The submission process should be easy, systematic and timely to minimise time between identification, referral and follow up. The information governance should not hold up the dissemination of data to the relevant partners. Identify other opportunities to raise smoking cessation when women are attending health care appointments during pregnancy. For example, consider widening training to other staff members working in acute NHS trusts. For example, receptionists, HCAs. Data ensure that smoking at time of booking and delivery indicators (SATOB and SATOD), are collated systematically and promptly, and returned to the relevant information teams. Raise the priority of stopping smoking amongst the public in Essex: especially pregnant women and their friends, partners and families. Conduct an evidence based review to identify examples of effective and cost efficient communications strategies or tools that could be used in Essex. For example, in social marketing and new media strategies to raise awareness and encourage quitting. Research evidence for specific effective and cost efficient interventions to help increase quitting rates. Assess the costs involved and possible benefits of those that look feasible. For example, offering free NRT to partners of pregnant women.

56 56 Smoking in Pregnancy: Health Needs Assessment 2017 Consider carrying out a review to fill the current knowledge gap about the demographics of pregnant Essex smokers. This is needed to inform efforts for considering targeted efforts to identify and encourage women to stop. For example, quantitative methodologies could be done to assess location, age and socio-economic status of pregnant smokers in Essex, while qualitative work could be done using focus groups or interviews to assess what interventions would be most effective and utilised. Investigate the reasons for the pathway gaps identified: the difference between the numbers of smokers identified and referrals received, and the reasons why women who are referred commit in low numbers to setting a quit date. Continue pathways review from identification to smoking cessation with the various stakeholders, with a view to streamlining and improving the pathways for implementation, and working out a plan to embed them in each local area. For example: increasing links between the midwives and smoking advisors to communicate about individual patients.

57 Smoking in Pregnancy: Health Needs Assessment APPENDIX ONE EXAMPLE OF PAPER FORM INCLUDED IN BOOKING NOTES Source: Broomfield Hospital, Mid Essex NHS Trust

58 58 Smoking in Pregnancy: Health Needs Assessment 2017 APPENDIX TWO EXAMPLE OF INFORMATION LEAFLET PUBLICISED BY REGIONAL GROUP Source: East of England Smoking in Pregnancy Group/Smoking in Pregnancy Challenge Group