CATCH: development of a home-based midwifery intervention to support young pregnant smokers to quit
Introduction
Seventy per cent of women have a baby (ISD, 2004), making pregnancy a great opportunity to offer most women, who smoke, help to stop. All-cause mortality increases by 50% for women who smoke (Houterman et al., 2003). The toll on UK babies includes 4000 miscarriages and stillbirths, more preterm and low-birthweight babies (RCP, 1992; Charlton, 1996), an increase in sudden infant death, asthma (RCP, 1992) and attention deficit hyperactivity disorder (Charlton, 1996; Batstra et al., 2003). Nearly half (45%) of women from unemployed or unskilled manual occupations smoke throughout pregnancy compared with 8% of professional, non-manual workers (RCP, 2000). Effective cessation support is needed to reduce these health inequalities.
The UK Government has funded a comprehensive strategy (McNeill et al., 2005) to reduce smoking outlined in the 1998 White Paper Smoking Kills (DOH, 1998). Pregnant smokers were one of the target groups for special funding (DOH, 1998; Pound et al., 2005). It is hoped to reduce the number of women in England who smoke during pregnancy from 23% to 15% by 2010 (McNeill et al., 2005). There is a target to reduce the proportion of pregnant women in Scotland smoking from nearly 24% in 2004 to 20% by 2010 (The Scottish Executive, 2004).
Pregnancy has been described as a ‘teachable moment’ for smoking cessation with many women quitting prior to antenatal booking (McBride et al., 2003). However, it remains difficult to attract pregnant smokers for specialist cessation support; in common with other smokers, most pregnant women are not ready to quit (Pound et al., 2005). Once engaged with a specialist service, intensive behavioural support, on a one-to-one basis, has been found to be most effective (Lumley et al., 2007). Forty per cent of pregnant smokers who set a quit date through specialist smoking cessation services in England were smoke free 4 weeks later (Judge et al., 2005).
Generally, smokers who are referred to specialist cessation services have asked for help to stop smoking. They choose a time in their lives to present when other issues are under control. They are, therefore, motivated and ready to quit, and benefit from standard treatment using withdrawal-orientated therapy (Hajek, 1989) and nicotine replacement therapy (NRT) or bupropion (NICE, 2002). As few as 2% of all smokers may present in this way in any one year (Chesterman et al., 2002).
Nearly all pregnant smokers are identified at maternity booking as part of routine health assessment. Like non-pregnant smokers, most will not be motivated or ready to change their habit, and will therefore be difficult to attract to specialist smoking cessation services. Reaching these women, which includes identification, referral and engagement to set a quit date, requires a different approach (Bauld et al., 2003).
Motivational interviewing (Miller and Rollnick, 2002), while not proven to be an effective intervention to reduce smoking during pregnancy on its own, does provide health-care workers with the confidence to talk to pregnant women about smoking without creating hostility (Lumley et al., 2007; Tappin et al., 2005). Not talking about smoking is a major obstacle to referral and engagement of pregnant smokers.
A Cochrane systematic review of 64 randomised controlled trials of smoking cessation support provided in pregnancy (from 1975 to 2003) concluded: ‘smoking cessation programs have been shown to increase smoking cessation, reduce preterm birth and low birth weight, and increase mean birth weight, smoking cessation programs need to be implemented in all maternity care settings’ (Lumley et al., 2007). The trials frequently used maternity booking in early pregnancy as a point to identify pregnant smokers. Interventions commonly included: information on the risks of smoking to the fetus and baby and benefits of quitting; recommendations to quit and setting a quit date; feedback about the fetus; feedback about harmful levels of nicotine; teaching cognitive behavioural strategies; advice tailored to ‘stages of change’; provision of rewards; social or peer support; and NRT. Interventions were provided by a range of therapists including midwifery staff, health educators and cessation specialists. Intensity of intervention varied substantially. Overall, there was a positive net effect of 6% in the proportion of women continuing to smoke between intervention and control groups. Services which included the provision of ‘social support and rewards’ were significantly more effective than those that did not. There was no evidence that any other type of support, including the provision of NRT, significantly increased quit rates. However, the interventions and participants were heterogeneous, making comparison between trials difficult.
To date, the efficacy of NRT in pregnancy is unknown. The largest published randomised controlled trial of NRT (delivered by transdermal patches) to date, showed no difference from placebo, but the trial was underpowered to detect this. Nonetheless, babies born to women in the NRT group had significantly higher birth weights than those in the placebo group, indicating that the intrauterine growth restriction caused by smoking is probably not attributable to nicotine (Wisborg et al., 2000; Coleman et al., 2007).
For non-pregnant smokers, use of pharmacotherapy has been found to nearly double cessation rates obtained with behavioural support alone (Silagy, 2000). In pregnancy, behavioural support is usually provided alone because of concerns that drugs may harm the fetus. It has been argued that while ‘this is understandable for bupropion, which is an avoidable drug, nicotine is part of the exposure of smoking, and if nicotine replacement is used instead of cigarettes, exposure to the many other toxins in tobacco smoke is avoided’. Thus, ‘If nicotine replacement were as effective in pregnancy as in non-pregnant smokers, withholding it would be harmful.’(Coleman et al., 2004).
The UK National Institute for Health and Clinical Excellence (NICE) has recently changed its guidelines to recommend that pregnant women can use nicotine replacement ‘after discussion with a health professional’ (NICE, 2002). However, doctors and pregnant women remain wary of using medications without good evidence of safety and efficacy during pregnancy. Use of NRT during pregnancy remains controversial.
In summary, there remains no standard intervention for pregnant smokers and most trials do not take cognisance of difficulties in attracting pregnant smokers to smoking cessation services.
Section snippets
The development of CATCH
A training and needs assessment was carried out by the local health board's health promotion department, to assess current practice in giving smoking cessation advice to pregnant women booked for care at the local maternity unit. This highlighted a lack of knowledge and skills (Walker, 2002), and few health professionals reported providing smoking cessation advice or support. Most thought it important but felt unskilled and feared that their relationship with women would be compromised.
The project team
A project midwife was seconded from the maternity unit with direct line management from the maternity services manager and project management by the health board tobacco coordinator. A part-time administrative officer completed the team with office space in the maternity unit. The project midwife was experienced, well known and respected within the maternity unit multi-disciplinary team. She was trained in withdrawal-oriented therapy (Hajek, 1989), motivational interviewing (Miller and
Evaluation
An external evaluation team was commissioned by NHS Health Scotland and ASH Scotland to evaluate CATCH as one of eight projects in a programme of young people's smoking cessation projects. An internal evaluation team included the project midwife, the tobacco coordinator, the hospital clinical research officer and a public health researcher.
The teams worked closely on a common set of evaluation tools and agreed how these would be administered. Evaluation tools were piloted with volunteer
Outcome evaluation
The self-reported smoking status of the 2313 women (of all ages) booking at the maternity hospital during the 16-month study period is given in Table 1.
Two hundred and eighty-nine young self-reported smokers (25 years and under) were eligible for the service. One hundred and fifty-two (53%) women were refered to CATCH. Of those, 65 (22%) joined the CATCH project along with 14 male partners (total 79) (Table 2). All clients who signed up to the service agreed to take part in the research.
Almost
Discussion
CATCH established a way of reaching young pregnant smokers that meets their expectations of a flexible, community-based service. It also meets the needs of maternity-based health professionals to refer to a specialist smoking cessation service. A holistic approach to smoking cessation was developed which takes due regard of individual circumstances and seeks to help clients address more pressing problems which may stand in the way of an attempt to give up smoking. Clients described a positive
Acknowledgements
This study was funded by NHS Health Scotland, ASH Scotland and NHS Argyll and Clyde. The views expressed in this paper are those of the authors and not necessarily those of the funders. The research was approved by NHS Argyll and Clyde Research Ethics Committee, and support provided by the Research and Evaluation Team of Argyll and Clyde's Public Health Department. The authors would like to express their gratitude to CATCH's clients for giving their time to this study.
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