Learning Outcomes

Following this training session you will be able to:

• Discuss the impact of smoking and benefits of quitting.

• Deliver brief advice about smoking cessation.

• Use a carbon monoxide monitor and undertake testing.

• Refer to the local stop smoking service through opt-out

pathway.

What We Will Cover…

• The impact of smoking and benefits of quitting.

• Smoking at time of delivery (SATOD).

• Smoking in pregnancy opt-out pathway.

• Raising smoking and referral.

• Carbon Monoxide (CO) testing.

• Quit smoking support and Nicotine Replacement Therapy (NRT).

• Electronic cigarettes.

• Your role.

Smoking in Pregnancy

National public health priorities:

-To increase healthy life expectancy.

-To reduce inequalities.

•To reduce the risk of foetal mortality by 40%1 – greatest modifiable cause of foetal

ill health and death.

•10% reduction in infant and foetal deaths achieved if all pregnant women stopped

smoking 2.

•Reducing smoking in pregnancy is a key priority.

Impact of Smoking: Mother and Baby

• Ectopic pregnancy

• Miscarriage

• Placental abnormalities

• Premature rupture of foetal

membranes

• Still-birth

• Preterm delivery

• Low birth weight

(175-200g lighter)

• Perinatal mortality

• Sudden infant death

syndrome

• Maternal nausea

• Maternal stress incontinence

• Maternal thrush, UTIs,

Chlamydia & PID

3

Impact of Smoking: Child

• Cleft lip and cleft palate

• Attention deficit and hyperactivity disorder (ADHD)

• Impaired lung function & cardio-vascular damage

• Acute respiratory conditions e.g. asthma

• Learning difficulties

• Problems of the ear, nose and throat

• Obesity

• Diabetes

• Meningitis

Children are more likely to become smokers themselves

– perpetuates cycles of health inequalities 14,15.

4-15

Smoking and Breastfeeding

• Mothers who smoke are less likely to breastfeed, they

produce smaller amounts of milk and feed for a shorter time.

• However, benefits of breastfeeding and smoking are still

greater than formula feeding.

• Babies exposed to nicotine in breast milk cry more and have

trouble getting to sleep.

• Babies of heavier smokers may also experience nausea,

vomiting, cramping and diarrhoea.

• Mothers should smoke after feedings to allow time for the

level of nicotine in milk to decrease before next feed – half

life of nicotine is around 90 minutes.

• The use of NRT exposes the baby to less nicotine than

smoking.

Impact of Second-hand Smoking

• WHO listed second-hand smoke (SHS) as human carcinogen – there is no

safe level of exposure 16.

• Babies and children are more vulnerable to SHS1 with increased risk of:

– Bronchitis

– Asthma

– Middle ear infections (glue ear)

– Sudden Infant Death Syndrome

• Estimated 3,057 additional incidents of childhood diseases each year within

Lancashire, directly attributable to SHS 17.

• Exposure of adults & children to SHS costs NHS in Lancashire £15.67

million to treat every year 18.

• Lancashire Smokefree Homes Programme – pledge to make home

and car smokefree.

Impact of Smoking: Financial

• Nationally, smoking in pregnancy costs NHS £20-87.5 million

each year 19.

• Supporting pregnant smokers to quit is 3-6 times more cost-

effective than treating smoking-related issues in new born infants 3.

• 1 in 5 babies admitted to Neonatal Unit as a result of smoking20

– 224 in Lancashire each year.

• Cost of complicated birth/care of premature baby is £12.5k

per baby vs. £1k for vaginal birth 21-23 – £2.8 million in Lancashire

each year.

• Stopping smoking in pregnancy could save £11.5k per baby

& £2.58 million in Lancashire each year.

• A smoker of 20 a day spends £55 a week and over £2,800

a year.

Oral Smokeless Tobacco: Paan

• The Paan Leaf itself is not harmful but

contains tobacco and other ingredients

that impact on oral health.

• Lime is corrosive damaging the lining

of the mouth.

• Paan Masala consists of spices and

artificial colourings.

• Linked to pre-cancerous lesions and

cancers of mouth, throat and tongue 24,25.

Oral Smokeless Tobacco: Shisha

Shisha Tobacco

Flavoured with fruits and sugar syrup.

Shisha Pipe

Burning charcoal.

Water is placed in the bowl, sucking on the hose

causes a vacuum in the air space above the water,

causing smoke to pass through the water producing

bubbles (hence the name “hubble-bubble”).

Typical 1 hour session involves inhaling 100-200

times the volume of smoke inhaled with single

cigarette 26.

Shisha Myths

MYTH: Shisha smoke is filtered through water so it filters

out any harmful ingredients 27.

TRUTH: Smoking tobacco through water does not filter

out cancer-causing chemicals. Water-filtered smoke can

damage the lungs and heart as much as cigarette smoke.

MYTH: Smoking a shisha pipe is not as addictive as

smoking a cigarette because there is no nicotine 27.

TRUTH: Just like regular tobacco, shisha contains nicotine.

Research has demonstrated that shisha smoking can result

in nicotine levels equivalent to ten stick cigarettes among

daily users 28.

Oral Smokeless Tobacco: Cannabis

• Most widely used recreational drug and is illegal

– Class B under Misuse of Drugs Act 1971.

• Appearance can vary:

– Hash: black/brown lump made from resin.

– Grass/weed: dried, chopped leaves.

– Skunk: modified and stronger form

of herbal cannabis.

• Cannabis is almost always mixed with tobacco

and smoked. Therefore has the same risks

during pregnancy as smoking cigarettes 29.

• Cannabis contains as many cancer causing

chemicals as tobacco.

Smoking At Time of Delivery (SATOD)

• National target in Public Health Outcomes Framework to

reduce smoking at time of delivery to 11% or less by 2015 30.

• However, SATOD rates remain higher in Lancashire than

England as a whole (16.8% vs. 12.0%) 31 affecting the health

of mums & babies:

– Chorley & South Ribble 16.6%

– East Lancashire 18.0%

– Fylde and Wyre 15.2%

– Greater Preston 17.0%

– Lancashire North 16.2%

– West Lancashire 14.4%

Smoking At Time of Delivery (SATOD)

• Teenage women 6 times more likely to smoke during pregnancy 32.

• Pregnant women from routine and manual occupations 5 times more likely

to smoke than professional counterparts 32.

• Maternity Trusts have mandatory duty to collect and submit quarterly SATOD

data to demonstrate smoking prevalence at local & national level.

• Relies on accurate inputting of smoking status at booking and delivery,

verified by carbon monoxide (CO) testing, by all midwives.

• Obtaining patient SATOD status at 36 week appointment, rather than delivery

more reliable 33.

Benefits of Stopping Smoking

• Mother & baby are not exposed to 4,000

chemicals of tobacco smoke and less

nicotine:

– Decreased risk of developing

smoking-related long-term conditions:

Respiratory, CVD, Cancer 34.

– Improved oxygen supply can help

in labour and assists post delivery

healing.

– Decreased risk of: miscarriage; Low

Birth Weight, Premature Delivery,

Stillbirth and Sudden Infant death

syndrome.

• Reduced nausea

• Assists breastfeeding

• Financial savings

• Nicer smelling breath, hair, clothes

• Looking younger – improved complexion

and fewer wrinkles 35.

Benefits of Being smokefree for Families

Reduced exposure to second-hand smoke:

Children:

• Improves health and reduces the risk of

wheezing, chest infections, glue-ear,

asthma symptoms, meningitis and dental

caries 4-13.

• Increases school attendance rates36

• Reduces exposure to smoking and

chances of them becoming a smoker

themselves14,15.

Non-Smoking Adults:

• Decreases risk of developing heart

disease, stroke & cancer 37,38.

Pets:

• Reduces risk of developing lung & nasal

cancer 39,40.

Other Benefits

• Home will smell and look fresher and don’t

need to re-decorate as often.

• Reduced risk of a cigarette-related fire.

Rationale for Opt Out Scheme

• Self-reported smoking status is an inaccurate way of identifying smokers – miss 25% of smokers 41-44.

• Women who do not admit to smoking will not be referred to a stop smoking service for support to quit –

this puts health of mother and baby at risk.

• Routine carbon monoxide monitoring to identify smokers & opt-out referral to stop smoking

service results in a higher proportion of women setting a quit date.

• NICE guidance recommends 3,45:

– Identifying pregnant women who smoke.

– Assessing women’s exposure to tobacco smoke through discussion and use of CO screening.

– Giving information on the risks of smoking & health benefits of stopping.

– Advise pregnant women to stop smoking – not just cut down.

– Refer them for help to quit and explain that it is normal practice to do this.

– Provision of smoking cessation support (stop smoking service).

Smoking in Pregnancy Pathway

• At booking appointment, smoking (cannabis, cigarettes & shisha) and e-cigarette status recorded and

CO reading taken for all women. Information given on stop smoking & smokefree homes.

• Refer all women to stop smoking service if:

– They are a current smoker

– Have a CO reading of 4ppm or higher

– They have quit smoking in previous 2 weeks

• Partner, friend or family member present at appointment can also be referred to stop smoking service.

• Women refusing CO test or referral should complete an opt-out form.

• Smoking included in subsequent appointments to monitor progress of quit attempt or encourage

engagement with stop smoking service.

• Smoking status recorded and CO reading taken for all women at 36 week appointment for SATOD.

Carbon Monoxide (CO) Screening

• CO monitoring is a routine breath test to measure the level

of this highly toxic gas in a pregnant woman.

• It can pick up and highlight the effects of:

– Smoking tobacco

– Exposure to second-hand smoke in the home or car

– Faulty gas appliances

• Level of CO in the lungs is based on the amount inhaled

from tobacco smoke or other sources in previous 8-12 hours.

• Screening all women normalises the test and allows opportunity

for advice – all midwives supplied with

a CO monitor.

• Obtain verbal consent. If the woman declines, ask her to sign

the opt-out form.

• Perform carbon monoxide screening at booking, 36 weeks

and on request. Record in notes.

How to do the CO Test

• Prepare the carbon monoxide monitor by wiping it with a non-alcoholic, manufacturer-approved wipe, insert a D piece and ask the patient to attach a disposable mouth piece.

• Turn on the monitor by holding button for 3 seconds and wait until the cursor is over the person icon.

• Ask the client to hold their breath for 15 seconds whilst double clicking the button.

• The audio bleep will sound at 12 seconds and when the bleep stops the patient will be asked to blow

into the mouthpiece aiming to empty lungs completely.

• The parts per million and equivalent CO Hb levels will rise and hold then display on the screen.

• Ask patient to remove mouth piece and dispose, remove D piece.

• Change D pieces each month.

Act on the Results

Non smoker reading <4ppm

•Advise the patient of where carbon monoxide comes from – tobacco smoke/faulty gas appliances.

•If the CO reading registers 4ppm or higher determine how the CO has entered her body.

Advise that she will automatically be referred to the stop smoking service unless she opts out.

•If the woman does not smoke, ask if there is any possibility of exposure to second-hand smoke –

give smokefree homes leaflet & recommend pledge .

•If no exposure to second-hand smoke, ask about household gas appliances and advise to contact

the free HSE number for advice – 0800 300363.

•Record outcome.

•Keep monitor calibrated – contact medical devices if not working properly.

Raising Smoking and Referral

Ask: “Does anyone in your household smoke tobacco products (cannabis, cigarettes and shisha) including yourself?”

•If the answer is NO ask: “Have you smoked in the last 12 months? If so, when did you give up?”

•This is important to ask as they may be struggling and would benefit from some support to remain quit throughout their pregnancy. If quit within previous 2 weeks, refer to stop smoking service.

It may be helpful to ask:

•“What are the positive differences that you have noticed since being smokefree?”

•“What difficulties have you experienced so far? How have you overcome these?”

Raising Smoking and Referral

• If the answer is YES they smoke: “We know that the local stop smoking service have supported many pregnant women to stop and I can refer you.”

• If the answer is YES their partner/family member/friend smoke: “If your partner/family member/friend also smokes and wants to give up, they can be referred as well.”

• Make referral to stop smoking service if the woman states that she is unwilling to make a quit attempt at this time, ask her to sign the opt-out form, provide information on the stop smoking service, smokefree homes programme and ask:

• “What do you think would motivate you to stop smoking?”

• “If you change your mind, I’m always here to help.”

Further Support

• Gain confidence to do this by doing the

very brief advice training on the National

Centre for Smoking Cessation and Training

(NCSCT) website:

http://www.ncsct.co.uk/publication_very

-brief-advice.php

Quit Smoking Support

• Your referral will ensure the woman

and her partner/family

member/friend gets an appointment

with the stop smoking service.

• Four times more likely to quit with

NHS stop smoking service 46.

Quit Smoking Support

• Free & confidential - they can

help with:

– Personalised quit plan

– Stop smoking medicines on

prescription (free to pregnant

women and those on benefits)

– Supportive tips

– Carbon monoxide monitoring

• Supported through pregnancy to

three months postpartum. Choice of:

– One-to-one support

– Group session

– Telephone/text

– Home visit

Nicotine Replacement Therapy

• Nicotine Replacement Therapy

(NRT) is licensed for use

in pregnancy and can be offered to

help reduce withdrawal symptoms –

free on voucher

or prescription 3,45.

• Not harmless to baby but less

harmful than smoking 3,45,46

– baby only receives nicotine,

not other 1000s chemicals present

in cigarettes/tobacco.

• Different products used for

12 weeks:

– Patches (16 hour)

– Gum

– Lozenges

– Inhalator

– Nasal Spray

– Mouth Spray

– Mouth Strips

E-cigarettes: What Are They?

Battery operated devices that aim to simulate combustible cigarettes. Don’t contain tobacco,

operate by heating nicotine and other chemicals into a vapour that is inhaled.

Three main types:

•Disposable products (non-rechargeable).

•Electronic cigarette kit – rechargeable with replaceable re-filled cartridges.

•An electronic cigarette that is rechargeable

& has a tank or reservoir filled with liquid nicotine.

Currently unregulated & unlicensed, safety and efficacy

remains undetermined – licensed as stop smoking medicine

by MHRA or as consumer product by European Tobacco

Directive in 2016.

E-cigarettes

• Research regarding clinical effectiveness as a stop smoking aid is currently

limited 47 – DH recommend stop smoking service support & licensed

pharmacotherapy e.g. NRT.

• WHO recommendation48 ‘Until such time as a given electronic nicotine delivery

system is deemed safe and effective and of acceptable quality by a competent

national regulatory body, consumers should

be strongly advised not to use any of these

products, including electronic cigarettes.’

• Not currently recommended in pregnancy 49.

Stop Smoking Services

Lancashire

• North: 01524 845145

• East: 0800 328 6297

• Central: 0800 328 6297

• West: 0800 328 6297

www.smokefree.nhs.uk

Stop Smoking Services

Your Role • Ask and record smoking (cannabis, cigarettes

and shisha) and e-cigarette status at booking.

• Give verbal and written information on stop smoking

and smokefree homes – recommend website & mobile

phone app.

• Undertake CO screening at booking, 36 week

appointment and on request.

• Refer women with a CO reading of 4ppm or higher,

smokers & those who have quit in previous 2 weeks

to stop smoking service.

• Check quit progress & encourage engagement with stop

smoking service throughout pregnancy.

Thank You

Any Questions?

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