1. Smoking Cessation In Pregnancy – Barriers & facilitators Fiona Dunlop Health Improvement Lead (Tobacco) With thanks to Jacki Gordon & Associates for undertaking the evaluation Fiona Dunlop Health Improvement Lead (Tobacco) With thanks to Jacki Gordon & Associates for undertaking the evaluation

2. Presentation overview  Background  Methods  Quantitative findings  Qualitative findings  Recommendations  Background  Methods  Quantitative findings  Qualitative findings  Recommendations

3. SPS pathway 1. CO test booking 2. Electronic referral 3. Opt in/out call 4. Appointment arranged 5. Face to face intervention 6. Telephone support 7. 3/12 month Follow up Other referrals Clinic Midwife Self GP/SCI In-patient

4. Rationale Condition 1: Why do women arrange an appointment with the SPS and then not attend?

5. Rationale Condition 2: Why do women who smoke and attend their appointment withdraw from the service before setting a quit date?

6. Rationale Condition 3: Why do women who have set a quit date withdraw from the SPS?

7. Rationale Condition 4: Why women who attend the service and stop smoking are successful in their quit attempts?

8. Methods  Short online literature review  Brief analysis of the SPS records to guide selection of sample and identify factors associated with disengagement  One-to-one telephone interviews  Short online literature review  Brief analysis of the SPS records to guide selection of sample and identify factors associated with disengagement  One-to-one telephone interviews

9. SPS data analysis Top line findings: Low SIMD associated with disengagement and poorer quit outcomes PNBS referrals less likely to attend PNBS and clinic referrals less likely to set a quit date Top line findings: Low SIMD associated with disengagement and poorer quit outcomes PNBS referrals less likely to attend PNBS and clinic referrals less likely to set a quit date

10. Characteristics of interviewees (n = 30) Referral SourceSIMD PNBSClinic Mid- wife Self123 Condition 1 8---71- Condition 2 222-51- Condition 3 611-35- Condition 4 52-1332

12. Women’s ‘smoking cessation journeys’ are complex and highly individual. There are many factors that can impact on adherence to the service and success

13. Views of service...  Overwhelming, positive re service and advisors.  Non-judgemental approach valued.  Feeling comfortable with the advisors.  Receptive because advisors were not ‘preachy’.  Overwhelming, positive re service and advisors.  Non-judgemental approach valued.  Feeling comfortable with the advisors.  Receptive because advisors were not ‘preachy’.

14. Condition 1: Why do women arrange an appointment with the SPS and then not attend? No contact details for service

15. Condition 2: Why do women who smoke and attend their appointment withdraw from the service before setting a quit date?

16. Condition 3: Why do those who have set a quit date withdraw from the SPS? Things get in the way!  No ready - motivation  Other issues e.g.  Poverty  Addictions  Boredom and stress  Barriers and challenges not always discussed/addressed  Timing of phone calls – disengagement  No contact details  No ready - motivation  Other issues e.g.  Poverty  Addictions  Boredom and stress  Barriers and challenges not always discussed/addressed  Timing of phone calls – disengagement  No contact details

17. Smoking reduction…  Many reduce the number of cigarettes smoked - all they can achieve but effort not valued  Feel Service is about stopping altogether– which it is.  Embarrassed to maintain contact if still smoking NRT  Quantitative analysis – less likely to quit using NRT – 50% data was missing  May have high expectations?  Conversely they will come of NRT too soon - side effects or feelings that NRT was no longer needed it.  Is our risk/benefit form contributing to this ?  Many reduce the number of cigarettes smoked - all they can achieve but effort not valued  Feel Service is about stopping altogether– which it is.  Embarrassed to maintain contact if still smoking NRT  Quantitative analysis – less likely to quit using NRT – 50% data was missing  May have high expectations?  Conversely they will come of NRT too soon - side effects or feelings that NRT was no longer needed it.  Is our risk/benefit form contributing to this ?

18. Other issues  Variability in ongoing support from midwives  Midwives and other health professionals not knowing how women got on  Missing / not picking up calls from SPS  Relapse  Variability in ongoing support from midwives  Midwives and other health professionals not knowing how women got on  Missing / not picking up calls from SPS  Relapse

19. Condition 4: Why women who attend the service and stop smoking are successful in their quit attempts?

20. Recommendations

21. Recommendation 1: Inequalities sensitive practice Finding:  Women from lower SIMDs are more likely to continue smoking in pregnancy Recommendation:  Review extent of / improve inequalities sensitive practices  address possibility of pre-attendance fears  ensure advisors know about / display sensitivity regarding the impact of social inequalities Finding:  Women from lower SIMDs are more likely to continue smoking in pregnancy Recommendation:  Review extent of / improve inequalities sensitive practices  address possibility of pre-attendance fears  ensure advisors know about / display sensitivity regarding the impact of social inequalities

22. Recommendation 2: Information provision Finding:  Women lacked SPS contact details  Unaware SPS available in number of locations. Recommendation:  All referrals should be given the phone number (and hours) of the service. Enter this in hand held records.  At booking, give all women leaflet about SPS service - reinforce the service values (non-judgemental, friendly etc.) and include the phone number Finding:  Women lacked SPS contact details  Unaware SPS available in number of locations. Recommendation:  All referrals should be given the phone number (and hours) of the service. Enter this in hand held records.  At booking, give all women leaflet about SPS service - reinforce the service values (non-judgemental, friendly etc.) and include the phone number

23. Recommendation 3: Referral and appointment practices Finding:  Feeling pushed into attending the service/ pressured quitting associated with disengagement /failing to quit. Recommendations:  Midwives should explain how the service operates, promote service and encourage women to attend. -Requires SPS clarity on who the service is for (just those ready to quit?) -Consider potential for midwives explaining smoking risks/quit benefits and addressing ambivalence? Finding:  Feeling pushed into attending the service/ pressured quitting associated with disengagement /failing to quit. Recommendations:  Midwives should explain how the service operates, promote service and encourage women to attend. -Requires SPS clarity on who the service is for (just those ready to quit?) -Consider potential for midwives explaining smoking risks/quit benefits and addressing ambivalence?

24. Recommendation 3 cont..  Advisors setting appointments must assess motivation in a manner that recognises women may find it hard to say that they are not ready to stop smoking.  While advisors may wish to stress the benefits of quitting as soon as possible, they need to accept and work within the constraints of women’s readiness to change when setting quit dates.  Advisors setting appointments must assess motivation in a manner that recognises women may find it hard to say that they are not ready to stop smoking.  While advisors may wish to stress the benefits of quitting as soon as possible, they need to accept and work within the constraints of women’s readiness to change when setting quit dates.

25. Recommendation 4: Overcoming boredom and stress Recommendation: Advisors need to identify whether boredom and stress are barriers and do so in ongoing manner Provide tailored advice/tips relevant to women’s lives  upskilling in stress management and CBT?? Recommendation: Advisors need to identify whether boredom and stress are barriers and do so in ongoing manner Provide tailored advice/tips relevant to women’s lives  upskilling in stress management and CBT??

26. Recommendation 5: Protocol for reduced consumption Finding:  Value advisors maintaining contact and encouraging women struggling to quit  Women avoiding talking to advisors when unsuccessful in quit attempts. Recommendation: Clear SPS protocol for women who fail to quit completely detailing level of support women will be given. This needs to be communicated. Finding:  Value advisors maintaining contact and encouraging women struggling to quit  Women avoiding talking to advisors when unsuccessful in quit attempts. Recommendation: Clear SPS protocol for women who fail to quit completely detailing level of support women will be given. This needs to be communicated.

27. Recommendation 6: Discontinuation of NRT Findings: Discontinuation was common and use possibly associated with poorer outcomes? Recommendation: If pattern is confirmed, it will be important to identify the mechanisms that underpin this Irrespective:  Important to keep door open to SPS even if stop NRT use  Consider feasibility of SPS offering a review visit

28. Recommendation 7: More joined up working Finding: Others (midwives) often unaware how women got on Recommendations: Consider a feedback mechanism Opportunities for others to provide encouragement e.g. midwives, radiographers etc? Clear and sustained referral mechanisms from FNP?

29. Recommendation 8: Preventing relapse Finding: Many had quit when previously pregnant Recommendation:  Expand reasons for not smoking  Consider how to pass the baton to postnatal services

30. Contact details telephone: 0141 201 4520 email: fiona.dunlop@ggc.scot.nhs.uk fiona.dunlop@ggc.scot.nhs.uk Web: www.nhsggcsmokefree.org.uk www.nhsggcsmokefree.org.uk