1. Insert name of presentation on Master Slide Using a range of NHS staff to deliver stop smoking services to pregnant women: (preliminary) findings from the Models for Access to Maternal Smoking cessation Support (MAMSS) study 12 June 2015 Mrs Lorna Bennett Specialty Registrar in Public Health Dr Aimee Grant Research Fellow

2. Overview Smoking in pregnancy in Wales Public health response: MAMSS project Preliminary outcomes Qualitative evaluation findings Lessons learnt & conclusion Models for Access to Maternal Smoking cessation Support (MAMSS)

3. Maternal smoking in UK Models for Access to Maternal Smoking cessation Support (MAMSS)

4. Contacts to the Stop Smoking Wales service by pregnant women 1 st April 2012 to 31 st March 2013 % of pregnant smokers (Estimated number of pregnant smokers = 6920) Number scheduled appointment94414% Number of treated smokers1442% Number successfully quit at 4 weeks (self-reported) 520.01% Number successfully quit at 4 weeks (CO validated) 21<0.01% Service Outcomes 2012-13

5. Public Health Response: MAMSS Design and deliver new service models for smoking cessation services for pregnant women Systematic implementation of NICE guidance in all areas Flexible, women-centred approach provided by: MSW or Midwife or Specialist stop smoking advisor for pregnant women Compare the effectiveness of the new models of service delivery with usual care Models for Access to Maternal Smoking cessation Support (MAMSS)

6. Methods Four Health Boards in Wales Quasi-experimental design Intervention and usual care sites Outcome and process evaluation Models for Access to Maternal Smoking cessation Support (MAMSS)

7. Referral from midwife to NHS Stop Smoking Service via fax or phone call. Stop smoking staff make an attempt to contact the pregnant women within 48 hours to discuss benefits of quitting, offer support and arrange an assessment session. NHS Stop Smoking Service staff attempt to contact the client by telephone twice more if contact has not been established, and send a follow up letter if no response. Referral from midwife to smoking cessation support within 48 hours MAMSS clinician attempts to contact pregnant woman by telephone (or face-to-face at clinic) within 48 hours to discuss support and to arrange an appointment for an assessment session. MAMSS clinician attempts to contact the client by telephone at least twice more if contact has not been established. Women are fast tracked into a one-to-one assessment session appointment within 48 hours. Assessment sessions are conducted in community venues. Women are offered six further sessions of intensive behavioural support in community venues or by telephone, each lasting around 30 minutes. Women are CO monitored at all treatment sessions and at 4-6 weeks after their quit date. If the client requires additional support following the seven sessions, the advisor will arrange to make contact by telephone in two weeks to provide an additional follow up. Approach: Flexibility in service model with a women centred approach. Face-to face assessment session, within 1 week of contact, in location of woman’s choice Women are offered intervention sessions at a location of their choice, each lasting around 30-60 minutes The number and frequency of treatment sessions will be according to the woman’ choice, including the option of support by text message or telephone. Women are CO monitored during face-to-face treatment sessions and at 4-6 weeks after their quit date USUAL CAREINTERVENTION REFERRAL TREATMENT

8. Data analysis Primary outcome measure = -% of treated smokers Secondary outcomes = -referrals, 4-week quits, CO validated quits, smoking status in 3 rd trimester, birth outcomes Sample size = 146 pregnant smokers Models for Access to Maternal Smoking cessation Support (MAMSS)

9. Reference: Bennett et al. Models for Access to Maternal Smoking cessation Support (MAMSS): a study protocol of a quasi experiment to increase the engagement of pregnant women who smoke in NHS Stop Smoking Services. BMC Public Health 2014, 14:1041 http://www.biomedcentral.com /content/pdf/1471-2458-14- 1041.pdf

10. Results: % referrals accepted (of those referred) Models for Access to Maternal Smoking cessation Support (MAMSS) No. accepted 108 133 23 94 40 204 10 93

11. Models for Access to Maternal Smoking cessation Support (MAMSS) No. treated smokers 28 93 8 42 9 87 6 49 Results: % treated smokers (of those referred)

12. Models for Access to Maternal Smoking cessation Support (MAMSS) No. 4 week quit 9 29 1 18 4 40 2 14 Results: % 4 week quitters (of those referred)

13. Models for Access to Maternal Smoking cessation Support (MAMSS) No. CO validated 2 27 1 7 2 33 2 12 Results: % CO validated quits (of those referred)

14. Qualitative evaluation methods 1.Documentary analysis of study management group minutes (09/2012 - 02/2014) 2. Semi-structured interviews Referring midwives (n=9) Treating clinicians (n=9) Service Users (n=7) Framework analysis using NVivo 10 Models for Access to Maternal Smoking cessation Support (MAMSS)

15. Identification and referral Midwives trained to follow NICE opt-out pathway Carbon Monoxide testing problematic –Poor data Majority ‘agreed’ to being referred Barriers to ‘agreement’ – most smokers already intending to ‘cut down’ One area MAMSS clinician in clinic – brief referral appointment Models for Access to Maternal Smoking cessation Support (MAMSS)

16. Intervention delivery Challenging to make contact with women –use of mobile phone Majority of appointments in women’s homes Treatment sessions were usually weekly for around 6-12 weeks Quit date set by 71% of those who had an assessment session –Variation between sites (94% -56%) Informal contact between sessions Some issues accessing NRT from pharmacy Models for Access to Maternal Smoking cessation Support (MAMSS)

17. Data collection Specialist Quit Manager system developed Delays – so local systems developed MAMSS clinicians found the system challenging; –inputting baseline questionnaires –Timely data entry (to meet Russell Standard) I-pads did not work in the community due to large areas without network coverage Significant amounts of data cleaning provided by Stop Smoking Wales Models for Access to Maternal Smoking cessation Support (MAMSS)

18. Lessons for Practice Need for greater control –Referral and identification of pregnant women –Setting and recording quit dates –CO monitoring and recording Home visits and informal contact was well received Need for a better relationship with pharmacies Models for Access to Maternal Smoking cessation Support (MAMSS)

19. Conclusion The MAMSS project provides evidence that women who smoke during pregnancy can be effectively supported to engage with stop smoking services if a flexible, bespoke service is offered. Models for Access to Maternal Smoking cessation Support (MAMSS)

20. Limitations of study Not a randomised controlled trial Different data systems used across the Health Boards – some still paper based CO monitoring and opt out referral not well established Models for Access to Maternal Smoking cessation Support (MAMSS)

21. Acknowledgements MAMSS National Steering Group: Joanne BassJulie Bishop Mererid BowleyCeriann Tunnah Catrin FordChristian Heathcote-Elliott Angela JonesSharn Jones Siobhan JonesRachel Lewis Margaret Munkley Carol Owen Shantini ParanjothyAnnie Petherick Hywel Jones (Cardiff University) Marian Owoniyi (Cardiff University) Dee Hickey (PHW Observatory) Mieko Thomas, Luis Goncalves, Ray Henry (PHW Informatics) Staff employed as specialist smoking cessation advisors for pregnant women Health Board maternity teams Community Pharmacies Local Stop Smoking Wales teams Pregnant women who were involved in MAMSS Models for Access to Maternal Smoking cessation Support (MAMSS)