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Smoking in Pregnancy

Introduction

Smoking is the single biggest cause of preventable morbidity and mortality in England and the most significant thing that a smoker can do to improve their health is to quit smoking. In the case of smoking in pregnancy, it is also one of the best things as smoker can do for the health of their unborn child. Smoking and being exposed to second-hand smoke, poses a significant risk to both mother and unborn child, including increasing their risks of developing smoking-related illness.

What do we know?

Smoking rates in adult men and women have more than halved in the last 30 years. Despite this, it is estimated that there are still 10 million adults who smoke in Great Britain today, and about half of the regular smokers will die prematurely as a result of their smoking (ASH, 2015).

Smoking kills almost 80,000 people in England each year and is the number one cause of preventable death in the country. Smoking continues to be one of the biggest health challenges and continues to contribute significantly to health inequalities in our communities (PHE, 2015).

There are more than 4,000 compounds found in tobacco smoke and whilst many have a toxic, mutagenic or carcinogenic effect,, nicotine is one of the most important chemical compounds that make tobacco products addictive. Whilst addiction is a complex combination of pharmacology, learned behaviour, genetics, and social and environmental factors, cigarettes are a highly efficient system by which nicotine is delivered to the body (RCP, 2000; SG, 2010). When smoke is drawn in, the large surface area of the lungs helps the nicotine rapidly cross the membrane into the bloodstream, delivering it to the brain within 10 - 19 seconds  (DHHS, 1989). It then increases the heart rate, blood pressure and overall metabolic rate, decreases appetite, blood flow to the skin and the amount of oxygen the blood can carry to vital organs, causing vasoconstrictions or narrowing of the coronary arteries. It also alters brain waves and functions of the endocrine system and causes skeletal muscle relaxation (DHHS, 1989; RCP, 2000; SG, 2010; DHHS, 1988).

Nicotine levels within the body rapidly increase immediately after the cigarette, and will slowly fall. It has a half-life of 6-8 hours (the time required for any specified property to decrease by half). As a result it will decrease slowly overnight and, a common measure for nicotine addiction is how soon a person requires a cigarette after waking up (Heatherton et al, 1991). In large quantities, nicotine is extremely toxic, but acute poisoning is rare, often occurring through accidental swallowing or skin contact with pesticides that contain nicotine (Higa de Landoni, 1991).Whilst nicotine is the not the substance strongly associated with the smoking-related illness, it is the important compound for addictions and therefore exposure to the thousands of agents which do (RCP, 1992).

Whilst the Royal College of Physicians concluded that 'pure nicotine may be harmful to the foetus in pregnancy but is likely to be far less hazardous than the effects of smoking' (RCP, 2000), it has been well established beyond all reasonable doubt that smoking in pregnancy is associated with a range of serious problems and adverse effects (RCP, 1992), including:

  • Risk of miscarriage increasing by almost one-quarter in pregnant smokers
  • premature birth - which has shown to be twice as common in pregnant smokers
  • low birth-weight, which can be caused by both maternal AND paternal smoking
  • risk of still birth and early neonatal mortality is increased by approximately one-third in babies of smokers.
  • complications during labour

Some of these risks are also present in pregnant women who are exposed to second-hand smoke. Children of smokers are also at increased risk of suffering from asthma, as well as other more serious illness, so quitting in pregnancy also has other long term benefits. Babies of parents who smoke are more likely to be admitted to hospital for bronchitis and pneumonia during the first year of life. Evidence shows a women and her unborn child will benefit from quitting even in the last few weeks of pregnancy (SG, 2010).

In addition to decreasing the risks outlined above, quitting smoking in pregnancy also has significant health benefits for the mother, for example after 20 minutes, pulse returns to normal; after 48 hours, all traces of nicotine is removed from the body and the ability to taste and smell improves; at 2-12 weeks, circulation improves; after 1 year excess risk of a heart attack is reduced by half; after 10 years risk of lung cancer reduces to half that of a continuing smoker and, finally after 15 years, the risk of heart attack falls to the same as someone who has never smoked (NHS, 2015).

Facts, Figures and Trends

Smoking Prevalence

The Government's Tobacco Control Plan, which was published in 2011, set out a strategy to reduce smoking prevalence and announced a number of targets to be achieved by 2015. A specific target in England was included for reducing smoking during pregnancy from 14% in 2009/10 to less than 11% by the end of 2015, which is likely to be achieved.

Estimated smoking prevalence in adults aged 18 years in 2014 in Reading is 17.0% - a figure which, as shown in Figure 1, remains very similar to the national average. This equates to just over 21,000 people (adults) in Reading.

Figure 1. Prevalence of smoking among person aged 18 years, Reading and England, 2010 - 2014.

image1

Source: Integrated Household Survey. Analysed by Public Health England..

Smoking during pregnancy used to be measured by the Infant Feeding Survey (IFS) which was carried out in the UK every 5 years (but was discontinued in 2014). The last survey was completed in 2010 and at the time in England 7% of pregnant women aged 16 to 49 were smokers and 18% were ex-smokers. Smoking prevalence in pregnant women is now published by Public Health England (PHE) as a part of the Public Health Outcomes Framework (PHOF) and is produced by the Health and Social Care Information Centre returns on estimated Smoking Status At Time of Delivery (SSATOD).

Figure 2 below shows the latest annual trend data for SSATOD. As shown, 7.4% of women in Reading were smoking at time of delivery in 2014/15. If we apply this to the number of women resident in Reading giving birth in 2014/15 (3,098), we can estimate that more than 200 of these women were smokers. Whilst England is has shown a consistent downward trend since 2010/11, the trend in Reading marginally fluctuates up and down, with no significant reductions.

Figure 2. Percentage of mothers smoking time of delivery (SATOD), England and Reading, 2010/11 to 2014/15*

image2

Source: Public Health England, Tobacco Control Profile 2015.

* PHOF data for Reading in 2010/11 and 2012/13 was based on aggregated data for the old Berkshire west PCT. This could therefore be an over/under estimation for the local authority. The data for 2013/14 is based on the women in Reading and should therefore not be directly compared with previous year's figures.

The percentage of women smoking at time of delivery in 2014/15 is significantly better in Reading than the England average (11.4%) and as shown in Figure 3 below, was similar to other local authorities in Berkshire.

Figure 3. Percentage of mothers smoking time of delivery (SATOD), England and all Berkshire Local Authorities, 2014/15

image3

Source: Public Health England, Tobacco Control Profile 2015.

We also need to consider this in the context of neonatal and infant mortality in Reading, which remains higher than it is nationally. Reducing smoking prevalence in pregnant women and their exposure to second-hand smoke can only have positive effect on the women and their unborn baby, particularly considering the evidence available that links smoking with increased risk of neonatal and infant mortality (RCP, 1992).

Cost of Smoking

In addition to the significant cost to life and health of individuals and families, there are wider implications of smoking, particularly in relation to cost. Action on Smoking and Health's [ASH] , a not for profit public health charity established by the Royal College of Physicians, have produced a tool which estimates the total cost to society (in England) is approximately £13.9bn a year. This includes the cost of treating smoking-related disease caused by smoking in England which is approximately £1.88bn a year. Furthermore, it has been estimated that between £20m and £87.5m each year is spent on treating mothers and their babies (0-12 months) with problems caused by smoking during pregnancy (Godrey et al, 2010).

Figure 3 outlines the estimated cost of smoking to society for the Reading area. Each year in Reading, it is estimated that smoking costs society £36m, this equates to approximately £1,700 per smoker. The total annual cost to NHS trusts in Reading as result of smoking-related ill health (including passive smoking) is approximately £4.4m. In addition, current and ex-smokers who require care later in life as a result of smoking-related illness, are estimated to cost £2m per year, £1.2m of this is expected to be a direct cost to the local authority and over £850k to individuals who self-fund  (DHHS, 1988).

Figure 3. Estimated cost of smoking in Reading (£millions)

image4

Source:  ASH Ready Reckoner Tool, December 2015.

National and local context

Probably the most authoritative guidance on reducing harms from smoking and, smoking cessation is published by the National Institute for Health and Care Excellence (NICE). Updated guidance, including guidance on smoking and quitting smoking in pregnancy and following childbirth, produced by NICE, can be found on NICE's website.

NICE (2010) national guidance, Smoking: Stopping in pregnancy and after childbirth (PH26), outlines how best to support women to stop smoking in pregnancy and following childbirth. The guidance provides advice on the use of carbon monoxide monitoring to systematically identify all pregnant women who smoke at booking, and on making onward referrals to local stop smoking services.

In addition to this, there are a there are a number of other national strategies, policy and legislation, as well as local strategies and policies which smoking directly impacts on, these include:

National Strategy, policy & legislation

Reading's Health & Wellbeing Strategy

Reading's Health & Wellbeing Strategy has a number of key targets which smoking cessation and tobacco control work contributes to. These include:

  • Promote and protect the health of all communities, particularly those disadvantaged
  • Reduce the impact of long term conditions with approaches focused on specific groups
  • Promote health-enabling behaviours & lifestyles tailored to the differing needs of communities.
  • Joint Strategic Needs Assessment - contributing to a number of health outcomes in the local population

The Berkshire Tobacco Control Action Plan 2014 - 2016 also outline key areas of work in Reading and across Berkshire which aims to prevent the uptake of smoking, particularly in younger people. In addition, the support of regulatory work for example ensures that legal restrictions on the sale and promotion of tobacco are enforced, intelligence gathering and sharing and, targets cultural awareness/education and tackling normalisation.

In addition to this, local smoking cessation services are commissioned by Reading Borough Council. Reading's local smoking cessation services, Smokefreelife Berkshire services are provided by Solutions 4 Health. Smoking cessation services aim to help people to quit smoking by working with them either on a one to one basis or in small groups to provide smoking cessation advice and support and direct supply of nicotine replacement. In addition to online, telephone and text support, the one to one or face to face services are available in many community settings for example GP surgeries, pharmacy's, local shopping centre and antenatal clinics. A mobile unit is also available which can respond to the specific needs of the community, providing smokers with the direct access to experts who can support them to quit.

While women who smoke are more likely to engage with smoking cessation services during their pregnancy, they are likely to start smoking again after the birth of their child. Services need to be specifically designed and targeted to ensure new parents are targeted and supported to maintain their motivation to quit and education and information provided on the harm and risks to children of second hand smoke.

What is this telling us?

Smoking-attributable morbidity and mortality in pregnant women, unborn babies and children is preventable, as it is with the general smoking population. A significant number of lives could be saved each year if we are able to reduce prevalence both nationally and locally. Smoking causes long-term conditions that significantly affect people's everyday lives, putting them at considerable increased risk of illness and early death. This risk extends to babies born to smoking parents, both during pregnancy and after. Quite apart from personal cost, smoking also leads to considerable costs for both health and social care services.

The most important thing about smoking is it is never too late to quit, with health benefits occurring as quickly as 20 minutes after the last cigarette - these benefits extend to the unborn baby. Surveys show that over half of smokers would like to stop smoking, but just over a third of these (between 30 - 40%) will make an annual attempt to quit. Some women find it difficult to admit to smoking during pregnancy, which in itself is an intense experience and, also may not be fully aware of the risks that second hand smoke poses to their unborn babies. Pregnant women and their partners are reliant upon having appropriate support available to them, particularly for smoking cessation attempts (NICE, 2010).

In addition to having appropriate smoking cessation services, a focus needs to remain on prevention of uptake, so stopping people from starting. Smoking cessation services also aim to support people to quit long term (Doll et al, 1994).

Nationally and locally we are still navigating the emerging presence of e-cigarettes, their use as a replacement mechanism for the delivery of nicotine, their use in public places and their use in smoking cessation services. Ongoing monitoring of national guidance and policies will continue to ensure that locally we are up to date with best practice and guidance.

What are the key health inequalities?

Marmot points out in his 2010 review, Fair Society, Healthy Lives, that tobacco control is central to any strategy to tackle health inequalities with half the difference in life expectancy and the biggest cause of health inequalities between the richest and poorest people in the UK being attributable to smoking. Quitting smoking can allow people to leap the health gap, with the poorest non-smoker having a substantially longer life than the richest smoker and, rich and poor smokers having similar life expectancies. On average, smokers lose 10 years of life in comparison to non-smokers.

According to the Infant Feeding Survey 2010, pregnant women from unskilled occupation groups are five times more likely to smoke than professionals (20% compared with 4%), and teenagers in England are six times more likely to smoke than older mothers (35% compared with 6%). Under-reporting by pregnant women who smoke is highly likely due to the stigma attached to the behaviour (McAndrew et al. 2012). Infants born to smokers are much more likely to become smokers themselves which creates on-going cycles of health inequalities (RCP, 2010).

There is also evidence that smoking in disadvantaged communities is more socially acceptable, possibly because there is a higher prevalence of the behaviour. Poorer smokers are more likely to smoke more each day, making them more addicted to nicotine. In addition, richer smokers who attempt to quite are more likely to succeed than poorer smokers (PHE, 2015).

Smoking is twice as common among routine and manual workers in England in comparison to those in managerial and professional roles. People with mental health disorders are also twice as likely to smoke, and ever more so for those with more severe mental health disorders. People from lesbian, gay and transgender communities are also significantly more likely to smoke as well as people who are unemployed and some black, minority ethnic groups (PHE, 2015).

Links to other sections in the JSNA

Cardiovascular Disease

Smoking in Pregnancy

Smoking in Young People

Cancer

Respiratory

General Wellbeing

References

Action on Smoking and Health [ASH] (2014). ASH Ready Reckoner and LeLan Solutions, September 2014 [Online]. Available at: http://www.ash.org.uk/localtoolkit/R8-SE.html. [Accessed: 29/12/15].

Action on Smoking and Health [ASH] 2015. Smoking Statistics: Facts at a glance. [Online]. Available at: http://www.ash.org.uk/files/documents/ASH_93.pdf [Accessed: 29/12/15].

Department of Health (2007). Implementation Plan for Reducing Health Inequalities in Infant Mortality. London: HMSO. Available at: http://www.sepho.org.uk/Download/Public/11120/1/DH_081336.pdf

Department of Health (2011). Healthy Lives, Healthy People: A Tobacco Control Plan for England. London: HMSO. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213757/dh_124960.pdf.

Department of Health and Human Services [DHHS] (1988). The health consequences of smoking: nicotine addiction. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health. Available from: https://profiles.nlm.nih.gov/ps/access/NNBBXS.pdf

Department of Health and Human Services [DHHS] (1989). Reducing the health consequences of smoking: 25 years of progress. A report of the US Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Centre for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health. Available from: https://profiles.nlm.nih.gov/ps/access/NNBBXS.pdf

Doll, R., Peto, R., Wheatley, K. et al. (1994). 'Mortality in relation to smoking: 40 years' observations on male British doctors'. British Medical Journal; 309:901-911.

Godrey, C et al. (2010). Estimating the costs to the NHS of Smoking in Pregnancy for Pregnant Women and Infants. Project Final Report. York: Department of Health Sciences, University of York.  Available at: http://phrc.lshtm.ac.uk/papers/PHRC_A3-06_Final_Report.pdf. [Accessed: 06/01/16].

Heatherton, T., Kozlowski, L., Frecker, R. and Fagerström, K. (1991). 'The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire'. British Journal of Addiction; 86(9):1119-27. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1932883

Higa de Landoni, J. (1991). Nicotine. Poisons Information Monographs. Ottawa: International Programme on Chemical Safety. Available from: http://www.inchem.org/documents/pims/chemical/nicotine.htm

HM Government (2006). National Health Service Act 2006. London: HMSO. Available at: http://www.legislation.gov.uk/ukpga/2006/41/contents.

HM Government (2010). A smokefree future: a comprehensive tobacco control strategy for England. London: HMSO. Available from: http://webarchive.nationalarchives.gov.uk/20100509080731/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_111749.

HM Government (2012). Health and Social Care Act 2012. Available at: http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted.

Marmot, M. et al. (2010). Fair Society, Healthy Lives. London: HMSO. Available at: http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review.

McAndrew et al. (2012). Infant Feeding Survey: 2010.London: Health and Social Care Information Centre. Available at: https://data.gov.uk/dataset/infant-feeding-survey-2010.

National Institute for Health and Care Excellence [NICE] (2010). Smoking: Stopping in pregnancy and after childbirth (PH26) London: NICE. Available at: https://www.nice.org.uk/guidance/ph26/resources/smoking-stopping-in-pregnancy-and-after-childbirth-1996240366789.

NHS (2015). Smokefree NHS.Available at: http://www.nhs.uk/smokefree [Accessed: 24/12/15].

Public Health England [PHE] (2015). Tobacco Control: JSNA Support Pack 2016-17.London: HMSO.

Reading Borough Council, North and West Reading CCG and South Reading CCG. (2013). Reading's Health and Wellbeing Strategy. [Online]. Available at: http://www.southreadingccg.nhs.uk/images/publications/PDFs/ReadingHealthandWellbeingStrategy.pdf.

Royal College of Physicians [RCP] (1992). Smoking and the Young. London: Royal College of Physicians.

Royal College of Physicians [RCP] (2000). Nicotine addiction in Britain. A report of the Tobacco Advisory Group of the Royal College of Physicians. London: Royal College of Physicians.

Surgeon General: Department of Health and Human Services [SG] (2010).  How tobacco smoke causes disease: the biology and behavioural basis for smoking-attributable disease. A report of the US Surgeon General.Rockville, Maryland: US Department of Health and Human Services.

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