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Pregnancy

Guidance Aims To Protect Thousands Of Unborn Babies And Small Children From Tobacco Harm
(Medical News Today:25 June 2010)

All pregnant women should be encouraged to have their carbon monoxide levels tested to determine
whether they smoke, thereby ensuring that pregnant smokers receive appropriate support to quit for the
good of their unborn baby. This change to current clinical practice is one of a number of
recommendations in new guidance published yesterday (23 June) by the National Institute for Health and
Clinical Excellence (NICE), to help women and their families give up smoking during and after
pregnancy.

Smoking during pregnancy can increase the risk of miscarriage, premature birth, still-birth and sudden
unexpected death in infancy[1]. Exposure to smoke in the womb is also associated with psychological
problems in childhood such as attention and hyperactivity problems[2]. Meanwhile, children of parents
who smoke tend to suffer from more respiratory problems like asthma or bronchitis and have problems of
the ear, nose and throat, compared to children in non-smoking households. Nearly half of all children in
the UK are exposed to tobacco smoke at home[3].

It is thought to cost the NHS between £20 million and £87.5 million each year to treat mothers and small
infants under 12 months old with problems caused by smoking in pregnancy[4].

To tackle this issue, new NICE guidance calls on midwives to assess every woman's carbon monoxide
levels at their first antenatal appointment by encouraging women to have a special breath test. High
carbon monoxide levels can be seen amongst active and passive smokers, so by testing the levels of all
pregnant women, those who smoke or who are regularly exposed to second-hand smoke will see a
physical measure of their exposure. The guidance also recommends that women who smoke and are either
pregnant or have recently given birth, are offered a range of options to help them quit, including
automatic referral to smoking cessation services and sensitive and non-judgemental support by
professionals.

Professor Mike Kelly, Director of the Centre for Public Health Excellence at NICE, said: "We've known
for many years that smoking and passive smoking can cause serious illnesses like lung cancer. During
pregnancy, smoking puts the health of the women and her unborn baby at great risk both in the short and
long-term, and small children who are exposed to second-hand smoke are more likely to suffer from
respiratory problems.

"One of our recommendations is for midwives to encourage all pregnant women to have their carbon
monoxide levels tested and discuss the results with them. This isn't to penalise them if they have been
smoking, but instead will be a useful way to show women that both smoking and passive smoking can
lead to having high levels of carbon monoxide in their systems. It will also alert non-smokers with high
carbon monoxide levels to possible CO poisoning, which can be caused by a faulty boiler or car
emissions."

In 2005, almost one third of mothers smoked before or during pregnancy[5]. Despite nearly half (49%) of
these women giving up before the birth of their baby, three in ten were smoking again less than a year
after childbirth[6]. Younger women aged under 20 are five times more likely to smoke while pregnant
than women over 35 years old[7]. Smoking during pregnancy is also more common in women who are
less educated, are not homeowners and are either single or live with a partner who smokes.

The guidance contains recommendations for GPs, midwives, health visitors and others involved in
antenatal and postnatal services, as well as other professionals including dentists, pharmacists and those
working in smoking cessation services, fertility clinics, children's centres, voluntary organisations and
local authorities.

Professor Catherine Law, Professor of Public Health and Epidemiology at UCL Institute of Child Health
and Chair of NICE's Public Health Interventions Advisory Committee, said: "This guidance aims to
protect the health of children by encouraging and supporting women and their families to give up
smoking during or after pregnancy and for the long-term. We know quitting can be difficult, which is why
the guidance calls for a multi-disciplinary approach to provide a network of support to help expectant
mums, or those who have a small child, quit for good. If they can do this, both they and their children can
look forward to healthier futures"

Key recommendations of the guidance include:

- Assessing a pregnant woman's exposure to tobacco smoke through discussion and use of a CO test at
their first antenatal appointment and subsequent appointments

- Routinely referring women who smoke to NHS Stop Smoking services and providing women with the
NHS Pregnancy Smoking Helpline number

- Suggesting to partners who smoke that they contact NHS stop Smoking Services for help to quit

- Formal training for healthcare and smoking cessation staff to ensure advice is offered in a non-
judgmental way

- Offering women personalised help, support and information on how to stop smoking.

The guidance also includes recommendations for NHS Stop Smoking Services when considering the use
of nicotine replacement therapy (NRT), such as:

- Discussing the risks and benefits of NRT with pregnant women who smoke, use only if smoking
cessation without NRT fails and use professional judgement when deciding whether to offer a
prescription.

- Only prescribing NRT for use when a woman has stopped smoking. Only two weeks of treatment should
be prescribed at any one time with subsequent prescriptions only given to women who can demonstrate
they are still not smoking.

Jane Brewin, Chief Executive of baby charity Tommy's, said:"The sooner women who are pregnant can
give up smoking, the better. Every baby deserves the best start in life and those born to smokers tend be
smaller and weaker than other infants. However, it's important pregnant women feel supported if they
make the decision to quit, and are aware of the stop smoking services available to them."

NICE has produced a range of tools to help organisations and health, childcare and smoking cessation
professionals implement this new guidance.
Deborah Arnott, Chief Executive of Action on Smoking and Health (ASH), said: "Only a very small
proportion of women smokers carry on smoking after getting pregnant, but those who do tend to be the
heaviest and most addicted smokers who need support and help from healthcare professionals to quit. We
welcome the NICE guidance which is designed to be practical and encouraging and not to condemn
pregnant smokers for their addiction."

Commenting on the role of NHS Stop Smoking services, Dr Elin Roddy, Chair of the British Thoracic
Society Tobacco Specialist Advisory Group, said: "Pregnancy is a vital time to encourage smoking
cessation as it improves not only maternal health but reduces the chances of premature birth and birth
complications. Stop smoking services make a significant and indeed cost-effective improvement to health
and Stop Smoking Practitioners, based both within primary and secondary care, provide an essential
contribution to the NHS. We encourage national policy-makers at all levels to continue to support stop
smoking services to ensure that all those who wish to stop smoking receive the necessary advice and
support".

NICE has produced a range of tools to help organisations and health, childcare and smoking cessation
professionals implement this new guidance. These can be downloaded from the NICE website.

Notes

About the guideline

- The NICE guidance on "Quitting smoking in pregnancy and following childbirth", including a version
for patients and carers, and corresponding implementation tools are available from the NICE website.
(from Wednesday 23 June 2010).

- The total annual cost to the NHS of smoking during pregnancy is estimated to range between £8.1 and
£64 million for treating the resulting problems for mothers and between £12 million and £23.5 million for
treating infants (aged 0-12 months)[8].

- The guidance was developed by the Public Health Interventions Advisory Committee (PHIAC) on
behalf of NICE. The recommendations were developed following a thorough review of available
evidence, economic modelling, expert advice, stakeholder comments and fieldwork.

- The recommendations mainly cover interventions to help pregnant women who smoke to quit. No
specific recommendations have been made for those planning a pregnancy or who have recently given
birth. This is due to the lack of evidence available on stop-smoking interventions for these groups and
does not constitute a judgement on whether or not such interventions are effective or cost effective.

- The baby charity, Tommy's, is currently developing a guide for professionals who work with pregnant
teens. The resource, "Talking about smoking in pregnancy", will aim to help professionals encourage
pregnant teens to quit smoking and engage with stop smoking services. It will be available from October
2010.

[1] Royal College of Physicians (1992) Smoking and the young. London: Royal College of Physicians

[2] Button TMM, Maughan B, McGuffin P (2007) The relationship of maternal smoking to psychological
problems in the offspring. Early Human Development 83 (11): 727-32

[3] Jarvis MJ, Goddard E, Higgins V et al. (2000) Children's exposure to passive smoking in England
since the 1980s: cotinine evidence from population surveys. BMJ 321: 343-5
[4,8] Godfrey C, Pickett KE, Parrot S et al. (2010) Estimating the costs to the NHS of smoking in
pregnancy for pregnant women and infants. York: Department of Health Sciences, The University of
York

[5,6,7] British Market Research Bureau (2007) Infant feeding survey 2005. A survey conducted on behalf
of the Information Centre for Health and Social Care and the UK Health Departments. Southport: The
Information Centre