Smoking Cessation In Pregnancy – Barriers & facilitators

Smoking Cessation In Pregnancy – Barriers & facilitatorsFiona DunlopHealth Improvement Lead (Tobacco)

With thanks to Jacki Gordon & Associates for undertaking the evaluation

Fiona DunlopHealth Improvement Lead (Tobacco)

With thanks to Jacki Gordon & Associates for undertaking the evaluation

Presentation overviewPresentation overview

Background

Methods

Quantitative findings

Qualitative findings Recommendations

Background

Methods

Quantitative findings

Qualitative findings Recommendations

SPS pathwaySPS pathway

1. CO testbooking

4. Appointmentarranged

5. Face to faceintervention

2. Electronicreferral

3. Opt in/outcall

6. Telephonesupport

7. 3/12 monthFollow up

Other referrals•Clinic•Midwife•Self•GP/SCI•In-patient

RationaleRationale

2521

1665

1372

908 812

289

0

500

1000

1500

2000

2500

3000

Referrals Contacted Arranged appointment

Attended Set quit date Quit @ 4 weeks

SPS Activity 1st April 2011 to 31st March 2012

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

RationaleRationale

2521

1665

1372

908 812

289

0

500

1000

1500

2000

2500

3000

Referrals Contacted Arranged appointment

Attended Set quit date Quit @ 4 weeks

SPS Activity 1st April 2011 to 31st March 2012

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

RationaleRationale

2521

1665

1372

908 812

289

0

500

1000

1500

2000

2500

3000

Referrals Contacted Arranged appointment

Attended Set quit date Quit @ 4 weeks

SPS Activity 1st April 2011 to 31st March 2012

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

RationaleRationale

2521

1665

1372

908 812

289

0

500

1000

1500

2000

2500

3000

Referrals Contacted Arranged appointment

Attended Set quit date Quit @ 4 weeks

SPS Activity 1st April 2011 to 31st March 2012

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

MethodsMethods

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

SPS data analysisSPS 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

Characteristics of interviewees (n = 30)Characteristics of interviewees (n = 30)  Referral Source SIMD

PNBS

ClinicMid-wife

Self 1 2 3

Condition 1 8 - - - 7 1 -

Condition 2 2 2 2 - 5 1 -

Condition 3 6 1 1 - 3 5 -

Condition 4 5 2 - 1 3 3 2

Women’s ‘smoking cessation journeys’ are complex and highly individual.

Women’s ‘smoking cessation journeys’ are complex and highly individual.

There are many factors that can impact on adherence to the service and success

Views of service...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’.

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

No contact details for service

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

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.

PovertyAddictions

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.

PovertyAddictions

Boredom and stress Barriers and challenges

not always discussed/addressed

Timing of phone calls – disengagement

No contact details

Smoking reduction…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?

Other issuesOther 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

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

RecommendationsRecommendations

Recommendation 1:Inequalities sensitive practice

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

Recommendation 2:Information provisionRecommendation 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

Recommendation 3: Referral and appointment

practices

Recommendation 3: Referral and appointment

practicesFinding: 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?

Recommendation 3 cont..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.

Recommendation 4: Overcoming boredom and stress

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??

Recommendation 5: Protocol for reduced

consumption

Recommendation 5: Protocol for reduced

consumptionFinding: 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.

Recommendation 6:Discontinuation of NRT

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 useConsider feasibility of SPS offering a review visit

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 useConsider feasibility of SPS offering a review visit

Recommendation 7:More joined up working

Recommendation 7:More joined up working

Finding:Others (midwives) often unaware how women got on

Recommendations:Consider a feedback mechanismOpportunities for others to provide encouragement e.g. midwives, radiographers etc?Clear and sustained referral mechanisms from FNP?

Finding:Others (midwives) often unaware how women got on

Recommendations:Consider a feedback mechanismOpportunities for others to provide encouragement e.g. midwives, radiographers etc?Clear and sustained referral mechanisms from FNP?

Recommendation 8:Preventing relapse

Recommendation 8:Preventing relapse

Finding: Many had quit when previously pregnant

Recommendation:Expand reasons for not smokingConsider how topass the baton to postnatal services

Finding: Many had quit when previously pregnant

Recommendation:Expand reasons for not smokingConsider how topass the baton to postnatal services

Contact detailstelephone: 0141 201 4520

email: fiona.dunlop@ggc.scot.nhs.ukWeb: www.nhsggcsmokefree.org.uk