Smoking at Time of Delivery (SATOD) is recorded by midwives when a woman is booked in to deliver her baby, with women self-reporting their status as a smoker/non smoker.

Between 2011 and 2016, Bury’s SATOD steadily declined from 16.7% to 11.2%, which was a sharper decline than the trend for England during the period (13.6% SATOD in 2011 to 11% in 2016). Our rate increased slightly over the past two years, with the 2018 SATOD standing at 12%: the reason for the slight increase in unclear.  However, the overall trend is downwards, which mirrors SATOD figures for England; and national smoking trends for all ages.

Contributing factors to the continuing national decline in smoking prevalence overall and SATOD rates include a combination of tobacco control measures, driven by both national and local government. For example, rise in price of tobacco products, introduction of smoke-free laws and plain packaging and mass media campaigns urging people to quit.

Quitting smoking is one of the best things a woman and her partner can do to protect their baby’s health through pregnancy and beyond. Pregnancy is a window of opportunity for significant health improvement. SATOD has been used as the key measure to monitor activity trends.

As identified in the ‘data development’ section below, locally, there are gaps in the information which prevent us from understanding the SATOD cohort. However, profiles from the Infant Feeding Survey 2010 (HSCIC) suggest that mothers in routine and manual occupations and those who had never worked were five times as likely as those in managerial and professional occupations to have smoked throughout pregnancy. There is also an association between the age of the mother and smoking status. For the UK as a whole, mothers under the age of 20 were nearly four times as likely to smoke before or during pregnancy, than mothers aged 35 or over (57% compared with 15%). As well as being more likely to smoke in the first place, younger mothers were less likely to quit before or during pregnancy: 38% of mothers under the age of 20 did so compared with 58% of mothers aged 35 or above. Whilst there are low numbers going through the smoking cessation service the profile of these individuals’ correlates with the national picture.
Since April 2013 local authorities have had responsibility for the delivery of a range of public health outcomes, including a reduction in smoking prevalence and SATOD. This is set alongside the backdrop of national policies around minimum unit pricing, PHE awareness campaigns and legislative changes such as restrictions in smoking within cars carrying passengers under 18 years of age (from October 2015). Bury Council commissions a core stop smoking service, Bury Stop Smoking Service, which has a target of enabling 30 pregnant women to quit smoking each year (4 week quits). This equates to more than the recommended 5% (16 pregnant women) of the smoking population being treated. The council also commissions a number of pharmacies to deliver stop smoking provision, but there is no specific requirement for them to deliver quits for pregnant women; although they have been offered specific training.
In previous years, the service had a part-time specialist stop smoking midwife who was able to provide training to midwives as well as specialist stop smoking advice and support to pregnant women. This post became vacant approximately two years ago and subsequently, the service reports that the numbers of pregnant women being seen by the service has decreased. Since losing the post the service has piloted a number of initiatives to increase the number of pregnancy referrals. In August 2014 they started a new ‘local’ pregnancy reward scheme (10 places available on the scheme) – pregnant women who accessed the service were informed of the scheme and requirements of this (maintain a CO verified 4 week quit) and thus awarded a £10 boots gift voucher once achieved; they would then be entered into a prize draw where an additional £15 boots gift voucher would be awarded. Uptake was minimal; 6 pregnant women signed up to the scheme, 2 of which maintained a CO verified quit and received £10 Boots gift vouchers. The low level of uptake could be attributed to the size of the reward as the Tobacco Free Futures reward scheme in 2012-13 achieved a 69% 4 week quit rate (71% CO validated); however, the incentive in this instance was £300. The service has also held meetings with Midwifery Teams to encourage referrals, provide training and offer baby CO monitors to encourage Midwives to approach the issue of stopping smoking in pregnancy and complete Carbon Monoxide readings at appointments. However, due to the remodel of maternity services, time commitments and other service priorities, engagement has been low.

There has been a national drop in footfall through stop smoking services and therefore there needs to be more creative ways of engaging with smokers and offering the support they need to quit. This said, pregnant women on the whole, will be in touch with a range of mainstream services throughout the course of their pregnancy, so the challenge is to ensure that services that work with pregnant women are developing the pathways that will lead them to stop smoking. However, as the data above identifies, there is a need to ensure that once the women enter smoking cessation services, the conversion rate from smoking to maintain quits is increased.

Bury Clinical Commissioning Group (CCG) commission acute trust services, including midwifery. Whilst NICE guidance recommends that all pregnant women, whether or not they are smokers are screened for Carbon Monoxide at booking and at each subsequent appointment, as well as offered support to quit smoking if they are smokers, there is no contractual requirement or KPI for Midwifery services at present for them to provide this. Similarly, whilst GP’s have the opportunity under the Quality Outcomes Framework to be incentivised to record smoking status, at present there is no contractual requirement for them to provide stop smoking services, although a number of them do.

Whilst smoking prevalence at time of delivery has reduced the numbers of pregnant women coming through the stop smoking services and setting quit dates has been minimal. This would suggest that either women are quitting without the support of the stop smoking service, utilizing e-cigarettes (which is an unknown impact on mother and child) or there is potential inaccuracies with the data.

Data Development Agenda:

Data gaps:
•Demographic profile of the SATOD data
•Profile SATOD by location (IMD) and GP Practice
•Smoking at time of initial booking (first visit by midwife) vs. SATOD
•Number of women who may be using e-cigarettes to quit
•Conduct an in depth review of SATOD data, how it is collected, recorded and how it compares to number of pregnant women who say they are smoking at time of booking

Intelligence gaps:
•Why did someone stop smoking at the time of diagnosis
•What supported behaviour change locally

A more detailed action plan will be developed following further engagement; however, it is proposed that the actions fall into 4 broad categories:

Data
•Work with the CCG and associated services to undertake a data audit of the SATOD and review of current data sources, such as booking information, in line with the ‘Data Development Agenda’ (above).

Services
•Audit of the local implementation NICE guidance in relation to smoking in pregnancy
•Further research on best practice from neighbouring authorities who are achieving the national target and have made significant improvement in SATOD reduction. Assess what lessons can be learned and what the service infrastructure looks like
•Explore the current and potential offer of midwifery services in conjunction with the CCG, including the establishment of a robust pathway and option to create an opt out referral to the Stop Smoking Service and mandatory CO screening. This will include an appraisal of the support required and the feasibility of a local KPI
•Review the current Intermediate Advice offer, the training requirements and the introduction of a performance measure
•Review the current Stop Smoking Service offer in line with the recent novation to the local authority and the formation of a wellness service
•Revisit the TFF and GM incentive schemes to review effectiveness and potential for local implementation

Community Assets
•Engage with front line service and community assets, such as: children’s centre managers, housing providers, welfare officers, social services, sports and leisure providers, GPs etc. to look at the possibility of a workshop to discuss the issues, develop the pathways, look at the training etc.
•Use a targeted approach, possible in an area of deprivation with high levels of smoking prevalence to pilot a range of activities e.g. staff training, direct/ electronic referral into services, incentive scheme. This action will be informed by the improvement data on the current cohort

Public Awareness
•Scope the benefit of a targeted local awareness raising campaign around the ‘starting well’ agenda and the local risk factors where performance needs to be improved. This action will require improvements in the intelligence that is currently held.
•Advertise the digital communication resources that have been developed by PHE, such as the ‘Information Service for Parents’

File Attachments:

Information sources:
•Smoking Cessation HSCIC performance returns
•PHE Smoking in Pregnancy Seminars Final Report May 2015
•Infant Feeding Survey 2010, HSCIC
•The BMJ ‘Financial incentives for smoking cessation in pregnancy: randomised controlled trial’, published 27 January 2015
•Smoking Cessation in Pregnancy: A call to action
•Smoking Cessation in Pregnancy: A review of the Challenge May 2015
•NICE Smoking cessation in maternity services guidance, available from: http://pathways.nice.org.uk/pathways/smoking

Reducing smoking in pregnancy is key public health priority.

Smoking is the biggest modifiable risk to a mother and child during and after pregnancy. Smoking during pregnancy can cause serious pregnancy-related health problems. These include complications during labour and an increased risk of miscarriage, premature birth, low birth-weight and sudden unexpected death in infancy. Additional potential impacts include sudden placenta rupture and stroke and heart disease in mothers, birth defects, obesity and asthma in children.

Smoking in pregnancy is viewed as a significant contributory factor in health inequalities between socio-economic groups. Women who smoke during pregnancy are predominantly found in low socio-economic groups. They are generally disadvantaged and live in environments where smoking is not viewed as a major health risk; indeed it can be promoted as a method to secure smaller babies, which incorrectly are considered as easier to give birth to.

In Bury, 12% of pregnant women smoke at the time of delivery in 2018 (1 in 8 of new mothers). Recognising that - as outlined above - smoking results in poor health outcomes for the mother and unborn child, national regional and local strategies acknowledge there is a pressing need to further lower the rate of smoking in pregnancy.

The government’s “Towards a smoke free generation: A Tobacco Control Plan for England” gives a target to reduce the rates of smoking in pregnancy to 6% or less by 2022 (Department of Health and Social Care, 2017). Greater Manchester Health and Care Partnership has set an ambitious target to reduce SATOD to 6% across all localities by 2021. Reducing SATOD rates will also contribute towards NHS Saving Babies’ Lives care programme (aiming to reduce stillbirths by 20% by 2021).

To accelerate the reduction in SATOD rates, localities in Greater Manchester are taking part in pilot project “Babyclear” (from 2018). Details of this pilot are contained in the “what works” section.
To support the drive to reduce SATOD rates, and improve health outcomes, there is commitment in the NHS Long Term Plan to implement “a new smoke-free pregnancy pathway for expectant mothers and their partners” by 2023/2024.

The Public Health Outcomes Framework 2019-20 includes a new indicator “Maternal smoking at booking”. Collection of this information – which includes data on age and ethnicity - will provide supporting evidence to identify inequalities and also – when linked with SATOD rates, provide quantifiable evidence of whether health and social interventions which support expectant mothers who smoke are effective.

• Public Health
• Midwifery services within Acute Trusts
• Lifestyle service
• GPs
• Health visiting
• Children’s Centres

Reducing smoking prevalence, and reducing the SATOD rate in Bury is a key action within the delivery of our Locality Plan (2017-2021) and a stated ambition in our Primary Care Health and Wellbeing strategy. Supports the Marmot principles of “starting well” and “living well”, which in turn contribute to the Single Outcomes Framework and the outcome “All people of Bury live healthier, resilient lives and have ownership of their wellbeing”.

Our Tobacco Control Delivery Plan 2019-2022, approved by the Health & Wellbeing in March 2019, sets out our commitment to outlines how, working with our partners, we can effectively impact tobacco use across the borough, working to improve the lives of the next generation of Bury residents.

The Delivery Plan sets out local priorities and actions whilst linking closely with the national Tobacco Control Plan (2017) and the Greater Manchester “Making Smoking History” strategy 2017-2021, which outlines ambitious commitments for the region.

Bury Council are signatories to the Local Government Declaration on Tobacco Control and Bury Clinical Commissioning Group have signed the sister pledge, the NHS Statement of Support for tobacco control.

NICE have produced guidance which identifies treatments that have proven to be effective in smoking cessation. NICE have also produced a series of pathways with guidance specifically for supporting pregnant women who smoke. Recommendations include:
• the identification of all pregnant women who smoke and referral to smoking cessation services, this should be done at the first maternity booking
• Routine CO screening and recording of smoking status of all pregnant women.
• Training for all maternity staff on addressing the issue of smoking.
• Clear pathways into specialist stop smoking support for all pregnant women who smoke.

Localities in Greater Manchester have been taking part in a pilot project to drive down SATOD rates: “BabyClear”. “BabyClear” is an evidence-based approach, developed by the Tobacco Control Collaborating Centre, with the primary aims of improving the health of pregnant women and  reducing health risks to their unborn children.

Goals include:
• To support pregnant smokers to set a quit date and achieve a CO validated 4-week quit,
• to provide enhanced support to those women who have set a quit date and achieved a  4-week quit, within the scheme, to remain smokefree throughout the pregnancy and for 3-months post-partum

Babyclear is structured around the key pillars of:
• Enhanced cessation support
• A financial incentive/ reward for achieving and maintaining smokefree status
• Support from a Significant Other (SOS)

Bury pregnant women are screened at Fairfield and Bolton hospitals, receive CO monitoring, and discuss their smoking with their midwife, completing a risk perception tool. Women are encouraged to sign up to the scheme, where – if they give up smoking – they are given “Love2Shop” vouchers at various intervals on their journey. They are also encouraged to sign up a “Significant Other” to support and encourage them, alongside support from a maternity support worker. Figures for 18/19, recently released show a 62% validated quit rate for Bury women taking part in the scheme, and a quit rate of 55% (as at August 2019) for the GM localities taking part in the “BabyClear” scheme. These rates are compare to England quit rates of 28% 18/19. The BabyClear clear scheme is being monitored by NHS England, as a means of providing the pathway for pregnant women outlined in the NHS Plan and which supports the NICE guidelines.  Greater Manchester Health & Social Care Partnership have been funding the pilot, and discussions are currently taking place about sustainability of the project post March 2020, when the funding ceases. Clearly, these quit rates from the Babyclear scheme would support an accelerated reduction in SATOD rates, as required by the our targets for 2021

Bury Council commissions the Lifestyle service, which supports behavioural advice and support to pregnant women who smoke, although support with payment for smoking cessation treatments e.g. NRT etc. was withdrawn in March 2019. Activity information for the Lifestyle service and impact on the Babyclear project (pregnant women are still given support by midwife and maternity support worker, and financial incentives but no NRT/ pharmacological support) are being very closely monitored.

In addition to the continued delivery of the Baby Clear programme, other measures to control tobacco consumption include:
• Redesigning services: combining smoking cessation services with the Bury Lifestyle Service, to ensure services are accessible and holistic.
• Continued engagement with primary care staff to ensure they provide very brief advice and signposting to appropriate services.
• Raising awareness of the dangers of smoking and the support services available, through promoting regional campaigns including TV and radio.
• Promoting smoke-free environments and events
• Enforcing tobacco regulation, ensuring compliance by traders to standards relating to point of sale bans, age restrictions on sales etc.
• Offering support to quit via existing services such as the Bury Lifestyle Service but also via other pathways ( via telephone helplines and websites).

The Royal College of Midwives issued a position statement (July 2019) which outlined their support for women quitting smoking in pregnancy, including an updated position on e-cigarettes “…if a pregnant woman who has been smoking chooses to use an e-cigarette (vaping) and it helps her to quit smoking and stay smokefree, she should be supported to do so”; this acknowledges the fact that e-cigarettes contain some toxins, but at far lower levels than found in tobacco smoke. We are currently reviewing our position on e-cigarettes for pregnant women and residents in general (as at September 2019), given that a Public Health England presentation concluded in March 2019 that e-cigarettes are more effective than other smoking cessation cessation aids e.g. NRT, all other factors being equal e.g. provision of behavioural support.