MAKING SMOKING HISTORY IN GREATER MANCHESTER
E.Benbow, A.Crossfield and M.Hancock on behalf of the Greater Manchester Health and Social Care Partnership Making Smoking History Programme
Background and Aims
Greater Manchester (GM) is leading the way for tobacco control in the UK and has an ambition to be the first global city to Make Smoking History (MSH). This will see smoking prevalence reduce by one third between 2016 and 2021 and eventually MSH by 2027. This is GM’s single greatest opportunity to close the gap on health outcomes.
GM has an ambitious strategy which delivers an innovative approach to population level tobacco control. This is based on an international evidence-based framework with an additional component to capitalise on citizen engagement.
Published national data shows the rate of residents who smoke in GM has fallen to 16.2% in 2018, from 18.4% in 2016. This represents around 46,500 fewer smokers since the programme began and has seen the gap between England and Greater Manchester prevalence rates fall from 2.9% in 2016 to 1.8% in 2018.
GM’s quarterly Smoking Toolkit Study data shows more smokers in GM are making a quit attempt compared to England as a whole, 42.2% compared to 28.3% in the last quarter.
The proportion of people who smoke is falling twice as fast in GM compared to England as a whole. Quit attempt rates are significantly higher in GM compared to England and a reduction in prevalence of this level and at this pace has never been achieved by any other major global city. Figures indicate that GM is on target to meet its bold target.
GREATER MANCHESTER SMOKEFREE PREGNANCY PROGRAMME
J.Coyne, A.Crossfield, H.Wareing, F.Frankland, M.Ussher, M.Hancock.
Nationally, an ambition has been set to reduce smoking rates in pregnancy to less than 6% by 2022 . In Greater Manchester GM we have committed to reduce smoking at time of delivery (SATOD) rates to meet this 6% target by the earlier date of 2021.
Delivery of system wide support for smoking cessation in pregnancy through the evidence-based babyClear model, embedding organisational change in line with NICE guidance and Saving Babies Lives recommendations. It includes a unique risk perception intervention for smokers at their booking scan and includes a Smokefree pregnancy incentive scheme which targets a defined group of vulnerable women.
Evaluation of the programme is in the early stages of implementation; however published data shows that SATOD rates in GM have reduced at a faster rate than England as a whole. In the first year of the programme CO screening at booking has increased from 20% to a GM average of 90%. Referrals to maternity stop smoking services have increased and quit rates in some localities are double the national average.
The approach ensures a standardised pathway for maternity stop smoking support and reduced disparity of service provision. Overall SATOD rates in GM are decreasing, with quit rates in some areas of GM more than double the national average.
Towards A Smokefree Generation – A Tobacco Control Plan for England (Department for Health, 2017),pg 10
Smoking: stopping in pregnancy and after childbirth (National Institute for Health Care Excellence, June 2010
Saving Babies Lives: A care bundle for reducing stillbirth (NHS England, 2016)
CARBON MONOXIDE SCREENING AT EVERY ANTE NATAL CONTACT
D. L. Hill, Portsmouth Hospital NHS Trust
L. M. Clarke
The aim of the project was to introduce Carbon Monoxide (CO) monitoring as part of all ante natal contacts. We aspire to detect at risk babies from women with increased levels of CO in pregnancy. It is known that exposure to CO in pregnancy can restrict oxygen from reaching the baby, which can slow its growth and development and can result in miscarriage, stillbirth and sudden infant death.
Exposure can be measured through a quick and simple breath test. Those women who have CO levels above 4 parts per million (ppm) and are smokers are referred to local smoke cessation services at each opportunity throughout the pregnancy. By introducing CO monitoring at every contact it becomes imbedded as part of routine ante natal care for all women and increases the occasions where you can address smoking in pregnancy.
By introducing this project it has increased our CO monitoring at booking from 6% to 61%. It was also important to use CO monitors that the midwives and maternity support workers have confidence in and have access to in all areas where ante natal women are seen. All maternity staff have received training in CO monitoring, the risks of CO exposure in pregnancy, the referral pathway for smoke cessation services and to give brief advice of the risks of smoking and exposure to passive smoking in pregnancy to the women and her partner.
Department of Health, (DOH), (2017), Towards a Smoke free generation.
National Centre for Smoking Cessation and Training, (NCSCT), (2015), Smoking Cessation: A briefing for maternity staff.
NHS England, (2016), Saving babies lives, A care bundle for reducing stillbirth.
NHS England, (2019), Saving babies lives care bundle Version 2: A care bundle for reducing perinatal mortality.
NHS, (2019), The NHS Long term plan.
A QUALITY IMPROVEMENT PILOT FOR SMOKING CESSATION SUPPORT TO FAMILY MEMBERS WISHING TO QUIT SMOKING TO IMPROVE THE QUIT ENVIRONMENT OF THE SMOKING PREGNANT WOMAN
F. Ballard. Poole Hospital NHS Foundation Trust.
Contact details; firstname.lastname@example.org. Poole Maternity Unit, Longfleet Road, Poole, Dorset, BH15 2JB. 01202 665511 Ext 2316
Affiliation; J.Green, B. Jacobs
Background: Overall the Smoking in Pregnancy Service statistics at Poole Hospital NHS Trust (PHFT) are better than both the regional and national SATOD rates.
Last year smoking rates reduced from 12.7% at booking to 8.3% at delivery using the Baby Clear model however, we can do more.
48% of women failed to engage in the service and of those that did engage, 25% failed to quit smoking. It is widely believed that it is the smoking partner and/or smoking household family members which inhibit her success. Last year (2018/19) we had 292 pregnant smokers at booking with 58.3% of the partners smoking too.
Existing signposting of partners and/or family to the local cessation service hasn’t worked, with only 4% of the 101 partners referred actually accessing the services last year.
Aim: To reduce our prevalence of smoking in pregnancy to 6% or less by the end of 2022 by: • Increase engagement of pregnant smokers from 52% to 75% and maintain or improve the current quit rate of 75%. • Increase the partner engagement rate from 4% to 30% and achieve a quit rate from 2.2% to 30%. • Tackle the public health benefits of the 20-45 year old targeted age group who smoke and usually do not access health care. • Reinforce the simple prevention strategy that prevention is better than cure.
Method: Partners, a significant other or family members of the pregnant smoker will be encouraged to be present during the initial home visit with the specialist midwife. It is during this consultation that the recommended holistic smoking cessation intervention; direct supply of pharmacotherapy and behavioural support will be offered to the whole family if they smoke. The initial weekly visits are crucial during the early period to support behavioural change which can then be reduced and tailored to the individual families’ needs. The measurement of exhaled CO measurements using a handheld carbon monoxide monitor will be used as a motivational tool and to validate the quit.
Initial Results: Early Results: 1. Engagement of pregnant smokers setting a quit date has remained static at 52% (pilot target 75%) but quit rates of those engaged has increased from 75% to 78% 2. Partner engagement rate has increased from 4% to 39% (pilot target 30%) 3. Partner quit rates have increased from 2.2% to 60% (target 30%) and interestingly 90% opted for Varenicline as their first choice of pharmacotherapy. 4. Two thirds of the family members are from the targeted 20-45 year olds who smoke and usually do not access health care.
Conclusions:Early indications are that this holistic project is successful at reinforcing the simple prevention strategy that prevention is better than cure to this important group of patients and this has the potential for national roll out. This is the first time direct supply of Varenicline has been offered to ‘Significant others’ by Specialist Midwives as part of a NHS Trust Smoke Free Pregnancy Service and over this next year we hope to see that this pilot has a positive impact on:
• Reducing our SATOD to hit the 6% target by 2022
• Accessing all demographics
• Targets the ‘forgotten smoker’, the 20-50 year old smoker who are our NHS’s future long term condition patients
• Targets the under 15 years olds who smoke (where the pregnant mother has a teenage child or younger sibling)
ACHIEVING A SMOKE-FREE PRISON ON A SMALL ISLAND
Dr R. Reardon; K. Heyes; A. Buttimer
La Moye prison in Jersey was exempt from smoke-free legislation implemented in 2007. The Jersey Tobacco Strategy (States of Jersey, 2016) highlighted that prisoners were a key group to target. This was further supported by the Jersey smoking profile showing smoking rate in 2017 was 16%, whilst smoking rates in prison remained high at 85% (States of Jersey, 2017).
Jurisdictions with smoke-free prisons were consulted to gain insights. These suggested e-cigarettes should be offered as an aid to quitting or to abstain from smoking whilst incarcerated.
Staff from various government departments worked collaboratively to enable the prison to go smoke-free including teams from public health, preventive programmes and prison staff.
Prisoners were made aware of the upcoming ban on smoking during 2018 and were offered stop smoking support in groups or one-to-one and free nicotine replacement therapy.
Prison staff received training in very brief advice with extended training for healthcare staff in the use of nicotine replacement and assessment of nicotine dependency.
In 2018, 42 prisoners received support to quit with 71% being successful. The prison became smoke free on 7 January 2019. In the first three months of January 2019 an additional 31 prisoners received support.
The prison population in Jersey is around 120, meaning more than half of the prisoners accepted support. The remaining prisoners chose to abstain by using e-cigarettes.
Despite concerns, there was no increase in violence within the prison. However, some prisoners have been using nicotine products to smoke with tea leaves. This is something that has also occurred in other prisons. Future work will look at offering varenicline as a first line treatment.
States of Jersey. (2016). Tobacco strategy 2017 – 2022. Strategic Public Health Unit: Jersey. https://statesassembly.gov.je/assemblyreports/2016/r.129-2016.pdf accessed
States of Jersey. (2017). Jersey smoking profile. Statistics Jersey: Jersey.
Corresponding author contact details:
Dr Rhona Reardon:Email: email@example.com
Dr R Reardon and K Heyes
Government of Jersey
Help2Quit Stop Smoking Service
Maison Le Pape, The Parade,St Helier. Jersey,
A Buttimer, Government of Jersey
States of Jersey Prison Service
La Moye Prison, La Rue Baal, St Brelade, Jersey
IMPACT OF AN IN-PATIENT SMOKING CESSATION ADVISOR
Z. Pond, R. Taylor. University Hospitals Southampton NHS Trust.
Hospitalisation presents a unique opportunity to initiate comprehensive tobacco cessation treatment.  A smoking cessation advisor post was created within our trust to support the ‘Risky Behaviours’ CQUIN  to provide face-to-face and telephone support and to identify barriers and solutions to identification, advice giving and onward referral and treatment.
Referrals are received electronically. Ward visits are made by the advisor or by phone if the patient has been discharged. They assess readiness to quit, give advice how to stop and recommend products. Onward referral is made for those where available. Where services are deemed inaccessible to the patient (eg housebound or frequent hospital attender) further ‘extended support’ is given. This consists of a variable number of phone contacts. Typically, one week post discharge, then at fortnightly intervals. This is mostly ‘behavioural’ with practical advice and encouragement including problem solving.
414 referrals were received over 5 months. 345 received in-patient visits. Others were not seen prior to discharge or were out-patients. 7% declined discussion. 56.5% had a recommendation re products. Others either declined or medication had already been prescribed. 8% were referred to an available service and 43.5% were signposted to support. Extended support was given to 11.1% (46 patients). These patients were often struggling to quit completely initially but with further support a number were able to quit completely. Further medication requests were needed for some. 39.1% (18 patients) of those given extended support were self-reported smokefree at 4 weeks following quit date.
An in-house smoking cessation advisor has not only facilitated the pathway to referral for smoking cessation where available but also allowed individualised extended support with good outcomes in difficult to access groups in the limited numbers supported to date.
1. The Ottawa Model https://ottawamodel.ottawaheart.ca/files/omsc/docs/omsc2011-12report.pdf
2. CCG CQUIN 2019/20 Indicators Specifications
THE ROLE OF HEALTH VISITORS IN SMOKING CESSATION – THE BETTER BIRTHS EXPERIENCE
Fiona Johnson. Public Health Dorset.
Introduction: Smoking during the postpartum period exposes infants and families to adverse health effects. During the Better Births initiative in Dorset it was recognised that Health visitors could support smoking cessation and relapse prevention.
Aim: To examine if using CO screening during Health visitor contacts supported women to stay smoke free postpartum and to better understand the benefits and barriers.
Method: 10 Health Visitors completed smoking cessation brief intervention and CO monitor training. A 6 month pilot project involved CO screening at the antenatal, new birth and 6-8 week visits. A mixed method research strategy was used with quantitative data from women screened and a focus group of 5 Health visitors to explore the experiences of conducting the intervention.
Results: 77% of women screened who gave up smoking during pregnancy remained smoke free 6-8 weeks post birth. Health visitors felt that the CO screening was a useful aid for conversation. However, time pressure was a barrier. Many women did not want to be referred on to Smoking cessation services. Health visitors recognised this could be a valuable opportunity to provide support but needed knowledge on NRT and e-cigarettes.
Conclusion: A higher percentage of women remained smoke free postpartum compared to other studies. The CO screening enabled the conversation about smoking behaviours to be meaningful. Barriers included lack of time and further training to cover cessation methods and e-cigarettes.
Training was provided by iPiP and funded by PHE as part of their work to reduce the prevalence of smoking in pregnancy.
HEALTHY LIFESTYLE FOR A HEALTHIER YOU AND BABY
S. McDonald(1), C. Sookunhull(2), T. Tomblin(3)
1Princess Alexandra Hospital
2East And North Hertfordshire NHS Trust
3West Hertfordshire Hospitals NHS Trust
Claire, Tara and I are working at three NHS Hospitals across Herts and west Essex. We work closely together as Healthy Lifestyle lead midwives, taking forward our LMS (Hertfordshire & West Essex) Better Births- prevention workstream. The workstream has 6 priorities identified by our local councils and CCGs; they are smoking in pregnancy, mental well-being, healthy weight, Breastfeeding, vaccinations, and making every contact count; with regards to alcohol consumption during pregnancy, domestic abuse & emotional resilience, oral health & folic acid & vitamins.
Our aims and objectives are to
· Achieve targets, identified by SBLV2, PHE, DH & Professional Bodies (RCOG, NICE, RCM) Herts & Essex County Council/CCGs
· Bring together workstream priority professionals/leads in order to share good practice, information & resources
· Utilise evidence to inform and change practice to improve the health & wellbeing of our women and their families
We have introduced the concept of, ‘communities of practice’ , with our professional leads from each of the workstream priorities and have been working collaboratively now for the last 7 months with some great feedback and positive results and achievements specifically in the areas of smoking cessation and healthy weight.
Communities of Practice; “Groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly.” (Lave and Wenger 2014). The learning that takes place is not necessarily intentional.
There are challenges and limitations not least in the identification of priorities for individual Trusts and inconsistencies in practice & provision across the LMS. As well as IT systems which do not talk to each other (a national problem), plus data collection & reporting. What we feel very passionately is that we are working together to improve the health & wellbeing for our women and their families across our LMS and across the boundaries.
COPING WITH CARBON MONOXIDE (CO) EXPOSURE: AN INTERPRETATIVE PHENOMENOLOGICAL ANALYSIS
Julie Connolly, Liverpool John Moores University.
Through this PhD research, I explored the lived experiences of 11 participants who are coping with unintentional exposure to carbon monoxide (CO), using Interpretative Phenomenological Analysis (IPA). Approximately 60 people of all ages lose their lives from preventable CO exposure in England and Wales each year (NHS, 2019), and people who survive CO exposure may be injured and have long-lasting, burdensome sequelae (Chavouzis and Pneumatikos, 2014). People also have to cope with the traumatic experience of the exposure itself.
CO is produced during the incomplete combustion of carbon-based material (Mandal et al., 2011; Kokkarinen et al., 2014), and is known as the ‘silent killer’ (Long and Flaherty, 2017), as it is undetectable to human senses and small amounts are extremely harmful. Academic and medical literature on CO is written from the perspective of healthcare professionals, and has therefore failed to address the perspectives of people who are coping with this experience. This research sought to address this situation.
Methodology and findings: An unstructured interview approach, where people were visited twice, was used to generate data. Two dyads were included in this number. This data was then analysed using IPA, where four superordinate themes emerged: ’traumatic experience’, ‘power, justice and judgement’, ‘identity and connectedness’ and ‘everybody seems to be in the dark’.
Discussion and conclusion: A feature of the research was the lack of voice afforded to those who have been exposed to CO. This often led to feelings of isolation. The participants also continued to face many challenges due to their exposure. As well as substantial sequelae from the exposure itself, they also faced issues due to the lack of knowledge about CO. My analysis suggested that many participants coped well with the effects of CO exposure. However, there were complexities around perceptions about the self and identity. Concepts of power and justice also operate with regards to living with the aftermath of exposure to CO.
REDUCING HEALTHCARE COSTS BY IMPLEMENTING AN INPATIENT TOBACCO CESSATION SERVICE
Kathleen B. Cartmell, Clara E. Dismuke, Georges J. Nahhas, Martina Mueller, Mary Dooley, Graham W. Warren, Vince Talbot, K. Michael Cummings
This study set out to test the hypothesis that 1-year post discharge healthcare costs will be lower among those patients of Medical University of South Carolina who are smokers and who are exposed to the tobacco dependence treatment service as compared to those who are not exposed to the tobacco dependence treatment service (TDTS).
In the United States, the Joint Commission (JC) recommends that all current smokers receive tobacco cessation services as an inpatient and be followed up within one month after hospital discharge. Few hospitals implement JC standards due to extra costs, the voluntary nature of the standards, and the lack of evidence demonstrating financial benefits to the hospital and insurers.
The Medical University of South Carolina (MUSC) implemented an inpatient tobacco dependence treatment service (TDTS) which provides a bedside consult with patients and phone follow-up using interactive voice response (IVR) technology after discharge consistent with JC standards. A previous study had found that those exposed to the TDTS had 2-fold higher quit rate 1-month after discharge compared to those not exposed to the program.
The study population included 3,158 smokers who were acute care patients admitted and discharged from the MUSC over a seven-month period. The study utilized in-place data capture mechanisms to link patient data across 3 data sets: 1) the MUSC electronic health records (EHR) database; 2) the MUSC-TDTS database (TelASK), and 3) the South Carolina Inpatient Hospitalization Dataset (i.e. state billing claims data). Initial linkage between the MUSC EHR and TDTS databases was done to identify MUSC inpatients eligible for the study, and this merged database was sent to the South Carolina Revenue and Fiscal Affairs Office (SC-RFAO) to obtain follow-up statewide healthcare utilization and cost data among our MUSC inpatient cohort.
Secondary data analyses were carried out to compare healthcare costs among smokers exposed to the TDTS and those not exposed to the service. Among patients in our dataset, we evaluated total healthcare costs post-discharge from MUSC for a 1-year period. Costs taken into account included post-discharge inpatient, ambulatory surgery and emergency department charges.
Results and Discussion
Exposure to the TDTS was associated with a clinically important reduction in health care costs. The average marginal impact of exposure to the TDTS on overall charges post index admission was a reduction of $8,429 after adjusting for age, race, payer, insurance status and Charlson score for the time period under consideration.
This study led to further analysis that incorporated the cost of development and implementation of the program in order to enable examination of overall program cost effectiveness from the perspectives of hospitals, insurers and patients. This result of this further analysis was published in 2019 in the journal Medical Care and is entitled: Effect of an Evidence Based Tobacco Treatment Service on 1-Year Post-Discharge Healthcare Cost Savings.
The organisers of the First SCAH Conference would like to thank the following organisations for their support:
The Platinum Sponsors:
Confirmed support has been obtained from the following companies: Thornhill Medical, Intermedical Ltd, NextGen360, MD Diagnostics and Pfizer through the purchase of trade exhibition stands. These supporting companies have had no input to the educational content of the programme. TelASK Technologies Inc. has been invited to give their North American experiences in the programme.