On Tuesday 26th June the latest in the series of Health Challenge Wales seminars took place at Cardiff University. The focus of this seminar was smoking in pregnancy, looking at this issue in relation to current research and how policy and practice are addressing it.
The introductory talk was given by Chris Tudor-Smith from the Welsh Government, who mapped out the policy context in Wales, some of the main harms caused by smoking in pregnancy, and the actions being taken to reduce prevalence levels. A key point which I took from this talk – and from several others – was the social patterning of smoking prevalence, with much higher rates in more deprived communities, and the link between smoking and health inequalities. Other key points to emerge from this talk (and which ran through the afternoon as a whole) were the importance of optimising referral pathways (e.g. to smoking cessation services) and the need to ensure systematic data collection in healthcare settings.
Next was an engaging talk from Tim Coleman from the UK Centre for Tobacco Control Studies. He presented results from an RCT of Nicotine Replacement Treatment (NRT) patches for pregnant women (the SNAP trial). The key findings were that in terms of prolonged abstinence (from quitting in pregnancy to end of pregnancy) NRT showed no effect in comparison to placebo, though it was effective in the short term (1 month post quitting). Interestingly, though, Tim pointed out that at 1 month post-pregnancy, smoking cessation rates were much higher in the NRT group participants. The talk, and the discussion afterwards, highlighted the complexity and multifaceted nature of intervening in this area, including the low rates of adherence to NRT among participants, and how increased metabolism rates in pregnancy might have impacted on nicotine levels, and therefore the efficacy of the patches.
The third talk, by Siobhan Jones from Public Health Wales, stressed the importance of health in pregnancy in influencing children’s health over the life course, and looked at some of the key policy challenges in reducing smoking rates. These included the need for more evidence on key treatments such as NRT, understanding the best sites, settings and staff to deliver interventions, consistent data collection and monitoring, creating and sustaining effective referral systems and increasing service uptake rates. She argued that we needed to implement what we know works in a systematic way, and to also look at new approaches.
Finally, Heather Morgan from Aberdeen University presented the findings from the BIBs study, which is examining the potential of using incentives for smoking cessation during pregnancy, and their feasibility and acceptability. The first stages of the study focused on reviewing the literature. A key strength of this study for me was the way in which it was engaging with mothers and other stakeholders to capture their views and to integrate these with the findings of the review. The studies reviewed suggested that incentives could be effective, but that their impact reduced over time, and there was some uncertainty about what levels of incentive were needed. Heather’s talk also highlighted the complexity of using incentives, including issues of stigmatisation, how best to deliver incentives (guaranteed payments or more informal methods such as lotteries), and the role women’s families played (particularly partners) in influencing cessation rates.
So what did I take away from the afternoon’s presentations? Some key points for me were firstly that smoking in pregnancy has relevance to a range of policy makers, practitioners and researchers, and we need to think about it in the context of long term health outcomes, health inequalities, and the financial implications for the broader NHS of reducing smoking prevalence. Secondly, as the afternoon progressed, the complexity and multifaceted task of addressing smoking during pregnancy was highlighted, which spans individual psychology, metabolism, service delivery, and social norms, and the connections between these multiple levels. Thirdly, context matters, and the ways in which services are implemented, how women access them, and the acceptability and feasibility of interventions is crucial when investigating whether they work. Finally, the area of smoking in pregnancy is one in which the evidence base has gaps and uncertainties. This might be addressed both by more consistent routine data collection as well as research trials and other studies.
As someone not working in the field of pregnancy or smoking cessation, it was good to take a ‘sideways step’ and find out more about the issues and challenges that colleagues in another, if related field, are engaging with. In Public Health research it’s important that we make connections across different behaviours and settings. And it’s good to know that there are lots of other people out there grappling with complexity – both in terms of finding what works and how, and the best ways of implementing interventions.
Dr. Jeremy Segrott (@DrJeremySegrott) is Research Fellow in Public Health at DECIPHer. For more information about the Health Challenge Wales seminar series visit the HCW page on the DECIPHer website or contact Zoe Macdonald. You can also follow the seminars via Twitter using the hashtag #hcwseminar.