Health inequalities, infant mortality and stillbirth

1. Health inequalities, infant mortality and stillbirth The role of tobacco control and smoking cessation Hilary Wareing, Director Improving Performance in Practice (iPiP) Limited

2. Objectives • What do we know about the impact on still birth, infant mortality and health inequalities? • What are the drivers and challenges? • What is the evidence for action and how do we make it work in practice? • Who needs to take action?

3. Smoking is an important modifiable risk factor in pregnancy

4. Smoking in pregnancy accounts for: • 1 in 12 • Premature births • 1 in 5 • Cases of low birth weight in babies carried to full term Slide courtesy of Dr Marilena Korkodilos, PHE

5. Smoking in pregnancy accounts for: • 1 in 14 • Preterm-related deaths • 1 in 3 • sudden unexpected deaths in infancy (SUDI) Slide courtesy of Dr Marilena Korkodilos, PHE

6. Deaths by age group

7. Infant mortality rates Ref: Why children die: death in infants, children and young people in the UK, Part A, RCPCH, May 2014

8. Low birthweight

9. Smokers vs Non smokers - stillbirth rates/ 1000 births

10. Smokers vs Non smokers vs stopped smoking stillbirth rates / 1000 births

11. Passive Smokers v non smokers - stillbirth rates/1000 births

12. The Challenges • Reduce the number of women of child bearing age who smoke. • Increase the number of women who stop prior to pregnancy or in very early pregnancy. • Increase the number of women accessing stop smoking advice and support. • Increase the number of women who set a quit date and the percentage who go on to have a smokefree pregnancy. • Decrease the number of women who relapse back to smoking in the post natal period. • Decrease the number of partners or other household members who continue to smoke during a woman’s pregnancy. • Consider how we can better support those who choose to self quit.

13. Reducing smoking in pregnancy: what needs to be done 1 2 3 4 Commissioning Using commissioning as a lever to develop, fund and review stop smoking services, particularly to disadvantaged groups Care pathways Developing appropriate care pathways for referral into stop smoking services Coordination and leadership Developing a strategy to support women and their partners to reduce smoking during pregnancy and in the postnatal period Communication Community engagement and understanding the needs of the local population is essential in developing flexible, responsive, acceptable services Slide courtesy of Dr Marilena Korkodilos, PHE

14. Where are we now? • 2014/15 Maternities 622,643SATOB 79,717 *SATOD 70,879SQD 18,887 (23.7% of SATOB)Quit at 4 weeks 8,838 (11.1% of SATOB)Quit (covalidated) 5,199 (6.5% of SATOB) • 2015/16 (Q1/2/3) Maternities 478,906SATOB 56,445*SATOD 50,717SQD 12,529 (22% of SATOB)Quit at 4 weeks 5,728 (10.1% of SATOB)Quit (covalidated) 3,457 (6.1% of SATOB) * No accurate data so using SATOD and quits

15. Key Drivers • NICE guideline PH26 How NHS professionals and others working in the public, community and voluntary sectors can identify women (including teenagers) who smoke when they attend an appointment or meeting. How to refer them to NHS Stop Smoking Services (or the equivalent). How NHS Stop Smoking Services staff (and staff from equivalent, non-NHS services) should contact and support all women who have been referred for help. How to help their partners or ‘significant others’ who smoke. When and how nicotine replacement therapy and other pharmacological support should be offered. Training for professionals.

16. Key Drivers • NICE guideline PH48 This guidance aims to support smoking cessation, temporary abstinence from smoking and smokefree policies in all secondary care settings. It recommends: Strong leadership and management to ensure premises remain smokefree. All hospitals have an on-site stop smoking service. Identifying people who smoke, offering advice and support to stop. Providing intensive behavioural support and pharmacotherapy as an integral component of secondary care. Integrating stop smoking support in secondary care with support provided by community-based services. Ensuring staff are trained to support people to stop smoking while using secondary care services. Supporting staff to stop smoking or to abstain while at work. Ensuring there are no designated smoking areas or staff-facilitated smoking breaks for anyone using secondary care services.

17. Key Drivers • Public Health Outcomes Framework for England (2013) 2 Health improvement • Objective People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities • Indicators Smoking status at time of delivery

18. Key Drivers • National Maternity Review (2016) 4.39. Smoking is the single biggest modifiable risk factor for poor birth outcomes and a major cause of inequality in child and maternal health outcomes.61 Smoking during pregnancy causes up to 2,200 premature births, 5,000 miscarriages and 300 perinatal deaths every year in the UK.62 It also increases the risk of developing a number of respiratory conditions, still birth, giving birth to a child with a congenital malformation, gastrointestinal defects, learning disabilities such as impaired general reasoning and verbal competence, and obesity.63

19. Key Drivers • Reducing stillbirth is a priority for the NHS: Reducing still birth is a Mandate objective from the government to NHS England It is in the NHS England Business Plan 2015-16 Reducing deaths in babies and young children, specifically neonatal mortality and stillbirths is a key indicator in the NHS Outcomes Framework. In addition, the Secretary of State announced a national ambition to halve the rates of stillbirths, neonatal and maternal deaths and intrapartum brain injuries by 2030, with a 205 reduction by 2020. This announcement was followed by ‘Spotlight on Maternity’ which sets out how this ambition can be achieved. The ambition is included in the 2016-17 Mandate.

20. Key Drivers • What is the Saving Babies’ Lives care bundle? Saving Babies’ Lives is designed to tackle stillbirth and early neonatal death. It brings together four elements of care that are recognised as evidence-based and/or best practice: • Reducing smoking pregnancy • Risk assessment and surveillance for foetal growth restriction • Raising awareness of reduced foetal movement • Effective foetal monitoring during labour

21. Key Drivers • NHS five year forward view (2014) Rather than the ‘fully engaged scenario’ that Wanless spoke of, one in five adults still smoke. A third of people drink too much alcohol. A third of men and half of women don’t get enough exercise. Almost two thirds of adults are overweight or obese. These patterns are influenced by, and in turn reinforce, deep health inequalities which can cascade down the generations. For example, smoking rates during pregnancy range from 2% in west London to 28% in Blackpool.

22. Key Drivers • NHS five year forward view (2014) More than half of the inequality in life expectancy between social classes is now linked to higher smoking rates amongst poorer people.

23. Key Drivers • Sustainability and Transformation Plans In December 2015, the NHS shared planning guidance 16/17 – 20/21 outlined a new approach to help ensure that health and care services are built around the needs of local populations. To do this, every health and care system in England will produce a multi-year Sustainability and Transformation Plan (STP), showing how local services will evolve and become sustainable over the next five years – ultimately delivering the Five Year Forward View vision of better health, better patient care and improved NHS efficiency. To deliver plans that are based on the needs of local populations, local health and care systems came together in January 2016 to form 44 STP ‘footprints’. The health and care organisations within these geographic footprints are working together to develop STPs which will help drive genuine and sustainable transformation in patient experience and health outcomes of the longer-term.

24. The Actions Identify and promptly refer all women smoking at booking usingCO screening and an opt out referral system Ensure engagement by women referred for stop smoking support Ensureintensive and ongoing support is delivered by appropriately trained staff in a variety of settings Provide opportunities for women to engage with the stop smoking service throughout pregnancy Advise on and provide pharmacological support Comprehensive tobacco control strategy and smokefree legislation.

25. AND... • Implement a robust care pathway that allows for tracing of pregnant smokers through their quit attempt and beyond into the post partum period, this should be developed in partnership with primary care, maternity services, the community and voluntary sector, health and support services. • Provide clinical leadership • Implementing a smokefree policy in hospital settings smokefree site smokefree working days

26. AND... • Identify smokers on admission to hospital and provide appropriate behavioural and pharmacological support • Link to smokefree homes initiatives • Ensure good data to enable monitoring of impact Remember: • It is not just about what you do but how, where and when you do it • It is about a whole system approach

27. BabyClear • Elements CO screening for all pregnant women An opt out referral system Briefing sessions for midwifery staff and other relevant health professionals Protocols and care pathways reflecting the evidence base and NICE guidance Advanced skills training to support Stop Smoking Advisors to work effectively with pregnant women Ways to reach out to those pregnant smokers who currently do not engage with the Stop Smoking Services, including a Risk Perception Intervention. Administrative / call centre staff training to increase the number of women accepting appointments Awareness raising and engagement with all health professionals involved with pregnant smokers Supporting materials developed with the support of young pregnant smokers. A performance management system Monitoring and evaluation of effectiveness

30. Incentive Schemes 9th June 2016 Fran Frankland Healthier Futures

31. Healthier Futures is a social enterprise and our mission is to help people live longer, healthier, happier lives. We do this by: Making smoking history for children Creating communities free from alcohol harm Empowering communities to live longer, healthier, happier lives Tobacco Free Future became Healthier Futures on 31March 2016

32. Incentive Schemes • Within the North West Healthier Futures have overseen seven Incentive schemes over the past eight years • Over 1000 women have participated • This presentation is a very brief sample of outcomes of 628 of the participating women

33. The Case for Financial Incentives • Interventions that use financial incentives to encourage smoking cessation in pregnant women have been found to be more effective than any other cessation intervention (Lumley et al, 2009) • Evidence supporting this finding was based upon results from just four trials in the USA and NICE has called for more research to establish the feasibility and effectiveness of incentives in a UK context • Incentive schemes were established in various parts of the UK, including ‘Give it Up for Baby’ launched in Dundee in 2007, the NW Pregnancy Reward Scheme 2010 and it’s ‘sister’ scheme the Supporting a Smokefree Pregnancy Scheme (SaSFPS) 2012 • A recently published randomised control study undertaken by the universities of Glasgow & Stirling found substantial evidence for the efficacy of incentives for supporting smoking cessation in pregnancy. • Tapin. D, Bauld. L. Purves, D. et al, (2015) Financial incentives for smoking cessation in pregnancy: randomised controlled trial.  BMJ 2015;350:h134 doi: 10.1136/bmj.h134

34. Pathway JOURNEY GENERAL NICE GUIDANCE PH26 SPECIALISED SUPPORTING A SMOKEFREE PREGNANCY PATHWAY Women are identified, by a healthcare professional and recruited to the scheme based on the following criteria: Teen pregnancy / living in an area of deprivation / high smoking prevalence / living with a smoker / smoked throughout previous pregnancies • Identification of pregnant women who smoke • Referral of pregnant smokers for help to stop smoking and explanation that it is normal practice to do this • Outline scheme • Discuss Significant Other (SOS) and smokefree home (SFH) • CO validate • Quit date set • Sign contract • Weekly face-to-face contact • Recruit SOS – sign contract • Specialist cessation support / SFH advice • CO validation • £10 for each week validated smokefree • Assessment of the woman’s exposure to tobacco made through discussion and use of CO screening • Provision of information on the risks of smoking and health benefits of stopping • Advice to stop smoking • Providing smoking cessation support (behavioural and pharmaceutical) • Minimum 4-weekly face-to-face contact • Specialist cessation support / SFH advice • CO validation • £20 for each 4-weeks smokefree • Reported and CO validated at any point from 36-weeks • 4-weekly contact and support • Face-to-face at 12-week point / CO validation • £60.00 to the woman if smokefree • £40 to the SOS if both they and the woman are smokefree Relapse at any point • Relapse – re-registered to scheme as a new episode. Second relapse – exit scheme

35. Age of Participants • 54% of the women are over the age of 25 • 9.4% of pregnant women are teenagers • Note: 66% of the teenagers achieved a 4WQ.

36. 4 Week Quit 67% achieved a 4WQ April 2015 – September 2015 nationally 46%* of women supported by their LSSS achieved a 4WQ (self reported) * 2016, Health and Social Care Information Centre.

37. Significant Other Support (SOS) and living with a smoker 62% of the participating women had one or more children living with them

38. Smoking Status at Time of Delivery 65% of all women who achieved a 4WQ went on to remain quit until birth

39. Comparison Between 4WQ within LSSS and 4WQ within the SaSFPS 22% increase in 4WQs within the scheme * 2016, Health and Social Care Information Centre. Q4 14-15

40. The Case for Financial Incentives • It is estimated that around one in five (20-25%) of babies admitted to Neonatal Units are there primarily as a result of smoking during pregnancy. • Centres for Disease Control and Prevention (2006) 2006 Surgeon General’s Report. The Health Consequences of Involuntary Exposure to Tobacco Smoke. http://www.cdc.gov/tobacco/data_statistics/sgr/2006/index.htm • The cost of delivering a complicated birth, the care of a LBW baby or the care of a premature baby is estimated at £12,500 per child compared to £1,000 for a normal vaginal birth • Honest H et al (2009). Screening to prevent spontaneous preterm birth: systematic reviews of accuracy and effectiveness literature with economic modelling. Health Technology Assessment13(43):1-351. • National Institute for Health and Care Excellence (2007) Intrapartum care: care of a healthy woman and their babies during childbirth. NICE Clinical Guidance 55. London:NICE. • London and Dunstable Hospital NHS Foundation Trust (2009). The average cost of one night’s stay in NICU is £1,200 per baby. • The cost of the incentive for one woman’s participation in the SaSFPS is a maximum of £300

41. A very crude estimate of savings • Emotionally = Incalculable, immeasurable, infinite • Financially = example - 50 additional women do not go onto to have complicated births = £625,000 (this does not include the cost of long term management of chronic conditions) • The sample presented here, an additional 138 women achieved a 4WQ

42. Thank youAny questions? Fran Frankland Healthier Futures (Formerly Tobacco Free Futures) Tel: 0161 238 6387 e:Fran.Frankland@healthierfutures.org