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Maternity and child health clinicians adding value from every contact by treating tobacco dependence Helping Pregnant Smokers Quit: London & South East Tobacco & Pregnancy Network Meeting 16 July 2015 Sin Williams Programme Consultant NHSE London respiratory network & Clinical Senate Helping Smokers Quit team

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Treating tobacco dependency Greatest value proposition for NHS today Long-term relapsing condition that starts in childhood Unique role for healthcare professionals: every clinician should know smoking status of every patient they see and Use established and evidence based pathways to help them quit Collective leadership Clinically led transformational change in healthcare provider culture Helping smokers quit London Senate Programme 2014-15

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Helping Smokers Quit in London Influencing Strategy 4 Sponsored by London Clinical Senate Council Delivered by HSQ Delivery Team chaired by Mike Gill Held to account by the HSQ Programme Board 2 specific deep dives: mental health and smoking in pregnancy Delivery team are experts in clinical change, champions of smoking cessation as treatment, influencers

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bedside & cot-side parent & household Commit to our CO4 campaign

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Why is helping pregnant smokers quit important? Active maternal smoking causes up to 5,000 miscarriages, 300 perinatal deaths, 2,200 premature singleton births and 19,000 babies to be born with low birth weight in the UK each year these adverse effects are entirely avoidable (1) Maternal overweight and obesity and smoking are the most important potentially modifiable risk factors for still births in high income country settings smoking cessation programmes in pregnancy are effective and should be implemented as part of routine care (2) 1.Tobacco Advisory Group (TAG) of the Royal College of Physicians (RCP) 2. Lancets Stillbirth Series 2 deep dives: maternity and mental health

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And the problem doesnt stop at delivery 35% of caregivers reported tobacco exposure, yet cotinine was detected in 56% of serum samples and 80% of saliva samples. Among caregivers who reported no exposure, serum and saliva cotinine levels were detected in 39% and 70% of children, respectively.

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And the problem doesnt stop at delivery 35% of caregivers reported tobacco exposure, yet cotinine was detected in 56% of serum samples and 80% of saliva samples. Among caregivers who reported no exposure, serum and saliva cotinine levels were detected in 39% and 70% of children, respectively.

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Reframe the problem: influence clinicians mental model & provide hope Maternity and child health clinicians adding value from every contact by treating tobacco dependence Develop and promote key messages: influence what clinicians do Deliver a professional relations programme: influence the endorsement system Publish claims: influence the reference structure

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Clinicians want to know the basis of the claims we make. What are the most convincing references & data? May need several elements pulled together Publish claims: influence the reference structure NICE PH26, ASH and PHE, Challenge Group? Best real London prevalence data? eg Haringey Public Health data 1 in 6 mothers smoke Tobacco Control Collaborating Centre data using urine cotinine testing at delivery? Outcomes data on smoking? RCP Tobacco Advisory Group 2010? Best references on the benefits and successful implementation? babyClear? What about paediatric community: maternal smoking affects asthma and allergy and admissions for wheeze: references and data?

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Reframe the problem: influence clinicians mental model & provide hope Maternity and child health clinicians adding value from every contact by treating tobacco dependence Develop and promote key messages: influence what clinicians do Deliver a professional relations programme: influence the endorsement system Publish claims: influence the reference structure

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Deliver a professional relations programme: influence the endorsement system Identify the people others listen to/read/want to impress; meet them, get them on board. Assess how confident they are and how important helping smokers quit is to them and help them raise to 8/10. Ask them to publicise the messages: they are the endorsers Prof Stanley Okolo, North Middlesex, Helping Smokers Quit Programme Board Prof Donald Peebles and Donna Ockenden, Co-directors NHS England (London), Sarah Dunsdon, Maternity Strategic Clinical Network; Prof Jacqueline Dunkley-Bent, Wendy Matthews and Diane Hamilton- Fairley NHS London Senate Council Susan Bewley, Kings Penny Chew, Smoking in Pregnancy Network Alun Lewis, London TC network Prof Jacqueline Dunkley-Bent, PHE, Marilena Korkodilos, PHE Deputy Director and PHE C&YP lead, Aideen Dunne, PHE London Health Improvement Manager: tobacco control, Nike Arowobusoye PHE: prevention in the acute trust Teresa Airley, Marian Gibbon BHRT and LBBD Sara Nelson, Child Health Strategic Clinical Network

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Reframe the problem: influence clinicians mental model & provide hope Maternity and child health clinicians adding value from every contact by treating tobacco dependence Develop and promote key messages: influence what clinicians do Deliver a professional relations programme: influence the endorsement system Publish claims: influence the reference structure

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Quit smoking is first element of stillbirth reduction care bundle (draft) 1. All pregnant women who smoke should be referred for help to quit 2. Identify and institute surveillance for pregnancies with fetal growth restriction (FGR) 3. Implement best practice for reduced fetal movement - RFM 4. Effective fetal monitoring during labour Implementing the evidence is effective and welcomed so dont be afraid to ask Women benefit from frank and factual information from a trained health professional about the harmful effects of carbon monoxide (CO), and evidence-based support to quit (babyClear) Systematic CO testing (at booking and 36 weeks) is a valuable motivational tool : Dont assume you can tell by looking Use the test to begin the conversation Can highlight poorly ventilated appliances, faulty exhausts and second-hand smoke Promote Smokefree Hospitals Is NRT on the formulary? Do you ask about smoking on admission? Is NRT sold in the shop? Reframe the problem: influence clinicians mental model & provide hope

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Maternity and child health clinicians adding value from every contact by treating tobacco dependence Develop and promote key messages: influence what clinicians do Deliver a professional relations programme: influence the endorsement system Publish claims: influence the reference structure

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Develop and promote key messages: influence what clinicians do http://www.tommysbabybe.org.uk/main.php

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Plan to learn from babyClear Counts real local prevalence using CO screening Systematic training, briefing of HCPs Evidence-based protocols and care pathways, opt out referral Advanced skills training to support Stop Smoking Advisors to work effectively with pregnant women Ways to reach out to those not engaged with the Stop Smoking Services Administrative/call centre staff training to increase number accepting appointments Awareness raising and engagement with all HCPs involved with pregnant smokers A performance management system Monitoring and evaluation of effectiveness The midwives have certainly been won over from a very skeptical start. Carol A. Mutton, Head of Midwifery/Service Manager, James Paget University Hospitals NHS Foundation Trust

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Commit to CO4 to improve the health of women and their children, knowing tobacco dependence is a chronic, relapsing condition that starts in childhood Improving the health of Londoners by building stop smoking clinical leadership and capacity COnversation with every woman who smokes that gives them a chance/opportunity to quit CO monitoring by clinicians COde the intervention so we can evaluate effectiveness COmmission the system to do this right: so right behaviours incentivised systematically

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Enabling COnversations : Clinicians trained in smoking cessation - so every patient who smokes is offered an opportunity to quit

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Why I have and use a CO monitor on the ward and in clinic or cotinine? CO (ppm) >20 Highly dependent Shisha smoker Cannabis smoker Cheap ~ 150 Quick and easy to use Diagnostic: - Smoking as contributing factor to illness - Tobacco dependence Motivational tool Outcome measure 29 4 Do your clinical teams who provide care for smokers have and use a CO monitor?

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Does your organisation have a dataset for all patients smoking status & interventions? Source: Survey of London providers, NHS England (London) September 2014

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What smoking cessation outcomes does your organisation measure? Source: Survey of London providers, NHS England (London) September 2014

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Do your organisation know how many of your staff smoke? Source: Survey of London providers, NHS England (London) September 2014

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www.londonsenate.nhs.uk/helping-smokers-quit/

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Sources of borough data on low birthweight and infant mortality (as proxy if no hospital data provided) Source: http://fingertips.phe.org.uk/profile/cyphof/data#page/0 London datahttp://fingertips.phe.org.uk/profile/cyphof/data#page/0 25 Low birthweight babies

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Sources of borough data on low birthweight and infant mortality (as proxy if no hospital data provided) Source: http://fingertips.phe.org.uk/profile/cyphof/data#page/0 London datahttp://fingertips.phe.org.uk/profile/cyphof/data#page/0 26

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Sources of borough data on infant mortality (as proxy if no hospital data provided) Source: http://fingertips.phe.org.uk/profile/cyphof/data#page/0 London datahttp://fingertips.phe.org.uk/profile/cyphof/data#page/0 27