Health, Housing and Adult Social Care Scrutiny Committee	13 December 2023
Report of the Director of Public Health

Smoking in Pregnancy

Summary

1. Smoking is the leading preventable cause of death and illness in York, with 8.7% of the York adult population currently smoking and 8.1% of pregnant women smoking at the time their baby is born.

2. Through the Public Health department, the Council has responsibility for the provision of smoking cessation services in York.

3. The York Tobacco Control Alliance, formed in 2019, brings together partners across the city whose mutual aims are to reduce the prevalence of tobacco use in York to below 5% of the adult population by 2025. In 2020, the City of York Tobacco Control Plan was launched, with strategic actions to support the ambition of reducing prevalence of tobacco use to below 5%.

4. This report summarises the work to reduce smoking during pregnancy in York.

Recommendations

5. Members of Scrutiny are asked:

a. to note this report and comment on progress to prevent uptake of cigarette smoking during pregnancy

b. to make recommendations for partners e.g. GPs and York & Scarborough Teaching Hospitals Trust to increase efforts to identify and refer pregnant women to stop smoking services

Background

6. Smoking is not a lifestyle choice. Nicotine has been shown to be a more powerful and addictive a substance than heroin, and most tobacco users start the habit in their late teens before developing a lifelong use of tobacco.

7. Smoking during pregnancy can cause many increased risks to both mother and baby. Supporting women to stop smoking has an immediate impact on:

a. Reducing the risk of complications in pregnancy and birth

b. Reducing the risk of stillbirth

c. Reducing the risk of premature birth, and associated breathing and feeding problems

d. Reducing the risk of a baby born with a low birth weight

e. Reducing the risk of sudden infant death syndrome (SIDS), also known as "cot death"

f. Increasing the likelihood of a healthier pregnancy and a healthier baby

8. Smoking cessation support in York is delivered by the Health Trainer service, part of the council’s Public Health team. This team of Health Trainers are trained to deliver two main functions; smoking cessation interventions; and a health trainer intervention covering stop smoking advice, alcohol awareness, weight management, physical activity and social isolation.

9. The Health Trainer service is responsible for providing support to residents that wish to stop smoking.  This is provided in accordance with NICE Guidance and staff are trained to deliver the service as set out by the National Centre for Smoking Cessation and Training (NCSCT) at Level 2, as well as supply Nicotine Replacement Therapy (NRT) and e-cigarettes. The service is provided on a one to one basis, either using virtual appointments or in a range of face to face community locations across the city.

10. Best practice in smoking cessation is to provide 12 weeks of funded NRT/e-cigarettes, as is routine in neighbouring local authorities. Due to current public health funding pressures, the service provision in York is as follows:

a. Pregnant smokers and their significant other: 12 weeks of NRT / e-cigarettes and behavioural support from a Health Trainer. There is also a voucher incentive scheme to support pregnant smokers and their significant other, as the evidence is clear on the benefits to quitting for mother and baby.

b. Adult smokers: 4 weeks of funded NRT / e-cigarettes and support for up to 12 weeks whilst self-funding NRT, from a Health Trainer

c. Smokers aged 12-18: NRT can be provided to young people over the age of 12 as part of a family intervention

11. The current rate of smoking at time of delivery (an England wide data set, submitted by the NHS on the number of women smoking at the time their baby was born) in York is 8.1%, which equates to 119 people. This is below the England rate of 8.8% and the Yorkshire and Humber rate of 11.6%. The figure below shows the rate for York and England, over the last 12 years. Like England, York has followed a general downward trend in the number of women smoking at the time their baby is born, from a high of 14.1% in 2011/2012.

12. The data at York level paints a fairly positive picture, of a downward trend, in line with England averages. However, when looking at ward level there are large inequalities in rates of smoking at time of delivery. The rate varies from as high as 13.8% in Heworth and Guildhall, to as low 0% in Wheldrake and Bishopthorpe. The table below, shows the smoking at delivery rates for each ward in York, during the 22/23 year.

% of women smoking at time of delivery - 22/23	York 8.1%
Ward - Heworth	13.8%
Ward - Guildhall	13.8%
Ward - Westfield	13.5%
Ward - Clifton	11.3%
Ward - Hull Road	11.1%
Ward - Holgate	10.7%
Ward - Heworth Without	9.1%
Ward - Dringhouses and Woodthorpe	9.0%
Ward - Copmanthorpe	8.3%
Ward - Fulford and Heslington	6.9%
Ward - Fishergate	6.8%
Ward - Osbaldwick and Derwent	6.1%
Ward - Acomb	5.6%
Ward - Strensall	5.5%
Ward - Rawcliffe and Clifton Without	4.5%
Ward - Huntington and New Earswick	4.2%
Ward - Haxby and Wigginton	3.9%
Ward - Micklegate	3.4%
Ward - Rural West York	2.0%
Ward - Wheldrake	0.0%
Ward - Bishopthorpe	0.0%

13. Anyone who is identified as smoking, is offered an opt-out (i.e. automatic) referral to the Health Trainer service from their midwife. In the 2022/2023, 91 referrals were received by the Health Trainer service, with 41 going on to engage with the service (i.e. responding to attempts to book a first appointment with a health trainer), 25 setting a quit date and 18 successfully stopping smoking. The table below shows the numbers of women at each stage of the process:

Year 2022 - 2023
Number of women smoking at booking	131
Number of referrals received by the Health Trainer service	91
Number of women who engaged with Health Trainer service	41
Number of women who set a quit date	25
Number of women who successfully quit smoking	18

14. As can be seen from the table above, there are various points at which women are lost from the pathway – 40 are never referred to the service (they may have chosen to opt out and declined the referral) and a further 50 who are referred never engage with the service (they may have said yes to their midwife to consent to the referral, but have had no intention of wanting to stop smoking, there may have been complication with their pregnancy, or they may have not found the service accessible).

15. Those who do engage with the service and set a quit date tend to go on and have successful quit attempts (18/25, 72%).

16. As an additional incentive for pregnant women, the health trainer service offers shopping vouchers for those who engage with the quit attempt, offering vouchers at 2 weeks, 4 weeks, 12 weeks and 3 months postnatal. At each time point, the women will provide a carbon monoxide reading to show that they are not smoking and then they will be issued with the voucher. In 2022/2023 13 of the 25 women setting a quit date opted in to the incentive scheme, with 10 successfully continuing to be smoke free at the 3 months postnatal point.  

17. The health trainer service is working closely with York and Scarborough NHS Trust maternity services to increase the number of women who are initially referred to the service. This is taking the form of refresher training for midwives on what the service is, how to refer and the incentive offer. Within the health trainer service, a follow up exercise is being undertaken with those who have not engaged with the service. It is hoped that through a better understand the barriers face by citizens, ways can be found to overcome these and increase the engagement rate with the service.

18. Nationally, the NHS Long Term Plan is investing in frontline services to tackle tobacco dependence for all inpatients, pregnant women and those in long-term mental health and learning disability services. These services will be in addition to, and delivered in conjunction with, local authority Stop Smoking Services. In York hospital, Tobacco Dependency Advisors (TDA’s) have been recruited and are providing a service across the hospital site for inpatients and those attending maternity services within the hospital. However, women who are predominately being seen within the community (as most pregnancies are), are still being referred to the council’s Health Trainer service.

19. Recently released NHS guidance (Saving babies lives: version 3, A care bundle for reducing perinatal mortality) directs midwifery teams to refer pregnant women to the in-house TDA service. However, in agreement with midwifery services at York and Scarborough NHS trust, the majority of women who are identified as smoking during pregnancy will continue to be referred to the Health Trainer service. At present the TDA service does not have the capacity to see women outside of the hospital setting, and it is felt that having a community based and/or virtual offer is beneficial for women. The trust are developing a plan to implement saving babies lives care bundle during 2024.

Council Plan

20. Smoking cessation services are funded through the Public Health ring-fenced grant. Provision of a stop smoking service is not a mandatory part of the grant, however it is considered best practice to have an evidence based service available to support citizens to stop smoking. In 2022, 74% of local authorities commissioned or provided a stop smoking service.

21. Locally, the provision of a stop smoking service aligns with the council plan core commitment of Health and the priority of A health generating city for children and adults. Reducing smoking prevalence for all population groups is also one of the 10 big goals outlined in the Joint Health and Wellbeing Strategy (2022-2032).

Contact Details

Author:	Chief Officer Responsible for the report:
Phil Truby Public Health Specialist Practitioner Advanced philip.truby@york.gov.uk 01904 553959	Peter Roderick Director of Public Health
	Report Approved	√	Date	21/11/23
Wards Affected:					All	X
For further information please contact the author of the report