Is NICE going too far?

[Sal321]

This BBC news story is about a suggestion by NICE (national institute for clinical excellence) that all pregnant women should be breath tested for smoking at their first MW appointment. I know I don't smoke, why should I be tested? I appreciate that I could refuse, but isn't this a bit of a weird recommendation?

health

But midwives already discuss smoking and offer cessation support at the booking appt. They do around here anyway. So that message is already being put across without basicly saying to people "I don't believe you when you say you don't smoke so blow into here and lets see".

The advice says, and includes reasons and evidence for:-

a) We want to reduce maternal smoking.
b) Interventions with pregnant women reduce rates of smoking
c) Many women lie about smoking
d) Testing, applied in the right way allows the women who would benefit from interventions to be identified more reliably.

I don't understand why this is so contentious.

TheCoalitionNeedsYou Sat 26-Jun-10 22:15:48
"The advice says, and includes reasons and evidence for:-

a) We want to reduce maternal smoking.
b) Interventions with pregnant women reduce rates of smoking
c) Many women lie about smoking
d) Testing, applied in the right way allows the women who would benefit from interventions to be identified more reliably."

Maybe because some of us do not believe that a) and d) are really compatible. When you have just identified someone as a liar, I think you have seriously reduced your chances of making them listen to your health advice.

Thecoalition: I don't think the rationale behind it is contentious, I think it's flawed.

If a woman smokes, and lies about smoking, she already knows that it is bad for her. She already knows it is jeapardising her unborn baby's wellbeing. How is proving to her that she is a liar, as well as choosing to do something harmful to her child, going to achieve anything further? That's the part I don't get.

I am totally in agreement with the aim of wanting to reduce maternal smoking. I can't understand why anyone smokes full stop, whether a mother, father or childless. But I don;t see how introducing the test changes anything.

b) Interventions with pregnant women reduce rates of smoking

"Evidence statement ER1.1
There is good evidence from one recently updated systematic review (++) on the effectiveness of interventions for promoting smoking cessation in pregnancy.
The review included 72 trials. Pooled results show that cessation interventions reduce smoking in late pregnancy (risk ratio [RR] 0.94, 95% confidence interval [CI] 0.93 to 0.96) and reduce incidences of low birth weight (RR 0.83, 95% CI 0.73 to 0.95) and pre-term births (RR 0.86, 95% CI 0.74 to 0.98) while increasing birth weight by a mean of 53.91 g (95% CI 10.44 g to 95.38 g).
The overall finding of the updated review is that smoking cessation interventions used in early pregnancy can reduce smoking in later pregnancy by around 6% (or 3% using studies least prone to bias)."

Yes, I totally understand that interventions help reduce the rate of smoking, but there are ALREADY interventions, that's my point! Pregnant women are already given information about smoking and support is readily available in many forms to help people give it up. What difference is a test going to make, when interventions in early pregnancy are already there?

You misunderstand me, Coalition. It is not that I (or probably most posters)do not believe that interventions can reduce smoking. It is that we do not believe that a test that shows mothers up as liars are going to give the right atmosphere for interventions. A mother who has just been caught out is going to be defensive and probably angry with the person who has caught her out: the last thing she is going to want to do is listen to her.

Evidence statement ER1.10
There is good evidence that women in the UK under-report smoking during pregnancy and that CO monitoring can aid in the identification of pregnant smokers. Two studies (one [++] and one [+]) found that around one in four pregnant women in the west of Scotland do not accurately disclose their smoking status when asked during the booking visit with a midwife. One of these studies described how routine CO monitoring in antenatal clinics, if implemented consistently, can improve the accurate identification of pregnant smokers and facilitate referral to smoking cessation services.

Yes, Coalition, but you are still missing my point.

(intervention reduces smoking) + (women lie about smoking) do not = women caught lying about smoking will respond well to intervention

I spent many weeks on antenatal wards and the women caught with fags and lectured by midwives only got more negative about health advice in general- as people do when they know they are in the wrong

This stuff isn't just made up. There is evidence in the advice document for the advice they are giving. We should try it and see. That's how we can prove or disprove the hypotheses.

Cory, the last study mentioned said testing facilitated interventions.
Many of the objections here seem to be based on the idea that midwives are going to be accusing people of lieing. That is not what the advice suggests. It suggests using the test to introduce the topic.
In order to see if it works in practice we need to put it into practice.

You know why smokers lie? It's to avoid the shame and guilt and criticism. So, do we not think that a test akin to a frikkin lie detector set up is doing nothing to generate an impression of support for those addicted?

I'm sure I'd smoke another 3 fags due to the stress and humilation alone, the day I had to disprove my toxicity to the midwife fgs.

That and weighing one's lard in the very public hallway of the antenatal dept.

We cannot eradicate all evils - people will always balls up in life and there will always be innocent victims of that reality.

To throw money at trying to change this fact is ridiculous unless one attempts to deal with this at grass roots level.

Why does anyone smoke in the first place? Why doesn't the Government ban smoking outright. The answer to the latter makes a mockery of funding such a freaky testing regime.

"So, do we not think that a test akin to a frikkin lie detector set up is doing nothing to generate an impression of support for those addicted?"

If the test was akin to a lie detector then you might have a point. It isn't.

I also like how people say "I think the money spent on this would be better spent on that" with no knowledge of how much each things cost or the costs that can be avoided/incurred as a result of them.

I think the money spent on crisps would be better spent on ponys.

I just don't agree with firefighting (snurk). Seriously. The amount of investment into dealing with the fundamental issues surrounding social behaviour versus investment into identifying, penalising and criminalising...

I don't ACTUALLY want to spend money or ponys instead of crisps. I like crisps.

CoalitionNeedsYou - this reminds me of the parking meter sketch in the chris morris radio show Blue Jame - "but he doesn't have a parking meter". I would give up.

Essentially many posters would rather listen to the little bit of information in their own heads than the evidence and research carried out by many. Thankfully Nice doesn't operate by mumsnet vote.

Look at the £190 Maternity grant which was designed to encourage healthy eating. It is being axed, not simply because cuts in public funding need to be made, but because there was no evidence that the target groups were using it for the intended purpose. In other words, if you care about nutrition and doing the best for your unborn child, you are probably doing it anyway, regardless of any extra payment. If you don't care, then the extra payment won't make a difference.

Isn't this rather the same? The risk of throwing money at something which isn't actually going to make a blind bit of difference. Everyone knows smoking is harmful. If you want to do it, you're going to, regardless of all the information out there in the public domain, and all the current support to help people quit.

Having now read the guidance (and much of the evidence as well), it's pretty clear that NICE probably didn't discuss this at all. I say this because issues of how to detect smokers weren't something that NICE asked the University of Sheffield to look at - their reviews were in different areas.

There are clearly pluses and minuses for directing health professionals to do a CO test. As quoted by Coalition above, the evidence does suggest that there's a problem of pregnant smokers lying so that fewer smokers get picked up. The evidence also suggests that health professionals lack the guts (my words) to even ask pregnant women if they feel it might be uncomfortable. There are TWO problems with not using the test and it's not just about pregnant smokers.

If you take a look at the guidance, MW are not recommended to ask women. (Although it would probably be better if they were recommended not to ask women.) If you don't ask, they don't lie, and the CO test isn't a test of truthfullness.

Some of those currently lying about smoking are likely to be doing so because they don't want to quit; others would like to quit and are probably embarrassed. The guidance is written to suggest that every pregnant smoker should get support to quit, in the knowledge that many won't take it up or even try. NICE's public health experts are making the judgment that there are enough embarrassed smokers that it'll be worthwhile. (It's very likely to be effective enough to make money spent on these services efficient - it probably improves health over time and reduces NHS spending so long as most people try. The figures are based on the assumption that 70% of thsoe successfully quitting during pregnancy will start again within a year.)

Personally, I don't much care about the affronted shrill minority who seem to be the majority on this thread - annoyance should be largely forgotten quite quickly by any sensible person! (It's not a relevant concern for me, but as an anti-smoker I'd be annoyed to be tested. I'd remember it, but it wouldn't actually bother me on a day-to-day basis and it wouldn't be a major factor in judging whether or not the NHS did a good job or not. A dead baby would be.)

The whole irony in this is that NICE has been (little c) conservative in what it's said and how paternalistic it would choose to be. The evidence (which is mostly from the US) suggests the most effective thing to do is probably to pay pregnant smokers to give up. The public health experts were cautious not to emphasise this type of treatment and probably for a good reason. THAT'S paternalism to possibly get upset about!

AvrilHeyTech - Evidence statement ER1.10
There is good evidence that women in the UK under-report smoking during pregnancy and that CO monitoring can aid in the identification of pregnant smokers. Two studies (one [++] and one [+]) found that around one in four pregnant women in the west of Scotland do not accurately disclose their smoking status when asked during the booking visit with a midwife. One of these studies described how routine CO monitoring in antenatal clinics, if implemented consistently, can improve the accurate identification of pregnant smokers and facilitate referral to smoking cessation services.

Evidence statement ER1.6
There is evidence from four UK studies (all [+]) that NHS Stop Smoking Services are effective in supporting pregnant women to stop smoking.
The NHS Stop Smoking Service interventions for pregnant women described in these articles consist of a combination of behavioural support (delivered in a range of settings and formats) and NRT (for most but not all women). They report varied outcomes but those that included 4-week post-quit date outcomes reported quit rates of between 32% and 48%. However, evidence from a national study of smoking cessation services for pregnant women in Scotland found that the reach and effectiveness of services varied significantly between health boards. Some areas offered no tailored (specialist) smoking cessation interventions for pregnant women.

So yes there is evidence.

and also
"Evidence statement ER1.1
There is good evidence from one recently updated systematic review (++) on the effectiveness of interventions for promoting smoking cessation in pregnancy.
The review included 72 trials. Pooled results show that cessation interventions reduce smoking in late pregnancy (risk ratio [RR] 0.94, 95% confidence interval [CI] 0.93 to 0.96) and reduce incidences of low birth weight (RR 0.83, 95% CI 0.73 to 0.95) and pre-term births (RR 0.86, 95% CI 0.74 to 0.98) while increasing birth weight by a mean of 53.91 g (95% CI 10.44 g to 95.38 g).
The overall finding of the updated review is that smoking cessation interventions used in early pregnancy can reduce smoking in later pregnancy by around 6% (or 3% using studies least prone to bias)."