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?

I don't see what is obtuse about saying that the evidence that "routine CO monitoring in antenatal clinics, if implemented consistently, can improve the accurate identification of pregnant smokers and facilitate referral to smoking cessation services."
and "smoking cessation interventions used in early pregnancy can reduce smoking in later pregnancy by around 6% (or 3% using studies least prone to bias)."
and "4-week post-quit date outcomes reported quit rates of between 32% and 48%" means that there is a reasonable possibility that this routine testing would reduce the level of smoking amongst pregnant women.

Avril, I think it's naive to assume that all those who choose not to disclose smoking status wouldn't stop if offered treatment ... no one is suggesting that everyone would, but you're claiming that noone would. That's a strong statement and one that you don't have any evidence for.

I think you might want to consider the role of avoidant behaviour in all of this.

AvrilHeytech - My reasoning is as follows. There is some evidence that it might work. There is no evidence that it won't work. So it is reasonable to try and and see if it works. I haven't seen anyone point out a flaw in that.

What is your source for the 6%? 25% didn't seem unreasonable to me, but my PoV is probably skewed by having lived next to Yorkhill Childrens Hospital 10 years ago.

I am delighted to see someone FINALLY arguing about the evidence as opposed to just saying that they reckon it won't work because that's what they reckon.

" There is simply no reason to assume that people who choose not to admit to their smoking would have a similar reaction to referral to smoking cessation services as those who are open about it. They might, but we can't know that."

Well, actually there are many reasons to do so: patient embarrassment, avoidant behaviour, medical profesisonal embarrassment.

The size of the benefits against the costs in "honest" smokers makes it a no-brainer. For those who wouldn't reveal that they're smokers it's a harder call and will depend on the numbers who would take treatment. I've not done the numbers but I suspect that if as few as one patient in ten choose to take up smoking cessation services then I suspect it's likely to be cost-effective.

That's not a hard criteria to meet ... and one where it's probably worth taking the risk of being wrong.

I'm a m/w though I don't do bookings as I work on labour ward. If I did work on community I wouldn't be giving anyone the test unless they asked for it. I'd make it quite clear that the test is there if they want it but that I'm not expecting anyone to volunteer for it.

Its a bit like how I'm currently meant to ask them post birth if they smoke. Even though they've probably been asked a million times already. I don't bother. If they stink of fags I tick yes if they don't then I tick no.

AvrilHeyTech - Yes I see what the error is. The difference between the self-reporting and tested smokers was 25% which was 6% of all women. So they should have said 1 in 4 pregnant smoking women do not accurately disclose their smoking status. I don't think this makes a significant difference to the argument though.

There is no evidence that it will alienate women. A lot of peoples fears of it doing so seem to be based on the presumption of a protocol being adopted that will try and catch women out and accuse them of lieing - which is not the case.

The evidence that the 25% of smokers (6% overall) will benefit is, amongst others,

"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)."

Their is clear evidence that this is a reasonable course of action to recomend. You do not need to reduce the number of premature births to get your money back. Premature babies are expensive.

stripeyknickers - you are directed by your professional body and your professional guidance to follow the protocols in place - your malpractice may be letting some women and children down and skewing figures on which further guidance will be based. How utterly ignorant.

I think it very likely that some women who would not necessarily admit to smoking would be happy to take up services to help them quit. Most smokers would like to quit. Most smoking pregnant women would love to quit.

OOPS "You do not need to reduce the number of premature births by much to get your money back. "

violethill - agree with you. In fact, I spent my 'Health in pg' grant on a day at the health farm which I thought was quite apt but perhaps not what it was intended for! But i do eat v healthily anyway

CakeandRoses/VioletHill - does anyone know the origins of the Health in Pregnancy grant? It smacks of a good idea that was watered down to the point of uselessness, but I don't know if that was the case.

Nope, sorry - I just spent it! Would be interesting to know its origin tho as I always thought it was a bit odd.

VoiletHill - "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."

Yes, but so is any intervention and that's not a reason not to do it. The Health in Pregnancy grant is a GOOD example. We tried it, didn't work, so we stopped doing it. This is not a waste of money. This is how you find out what works.

This is the info on the pg grant but doesn't really say much : www.dh.gov.uk/en/Publicationsandstatistics/Legislation/Actsandbills/HealthandSocialCareBill/D H_080449

From this:- "Entitlement to the Health in Pregnancy Grant will be linked to the requirement for pregnant women to seek health advice from a health professional. It may therefore provide a greater incentive for expectant mothers to seek the recommended health advice at the appropriate time."

It looks like one purpose of it was to get people to go and see the Doctor/Midwife so maybe it is succeeding at some of it's aims.

And the health in pregnancy grant actually did leave me with a bit of extra cash which I could spend on nice fruit and vegetables for myself.

I didn't ring fence the cash for fruit and veg etc but it allowed me some room in my budget to throw a few extra fresh and tasty bits and pieces in my basket.

When I was pregnant with Erin, I was off most fruit and veg. I couldn't eat sliced carrots without wanting to throw up, yet if they were cut like batons, then i'd eat them ok .

My MW suggested I spent my health in pregnancy grant on a buggy - I think this might have been a little "off message"

Look. Pregnant women (and I have been one 5 times, 2 healthy DSs), attend midwife appointments for the sake of their health and that of their baby. If they are smoking, health professionals need to know.

We all have to have blood tests and be weighed so what's wrong with a puff test? If you've never smoked, you will pass with flying colours and if you have, the MW will at least have that information.

For what its worth, I am inflexible in my opinion that smoking when pregnant is inexcusable. I chain smoked for 17 years until that first blue line and never smoked again. It was NOT too hard. Walking through a crowd of heavily pregnant women smoking in dressing gowns outside the maternity wing after losing a baby made me very angry.

NestaFiesta - the MW has the information already - I have told her I don't smoke. And we do not have to have blood tests or be weighed. Whilst we generally choose to, it is our right to refuse.

Nesta - I'm very sorry that you've lost babies and can understand your anger when you see what you view as other women endangering theirs.

However, I have no wish to pass any unnecessary test with flying colours. I don't smoke, I never have and I'm never around other smokers - that's all the information that the MW and more importantly I need to know. I do not need my taxes to be spent on MW time, admin and equipment to tell her something that I can tell her in 2 seconds for free.

To Cake and Sal- fine- just say no! I was supposed to be weighed and said no. At the end of the day all ante natal care is non compulsory.

I am sure nobody will hold a gun to our heads or arrest us if we refuse. I think the point behind the testing is that smokers may underplay the fact they smoke or how many they have. This is a way of checking it out. They can't always take our word for things if they don't know us from Eve.

I can see why people might feel its an invasion of privacy or implies doubt that they are truthful, but this is a debate and my opinion is that I would be fine with it and personally don't see the harm. People fib all the time about how much they drink and I for one used to lie to myself about how many I smoked a day before I stopped.