Smoking, attitudes to smoking and provision of smoking cessation advice in two teaching hospitals in Ireland: do smoke-free policies matter?

Smoking cessation Through Optimization of clinical care in Pregnancy: the STOP pragmatic randomized controlled trial

BACKGROUND

Smoking cessation improves pregnancy outcomes, yet there is uncertainty around the efficacy of models of antenatal intervention for smoking cessation in pregnancy.

OBJECTIVE

This study aimed to test the Smoking cessation Through Optimization of clinical care in Pregnancy (STOP) clinic as an antenatal care pathway for smoking cessation in pregnancy. The STOP intervention is a smoking cessation clinic staffed by a dedicated multidisciplinary team of obstetricians, midwives, and smoking cessation practitioners, who provide motivational and psychological support and intensive clinical monitoring of pregnancy.

STUDY DESIGN

This was a pragmatic randomized controlled trial of the STOP clinic compared with routine antenatal care at a tertiary urban maternity hospital delivering >8000 infants per year. The primary outcome measured was continuous abstinence from smoking before 28+0 weeks' gestation, sustained throughout the duration of the pregnancy, and validated using biological measures. The secondary outcomes included maternal and fetal morbidity, delivery and neonatal outcomes, smoking outcomes, and qualitative measures.

RESULTS

A total of 436 women were randomized, with 430 women included in the primary outcome analysis. Women attending the STOP antenatal clinic were more likely to quit smoking compared with those in routine care (odds ratio, 3.62; 95% confidence interval, 1.43-9.17). In addition, women who continued to smoke in the STOP clinic smoked fewer cigarettes daily at the time of delivery compared with controls: 5±4 in the STOP clinic and 7±5 in the control group (odds ratio, 0.28; 95% confidence interval, 0.13-0.59). However, this intervention did not alter postpartum relapse rates (4.3% intervention arm vs 1.5% control arm, not significant) at 4 to 6 months following delivery. The mean birthweight was similar in the intervention and control arms; however, quitters in both groups had infants with significantly higher birthweights compared with those of continued smokers.

CONCLUSION

The STOP antenatal model of care leads to higher smoking cessation rates among pregnant smokers and lower daily cigarette consumption at time of delivery. Currently, there is no defined or dedicated antenatal pathway for pregnant smokers, despite the high-risk nature of their pregnancies. Our findings suggest that improved smoking cessation rates in pregnancy may be achieved using the holistic approach of the STOP model of care.

Smoking cessation Through Optimisation of clinical care in Pregnancy: the STOP randomised controlled trial

BACKGROUND

Cigarette smoking negatively impacts on maternal and fetal health. Smoking cessation is one of the few interventions capable of improving pregnancy outcomes. Despite the risks, the most effective antenatal model of care for smokers is still unclear, and specific recommendations for screening for fetal growth restriction are absent.

METHODS

This is a pragmatic randomised controlled trial of a dedicated smoking cessation clinic versus routine antenatal care as an intervention to reduce cigarette smoking behaviour. Smoking mothers randomised to the Smoking cessation Through Optimisation of clinical care in Pregnancy (STOP) clinic will have all antenatal care provided by a team comprising an obstetrician, a midwife, and a smoking cessation practitioner. This intervention includes ultrasound screening for fetal growth restriction. The control arm comprises two groups: one receiving standard care with ultrasound screening for fetal growth restriction, and one receiving standard care with ultrasound screening for growth restriction only if clinically indicated by their healthcare provider. Four hundred and fifty women will be recruited and randomised to either intervention or control arms stratifying for age, parity, and history of fetal growth restriction.

RESULTS

The primary outcome is self-reported, continuous abstinence from smoking between the quit date and end of pregnancy, validated by exhaled carbon monoxide or urinary cotinine. The quit date is targeted as being at or before 16 weeks' gestation and no further than 28 weeks' gestation. The secondary outcomes are a set of variables including maternal and fetal morbidity and mortality, neonatal complications and delivery outcomes, smoking and psychological outcomes, and qualitative measures.

CONCLUSIONS

Despite much research into cigarette smoking in pregnancy, the optimal model of care for these women is still unknown. This study has the potential to improve the model of antenatal care provided to pregnant women who smoke and to improve outcomes for both mother and infant.

TRIAL REGISTRATION

ISRCTN11214785 . Registered on 8 February 2018.

Prospective study of provided smoking cessation care in an inpatient psychiatric setting

OBJECTIVE

People with mental health difficulties (MHD) are more likely to smoke and to have smoking-related diseases, yet little research has investigated the provision of smoking cessation care in psychiatric inpatient settings. This study aimed to evaluate current levels of cessation care provided, and 3-month quit-rates, in one such setting in Ireland.

METHODS

From January to October 2016, inpatients across all 8 adult wards of St Patrick's University Hospital were recruited to participate in a baseline face-to-face survey (N = 246), assessing demographic information, smoking history and quit attempts, motivation to quit, nicotine dependence, attitudes towards cessation advice and actual care received. For baseline current smokers (n = 84) who consented, casenotes were also audited for documentation of smoking status and cessation care (n = 77/84) while quit rates were assessed at three months (n = 72/84), including a carbon monoxide test for those who reported quitting.

RESULTS

Current smoking prevalence was 34% (n = 84/246). At baseline 75% of smokers wanted to quit and 48% reported they would like cessation advice while in hospital. Few reported receiving cessation advice from any healthcare professional in the past year (13%), while just 6% had smoking cessation care clearly documented in their casenotes. The 3-month quit-rate was 17%, with a 100% pass rate for those completing an objective CO validation test.

CONCLUSION

Despite a high current smoking prevalence among psychiatric inpatients, and similar motivation and quit rates to other populations, current cessation care rates are low. Smoking cessation care needs to be prioritised in psychiatric settings.

Medical student INtervention to promote effective nicotine dependence and tobacco HEalthcare (MIND-THE-GAP): single-centre feasibility randomised trial results

BACKGROUND

Although brief cessation advice from healthcare professionals increases quit rates, smokers typically do not get this advice during hospitalisation, possibly due to resource issues, lack of training and professionals' own attitudes to providing such counselling. Medical students are a potentially untapped resource who could deliver cessation counselling, while upskilling themselves and changing their own attitudes to delivering such advice in the future; however, no studies have investigated this. We aimed to determine if brief student-led counselling could enhance motivation to quit and smoking cessation behaviours among hospitalised patients.

METHODS

A mixed-methods, 2-arm pilot feasibility randomised controlled trial with qualitative process evaluation enrolled 67 hospitalised adult smokers, who were recruited and randomized to receive a brief medical student-delivered cessation intervention (n = 33) or usual care (n = 34); 61 medical students received standardised cessation training and 33 were randomly assigned to provide a brief in-hospital consultation and follow-up support by phone or in-person one week post-discharge. Telephone follow-up at 3- and 6-months assessed scores on the Motivation to Stop Smoking Scale (MTSS; primary outcome) and several other outcomes, including 7-day point prevalent abstinence, quit attempts, use of cessation medication, and ratings of student's knowledge and efficacy. Data were analysed as intention to treat (ITT) using penalised imputation, per protocol, and random effects repeated measures. Focus group interviews were conducted with students post-intervention to elicit their views on the training and intervention process.

RESULTS

Analyses for primary and most secondary outcomes favoured the intervention group, although results were not statistically significant. Point prevalence abstinence rates were significantly higher for the intervention group during follow-up for all analyses except 6-month ITT analysis. Fidelity was variable. Patients rated students as being "very" knowledgeable about quitting and "somewhat" helpful. Qualitative results showed students were glad to deliver the intervention; were critical of current cessation care; felt constrained by their inability to prescribe cessation medications and wanted to include cessation and other behavioural counselling in their normal history taking.

CONCLUSIONS

It appears feasible for medical students to be smoking cessation interventionists during their training, although their fidelity to the intervention requires further investigation. A definitive trial is needed to determine if medical students are effective cessation counsellors and if student-led intervention could be tailored for other health behaviours.

TRIAL REGISTRATION

NCT02601599 (retrospectively registered 1 day after first participant recruited on November 3rd 2015).