1. 1 Addressing the challenge of smoking in pregnancy: new problems and new solutions Robert West University College London www.rjwest.co.uk

2. 2 Outline ‘New’ evidence on the long-term harm to people whose mother smoked during pregnancy The problem of identifying pregnant smokers NRT for pregnant smokers Brief advice for pregnant smokers Other approaches to curbing smoking in pregnancy Recommendations for discussion

3. 3 The damage caused by smoking in pregnancy: violent behaviour Smoking is strongly linked with conduct disorder in children and later criminal behaviour even once other factors have been controlled for The relationship is specific for conduct disorder and not present for ADHD and could be specific for males Cigarette smoke contains a monoamine oxidase (MAO) inhibitor (probably not nicotine) Giving an MAO inhibitor to pregnant rats increases the levels of aggression in their offspring

4. 4 A recent study

5. 5 The size of the effect

6. 6 Replicability From: Kate Picket

7. 7 More evidence of causality

8. 8 The damage caused by smoking in pregnancy: lung damage Smoking in pregnancy reduces the eventual lung capacity of the offspring Lung capacity declines from early adulthood Some of those with a lower initial lung capacity will, though normal aging, go on to develop COPD even if they never smoke

9. 9 Quartiles of birth weight in relation to FEV 1 at 53 years

10. 10 Standardised mortality ratios (numbers of deaths in parenthesis) for chronic obstructive airways disease and lung cancer in 5718 men, according to birth weight and weight at 1 year

11. 11 The damage caused by smoking in pregnancy: heart disease Low birth weight is also associated with an increased risk of cardiovascular disease later in life

12. 12 Identifying pregnant smokers There is evidence that: –pregnant smokers deny that they smoke to doctors and midwives –those that admit to smoking report smoking less than they actually do If they will not admit to smoking, it is very difficult to help them

13. 13 NRT for pregnant smokers NRT is effective in helping non-pregnant smokers to quit The one trial that has looked at it did not find an effect of the patch on pregnant smokers Trials have also failed to find effects of standard NRT treatment in patients with smoking related disease Nicotine is known to be harmful to the fetus though it is believed to be much less harmful than cigarette smoke Many pregnant smokers want NRT and it appears to be a way of engaging with them so that they can receive behavioural support which has been shown to be effective

14. 14 Brief advice for pregnant smokers No evidence for effectiveness in UK population, whether delivered by midwife or using stage-matched materials or motivational interviewing

15. 15 Other approaches to curbing smoking in pregnancy 1.Taxation: pregnant smokers are more responsive to price than similar smokers who are not pregnant 2.Social pressure: rates of smoking in pregnancy are apparently very low in countries such as Columbia where there is a strong taboo 3.Better education: how aware are pregnant smokers of the extent of the damage they are doing to their fetus? 4.Engaging with the partner: where pregnant smokers have a partner, stopping alone is probably very difficult 5.Exercise classes: moderate or light exercise does not appear to help with stopping smoking even though it does reduce urges to smoke and withdrawal symptoms; some pregnant smokers may be interested in engaging in more strenuous exercise which does have some evidence for efficacy 6.Promoting a cultural shift: poor smokers in countries with low female smoking prevalence do not appear to suffer from increased stress by being denied the opportunity to smoke; could we foster a cultural shift away from seeing smoking as a means of support to viewing it as a cause of stress

16. 16 Recommendations 20p on a pack of cigarettes with the proceeds to go towards tobacco control Intensive public information campaign publicising the full extent of the damage caused by smoking in pregnancy: using mass media campaigns and media advocacy Devise better ways of assessing smoking at booking visit, using more sensitive questioning accompanied by the offer of tailored flexible support National protocols with costings for helping pregnant smokers to stop, including specification of the numbers of trained specialists needed per thousand births National and local routine anonymised monitoring of smoking rates at booking and at birth, using urinary cotinine