Shadow Minister for Health: lack of progress in smoking cessation in pregnant women

The Shadow Minister's motion appears to challenge the closure of training facilities for midwives in Scotland. The wording is as follows:

*S4M-03281 Richard Simpson: Birth Rates in Scotland 

That the Parliament notes that the number of births reported by the Registrar General in the most recent midyear population statistics was 52,687 (2001), 51,239 (2002), 51,792 (2003), 53,576 (2004), 54,259 (2005), 54,961 (2006), 56,726 (2007), 59,240 (2008), 59,331 (2009), 58,937 (2010) and 58,766 (2011); notes that, following the low point in 2002, an increase of over 7,000 births annually is being sustained; understands that there are growing concerns regarding births where there are complex needs, such as multiple births or where drugs and alcohol issues are involved; believes that there has been a lack of any substantial progress in reducing the number of pregnant women who smoke or, after having successfully given up in pregnancy, resume smoking; notes what it considers to be the continuing low levels of initial or sustained breastfeeding; understands that there are demographic workforce pressures and these might be exacerbated by new pension arrangements; calls into question the whole basis of what it understands is the decision of the Scottish Government to cut the intake of midwifery students by 40%, with the closure of midwifery training at three university nursing and midwifery departments, and considers that this increasingly appears to be a misguided decision. 

Supported by: Mark McDonald*, Lewis Macdonald*, Iain Gray*, James Kelly*

No doubt this is a party political challenge along the lines of  'we would do better by pregnant women by not closing midwife training facilities'. But he is asking the Chamber to agree that £40 million of public expenditure is failing to persuade a critical target population to stop smoking. It's hard to imagine that £40 million (or more) spent under a different administration will stop people smoking.

I had thought with Give it Up for Baby (the scheme paying expectant mothers £12.50 a week to enrol in smoking cessation and keep off cigarettes for the duration) that they had found the magic bullet. The scheme, started in Dundee, has recently been declared a rip-roaring success and it has been announced that the government wishes to launch it across Scotland. I guess it is a little reassuring that not all the Parliamentarians are fooled by this hype. The facts are:

1. Scottish health boards have other priorities, many of which are far more urgent than smoking cessation;
2. Even if they didn't and the money available to be spent on this was limitless there is no proof that this expenditure would bring down the smoking rate further.

News:  1. There has been a reduced nicotine inhaler on my local supermarket shelf for nearly a month.
2. We are in the middle of the 2012 UK National Smoking Cessation Conference. Tomorrow's programme (i.e. for Tuesday) is here.

Scottish Government pays incentives to allow expectant mothers to shop at Asda

Free NRT thrown in, although it will probably be claimed that this is optional. The compulsory part is giving up smoking. Public health  minister Michael Matheson claims that this scheme has been 'a success' (a 50 per cent success rate at one month). Launched in Tayside, he now wants it rolled out across Scotland (the news article claims £50 a month is paid out, but other sources give £12.50 a week).

The Taxpayers Alliance's investigations showed over £60,000 had been spent with only a quarter of those attempting to quit succeeding even in the short term. There were allegations that some non-smoking families resented the financial help given to parents who succeeded in quitting under the scheme. According to the National Institute for Clinical Excellence, the long-term prospects for people quitting under this scheme are not necessarily good:

However, a search by the Cochrane Collaboration of all the available evidence looking at whether competitions and incentives help smokers to quit in the medium to long term showed that such incentives do not enhance long term smoking cessation rates, with early success tending to dissipate when the rewards are no longer offered.

Earlier this year a Tobacco Control Study was reported in several papers including the Scotsman showing that nicotine patches, even in conjunction with counselling, do not give quitters an advantage over people stopping without pharmaceutical support.

This has to be a pharmaceutical company's dream: patients getting a financial incentive to participate in a programme that gives them free medication.

It seems that no cost is too great where smoking cessation medications are concerned. Look at the delegate list for this year's UK National Smoking Cessation Conference. So far 261 people have registered for at least one day, at £250 (£375 for two days) with recommended accommodation at £99 per night. At a guess I would hazard that most of it is reclaimable on expenses, plus food. So the cost to the public purse so far (for 261 delegates) has run from anything between just over £62K (for one day with no accommodation), to nearly (£150K for two days with two nights' accommodation. Some people might even need three nights!) And they still have a few weeks to sign up more delegates.

All in a concerted campaign to dissuade people from using a legal product.

Nicotine patches: change of tune from the UK Centre for Tobacco Control Studies

From this:

The prevalence of smoking is higher among Pakistani and Bangladeshi males than among the general population. Smokers who receive behavioural support and medication quadruple their chances of stopping smoking, but evidence suggests that these populations do not use National Health Service run stop smoking clinics as frequently as would be expected given their high prevalence of smoking. [emphasis added] 

To this:

FREE nicotine patches or intensive counselling via an NHS helpline do nothing to help smokers quit, says a Government- funded study.

This latter study is led by Tim Coleman, and the earlier study was co-authored by Rachna A. Begh, both of the UK Centre for Tobacco Control Studies. Three years elapsed between the two pieces.

What are the policy implications? The concluding paragraph of Tim Coleman's study is non-committal:

In England, where support for smoking cessation is available to all smokers either free or at relatively low cost, adding additional proactive telephone counselling or an offer of free nicotine replacement therapy to usual quitline care did not affect smoking cessation rates. On the basis of this study, providing these through a quitline is not recommended.

and:

What is already known on this topic

• Quitlines can support large numbers of smokers in achieving smoking cessation.
  
  
• The most effective and cost effective methods of support through quitlines need to be determined.

What this study adds

• Among callers who sought help to stop smoking through the English quitline, offering free nicotine replacement therapy was no more effective than standard support by the quitline.
  
  
• Cessation rates were not improved by offering additional telephone contacts with advisors providing proactive counselling.
  
  
• Offering free nicotine replacement therapy or proactive support were no more effective than standard reactive quitline support

It is tempting to ask what nonsense we have been fed for the last few years about NHS being four times more likely to quit. Freedom2Choose has raised this question more than once in the past (also here).  Three years ago the mantra 'four times more likely to quit with NHS help' was received wisdom.

The Department of Health page making this claim is now archived.  However, new Department of Health guidance, dated 2011/2012, lists Nicotine Replacement Therapy with an A evidence rating ('the recommendation is supported by good (strong) evidence').  Make of this what you will. (The same document gives Champix an A evidence rating, and states there is 'no clear evidence' of a link between taking Champix and increased depression or suicidal thoughts.)

This is an extremely messy picture. The notion that NRT doesn't work is backed by other evidence besides Tim Coleman's study, but it is not supported by the Department of Health guidance linked above. Nor is it reflected in the Scottish 'Give it up for baby' campaigns, which routinely supply free patches, and pay expectant mothers to make use of the quitting service. The  body promoting 'Give it up for baby' is, rather sinisterly, named NMSC (National Social Marketing Centre), with the slogan 'leading behaviour change'. Instead of evidence-based persuasion, we have psychological manipulation of people's behaviour to suit the whims of policy makers and planners. Behaviour change could well take priority over the supporting evidence, with planners claiming that 'the ends justify the means'.  (Incidentally Tim Coleman has also recently 'discovered' that patches don't help pregnant women stop smoking either.)

Prediction: the UK Centre for Tobacco Control Studies will call for 'more research' to solve the problem of quitting; the Department of Health and National Social Marketing Centre will continue to promote the use of nicotine patches.

Nicotine replacement could be made stronger for expectant mothers

Nicotine replacement therapy is not only distributed free on prescription in Scotland, but in areas that have taken up the 'give it up for baby' programme pregnant women are paid to use it.

A report from the University of Nottingham now 'discovers' that NRT doesn't work for pregnant women, concluding that changes in the mother's metabolism resulting from pregnancy suggest that patches with a stronger dose of nicotine could be the answer. Now they will need to find an optimum level of nicotine that is strong enough to 'work' but not strong enough to harm the foetus.

Tim Coleman, author of the study, is a leading figure in UK Centre for Tobacco Control Studies, with acknowledged personal interests in the development of smoking cessation drugs. True to form he has identified a research opportunity in the unreliability of the nicotine replacement cessation regime. That's his living I suppose but these days it's not hard to think of many better ways to use resources.