Smoking cessation advice recorded during pregnancy in United Kingdom primary care

Hardy et al. BMC Family Practice 2014, 15:21 http://www.biomedcentral.com/1471-2296/15/21 RESEARCH ARTICLE Open Access Smoking cessation advice recorded during pregnancy in United Kingdom primary care Bethany Hardy1, Lisa Szatkowski1, Laila J Tata1, Tim Coleman2 and Nafeesa N Dhalwani1,2* Abstract Background: United Kingdom (UK) national guidelines recommend that all pregnant women who smoke should be advised to quit at every available opportunity, and brief cessation advice is an efficient and cost-effective means to increase quit rates. The Quality and Outcomes Framework (QOF) implemented in 2004 requires general practitioners to document their delivery of smoking cessation advice in patient records. However, no specific targets have been set in QOF for the recording of this advice in pregnant women. We used a large electronic primary care database from the UK to quantify the pregnancies in which women who smoked were recorded to have been given smoking cessation advice, and the associated maternal characteristics. Methods: Using The Health Improvement Network database we calculated annual proportions of pregnant smokers between 2000 and 2009 with cessation advice documented in their medical records during pregnancy. Logistic regression was used to assess variation in the recording of cessation advice with maternal characteristics. Results: Among 45,296 pregnancies in women who smoked, recorded cessation advice increased from 7% in 2000 to 37% in 2004 when the QOF was introduced and reduced slightly to 30% in 2009. Pregnant smokers from the youngest age group (15–19) were 21% more likely to have a record of cessation advice compared to pregnant smokers aged 25–29 (OR 1.21, 95% CI 1.10-1.35) and pregnant smokers from the most deprived group were 38% more likely to have a record for cessation advice compared to pregnant smokers from the least deprived group (OR 1.38, 95% CI 1.14-1.68). Pregnant smokers with asthma were twice as likely to have documentation of cessation advice in their primary care records compared to pregnant smokers without asthma (OR 1.97, 95% CI 1.80-2.16). Presence of comorbidities such as diabetes, hypertension and mental illness also increased the likelihood of having smoking cessation advice recorded. No marked variations were observed in the recording of cessation advice with body mass index. Conclusion: Recorded delivery of smoking cessation advice for pregnant smokers in primary care has increased with some fluctuation over the years, especially after the implementation of the QOF, and varies with maternal characteristics. Keywords: Pregnancy, Smoking, Primary care, Smoking cessation advice Background Smoking during pregnancy is harmful to both the mother and the unborn child and is associated with substantial morbidities such as ectopic pregnancy, premature rupture of membranes, pre-eclampsia, placental abruption, stillbirth, low birth weight, premature birth and childhood * Correspondence: 1 Division of Epidemiology and Public Health, University of Nottingham, Clinical Sciences Building, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1 PB, UK 2 Division of Primary Care, University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, UK asthma [1-5]. Data from the 2010 Infant Feeding Survey show that 26% of mothers in the United Kingdom (UK) smoked at some point before or during their pregnancy and 12% of women smoked throughout their pregnancy [6]. Given the high proportion of mothers currently smoking during pregnancy and the resulting health impacts, reducing smoking during pregnancy in the UK is a national priority [7]. Offering smokers brief cessation advice lasting no more than five minutes during routine consultations with a general practitioner (GP), during which doctors make clear © 2014 Crown copyright; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Hardy et al. BMC Family Practice 2014, 15:21 http://www.biomedcentral.com/1471-2296/15/21 that smoking is harmful and offer help with cessation [8], is one of the simplest and most cost-effective tools to reduce the burden of smoking in the general population and increases rates of quitting by two-thirds compared to unassisted quit rates of 4% (OR 1.66, 95% CI 1.42-1.94) [9]. In pregnant women, cessation rates with brief advice have been low (5-9%) compared with intense advice and counselling (14-17%) [10,11]. However, physician advice to quit has been cited by pregnant women as one of the most important factors which influences their decision to stop smoking [12] and has been recommended in the recent World Health Organsation guidance for the management of tobacco use in pregnancy [13]. Current UK guidelines also recommend that smoking cessation advice should be offered at every available opportunity by health professionals who come into contact with pregnant women, including GPs and midwives, as only after smoking and smoking cessation is raised can it be possible to refer women on for the more intensive behavioural support or other smoking cessation therapies that are known to work [14-17]. The Quality and Outcomes Framework (QOF) introduced in UK primary care in 2004 financially rewards GPs for offering cessation advice to smokers and documenting this advice in the patients’ electronic medical records [18]. However, there are no specific QOF targets for offering and recording cessation advice to pregnant women who smoke and little is known about the frequency with which smoking cessation advice is indeed routinely delivered and recorded by primary care health professionals during pregnancy. Data from Health Education Authority (HEA) surveys carried out in the 1990s showed that less than half the women interviewed who were smokers received cessation advice from a health professional [19], and another study conducted in 200 antenatal clinics in Leicester, UK reported that only 34% of current smokers received advice from their GP, 19% from a midwife, 12% from an obstetrician, 9% from family and friends and 26% received no advice at all [20]. Given the national guidelines and the effectiveness of smoking cessation advice in increasing quit rates, we aimed to determine the proportion of pregnant smokers with smoking cessation advice recorded in their electronic primary care records in recent UK data. In addition, we aimed to investigate whether socioeconomic factors and women’s existing medical conditions in pregnancy were associated with this recording. Methods Data source and study population The Health Improvement Network (THIN) is an electronic primary care database containing anonymised patient records from general practices across the UK [21]. THIN was set up by Cegedim Strategic Data (CSD) Medical Rese (...truncated)