Cynulliad Cenedlaethol Cymru | National Assembly for Wales
Y Pwyllgor Plant, Pobl Ifanc ac Addysg | Children, Young People and Education Committee
Y 1,000 diwrnod cyntaf| First 1,000 Days

FTD 03

Ymateb gan: ASH Cymru
Response from: ASH Wales

ASH Wales is the only public health charity in Wales whose work is exclusively dedicated to tackling the harm that tobacco causes to communities.  Further information about our work can be found at http://www.ashwales.org.uk/

We are engaged in a wide range of activities including:

· Advocating for tobacco control public health policy

· Undertaking tobacco control research projects

· Training young people and those who work with young people to provide factual information about the health, economic and environmental effects of smoking

· Engaging young people and professionals working with young people through the ASH Wales Filter project

· Bringing health information and advice to the heart of the community

We also oversee the Wales Tobacco or Health Network (a network of over 300 individual members) and the Wales Tobacco Control Alliance (an alliance of 35 voluntary and professional bodies in Wales), providing forums for sharing knowledge and best practice.  Our newsletters for those interested in tobacco control directly reaches 1,190 subscribers every month, whilst our combined social media channels have a following of over 6,400 individuals and organisations, with the content of our three websites being viewed around 6,000 times every month combined.  ASH Wales has no direct or indirect links with, and is not funded by, the tobacco industry.

ASH Wales response to consultation

ASH Wales strongly agrees with the assertion that the period of time from pregnancy through to a child’s 2^nd Birthday represents a critical window of time in a child’s life.  It is essential children of this age are given the best opportunity to reach their potential and succeed in life, and the Welsh Government has an important role to play in facilitating this.

One way the Welsh Government can influence this period of a child’s life is to take action to reduce smoking in pregnancy rates across Wales.  Smoking during pregnancy is the single biggest modifiable risk factor for poor birth outcomes and a major cause of inequality in child health¹.  Every time a mother smokes a cigarette she inhales carbon monoxide which serves to reduce the amount of oxygen to the placenta thereby directly causing significant harm to the baby. Indeed, smoking in pregnancy has been found to increase the likelihood of miscarriage, stillbirth, Sudden Infant Death Syndrome and low birth weight babies¹.  The consequences of smoking in pregnancy are not solely confined to the prenatal or postnatal stages of a child’s life, however.  Children born to mothers who smoke additionally exhibit slower rates of development during infancy, an increased likelihood of lower educational attainment during childhood and a greater need to utilise health and social care services in adulthood¹.  Much progress is required to reduce smoking prevalence among pregnant women in Wales with current rates far too high, ranging from a low of 13.1% in Powys THB to a high of 24.4% in Cwm Taf UHB².  Smoking during pregnancy is strongly associated with a number of factors including age and social economic position. Mothers aged 20 or under are five times more likely than those aged 35 and over to have smoked throughout pregnancy³.  Mothers in routine and manual occupations are more than four times as likely to smoke throughout pregnancy – compared to those in managerial and professional occupations³.  Pregnant women are also more likely to smoke if they are less educated, live in rented accommodation and are single or have a partner who smokes³.

Furthermore, not only is smoking during pregnancy a major issue in Wales but so too is smoking during the postnatal period.  Evidence suggests an extremely high proportion (50% to 70%) of women who stop smoking during pregnancy resume the habit 6 to 12 months after giving birth⁴.  This itself represents a major problem due to the harms associated with second-hand smoke.  New born babies and very young children are especially vulnerable to exposure to second-hand smoke as they breathe more rapidly, inhaling more pollutants per pound of body weight (a higher relative ventilation rate)⁵ than adults.  They also ingest higher quantities of tobacco smoke pollutants due to more hand-to-mouth behaviours⁶. In addition, they have little control over their environment and are often unable to remove themselves from the risk of exposure to tobacco smoke.  Second-hand smoke contains more than 7000 chemicals, with hundreds considered toxic and around 70 identified as causing cancer^7,8,9,10.  There is no risk free level of exposure to second-hand smoke, with it being found to cause numerous health problems in infants, including more frequent and severe asthma attacks, respiratory infections, ear infections, and sudden infant death syndrome^7,10.

Given the above ASH Wales is calling for the Welsh Government to take action to reduce the number of women in Wales who smoke during their pregnancy, as well as the number who resume smoking after giving birth. Specifically we would like to see:

- A Welsh Government target for smoking rates during pregnancy of 8% by 2020 to be included in the Tobacco Control Action Plan (TCAP) for Wales. Smoking prevalence in Wales has fallen in recent years to a low of 19% in 2015¹¹.  Whilst extremely positive such a development must be considered in the context of the smoking rates observed among sub-sections of the population where smoking continues to be a problem.  Much work still needs to be done to reduce smoking prevalence among pregnant women and in order to focus the mind of policy makers in Wales a specific smoking target level that must be met within a certain timeframe for this cohort would be most welcome.  The target of 8% corresponds to the figure included in the ‘Smoking Still Kills’ report published by Action on Smoking and Health and funded by Cancer Research UK and the British Heart Foundation¹².

- A reduction in health inequalities by reducing smoking prevalence amongst the three highest quintiles of deprivation (Welsh Index of Multiple Deprivation) at a faster rate than quintiles one and two. Smoking rates in Wales are higher among the more deprived areas of the country relative to the more affluent. In 2015, the percentage of adults from the least deprived areas of Wales reported as being a smoker was 11% compared to a figure of 29% recorded among the most deprived adults within the Welsh population¹¹.  Similarly smoking prevalence is higher among pregnant women from deprived communities³.  Reducing smoking during pregnancy rates in Wales will therefore serve to reduce the extent of health inequalities.

- Smoking cessation services targeted at the specific needs of pregnant women who smoke. From the communications we have had from both pregnant mothers and those responsible for their care it has become clear that current stop smoking services do not suit the complex and specific needs of pregnant women.  For example, many young mothers in particular would not entertain the prospect of attending a group based smoking cessation programme.  In many areas of Wales however this is all that is on offer.  Stop smoking services in Wales must be more flexible in terms of the size of the group to which support is offered and the locations/times at which the sessions are delivered.  Consideration should be given to the provision of one-to-one specialist smoking cessation support to pregnant women at their home.

- Secured funding for smoking cessation services. To ensure the provision of a high quality stop smoking service in Wales it is imperative the funding of cessation services is protected.  The current financial climate and cuts to NHS budgets means stop smoking services are at risk of reduced funding. The government needs to ensure that smoking cessation providers receive the necessary monies to deliver their services to those with greatest need, including young pregnant mothers from deprived communities in Wales where smoking prevalence is highest.  Furthermore, in order to deliver a more specialist service involving one-to-one sessions with pregnant women in their own homes additional funding for smoking cessation services will most likely be required.  To make this possible we are calling on the Welsh Government to introduce a new levy on tobacco manufacturers and importers, and for this levy to be ring-fenced and used specifically to boost the funding of smoking cessation services.  We are also calling on the Welsh Government to explore alternative funding streams for cessation and prevention services.

- The introduction of a national communications strategy on tackling smoking among pregnant women and their families. Targeted communication, particularly to those from more disadvantaged backgrounds, is vital to help support women in taking steps to stop smoking during their pregnancy.  Accurate and consistent messaging is important, both in face to face discussions and in public messaging around the risks of smoking during pregnancy and where to get help or information.  ASH Wales is currently in the process of undertaking a campaign to improve the knowledge of the risks to both mother and child associated with smoking whilst pregnant, and the options available to them to quit. In collaboration with Public Health Wales, Flying Start and midwives from Abertawe Bro-Morgannwg University (ABMU) Health Board we have developed an information booklet on smoking in pregnancy. We have produced 8,000 copies with 5,000 of them sent out to ABMU hospitals - Singleton, Neath Port Talbot and the Princess of Wales.  These have been placed in the pregnancy information bounty packs, given to every mum-to-be at their midwife booking-in appointment.  In addition to the harms to unborn babies resulting from smoking during pregnancy it is also essential mothers themselves, plus family members, especially those cohabitating with the mother, are made aware of the risks to the health of new born babies and infants from them being exposed to second-hand smoke, particularly in the home.

To ensure this information provision ASH Wales is calling for the Welsh Government to fund a national, all-Wales wide, mass media campaign providing information on the harms associated with smoking and second-hand smoke, and for this to be targeted at both mothers and their family members from deprived communities across Wales.

- A nationally mandated programme for training professionals to tackle smoking in pregnancy. Training programmes do exist but uptake is not high. Many professionals are involved in supporting women through pregnancy, all of whom need to have appropriate levels of training. Little progress has been made to introduce the issue into core curricula or to ensure that training is ongoing through a health care professional’s career. Without a step change in the way training happens progress will continue to be too slow.

- A robust and consistent national data collection system implemented across the country to drive targets and actions. While some areas have implemented effective systems to record the smoking status of pregnant women, in too many areas this is not happening routinely or in a robust fashion.  It is evident from areas that have reviewed their processes that historic data is often found to be inaccurate or incomplete.  All pregnant women should be CO screened at the booking appointment and this recorded to identify smokers and/or those at risk from CO exposure.  Given that smoking is the single biggest modifiable risk factor for poor birth outcomes it is unacceptable that smoking status is still not being consistently recorded for all pregnancies.  Without data at booking and throughout pregnancy it is not possible to assess performance and drive improvements in practise across the country.

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References

¹  Smoking in Pregnancy Challenge Group (2015). Smoking cessation in pregnancy: A review of the challenge.

²  Public Health Wales Observatory (2016). Pregnancy and Childhood Surveillance Tool: Pregnancy indicators

³  British Market Research Bureau (2007) Infant feeding survey 2005. A survey conducted on behalf of the Information Centre for Health and Social Care and the UK Health Departments.

⁴  World Health Organization (2010). Gender, women and the tobacco epidemic

⁵Canadian Institute of Child Health (1997). Environmental hazards: Protecting children. Canada.

⁶  Matt GE, Quintana PJE, Hovell MF, Bernert JT, Song S, Novianti N, et al. (2004). Households contaminated by environmental tobacco smoke: sources of infant exposures. Tobacco Control. 13(1):29-37.

⁷  U.S. Department of Health and Human Services (2014). Let’s Make the Next Generation Tobacco-Free: Your Guide to the 50th Anniversary Surgeon General’s Report on Smoking and Health.

⁸  U.S. Department of Health and Human Services (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General.

⁹  U.S. Department of Health and Human Services (2010). A Report of the Surgeon General: How Tobacco Smoke Causes Disease: What It Means to You.

¹⁰  U.S. Department of Health and Human Services (2014). The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.

¹¹  Welsh Government (2016). Welsh Health Survey 2015.

¹²  ASH (2015). Smoking Still Kills: Protecting children, reducing inequalities.