With the smoking ban this year, smoking cessation has received more attention from the government, from the media and from the public than ever before. Considering the entirely preventable toll of more than 100,000 smoking-related deaths each year in the UK, this is not before time.
The government target to reduce the rate of smoking in pregnancy to 15 per cent by 2010 is clearly important, but there is reason to question the focus on persuading pregnant women to stop, which I believe is well meant, but misplaced. Much better to get them to stop before they are pregnant.
Prevalence and risks
There is no doubt that smoking in pregnancy is a key health issue, not least because it continues to be so common.
Young women smoke more than any other group, with a prevalence of over 30 per cent. Moreover, 17 per cent of pregnant women admit to continuing to smoke throughout pregnancy, although the true rate may be much higher.
Many smokers are in denial and often lie about smoking in pregnancy.
There is good evidence from secret monitoring of urinary cotinine (a metabolite of nicotine) in pregnancy, which shows that up to 80 per cent of women who were smoking before conception continue to do so during pregnancy, although many deny it.
These women may well have cut down on their smoking, but are in fact smoking harder to get the same nicotine dosage from a smaller number of cigarettes.
We know that pregnant women who smoke take in the same level of toxic substances from smoking as they did before they became pregnant.
The harmful effects on the foetus of smoking while pregnant are well documented, and include low birth weight and prematurity, causing more frequent use of neonatal intensive care, increased rates of miscarriage and neonatal death, a higher risk of sudden infant death syndrome, and, as the child grows, higher rates of ENT, chest and other problems.
The unborn child, of course, has no choice in the matter and no means of escape; in effect, the mother is smoking for two.
It might seem logical, therefore, to focus a lot of smoking-cessation campaign attention on pregnant smokers, not least because they might be thought to be a highly motivated group who can successfully be persuaded to give up.
The standard and correct recommendations are that pregnant women should be offered information about the risks attached to smoking, referral to a smoking-cessation service and treatment with nicotine-replacement therapy, preferably of an intermittent type in order to minimise foetal exposure to nicotine.
NICE recommends nicotine-replacement therapy as the only form of pharmacotherapy for use in pregnancy. This makes sense as nicotine is a relatively safe substance.
Essentially it is the nicotine that makes smokers smoke, but it is the other substances in cigarette smoke that do the damage. Also, most babies would anyway be exposed to nicotine if, as is likely, the mother continued smoking.
Unfortunately, however, cessation rates in pregnant women are low.
In fact, almost any smoking-cessation pregnancy specialist will tell you they are a very difficult group to treat successfully.
There are many possible reasons for this.
Newly pregnant women are frequently not in a state of mind where they are at all interested in battling their nicotine addiction.
It is as if the time to stop was imposed on them.
Moreover, pregnancy is a time of great upheaval for many women, who often face many stressful life changes simultaneously.
Rather than just targeting pregnant women, it makes sense to focus our attention on all young women, many of whom will of course go on to have children in the near future.
This gives future mothers the chance to stop smoking when it suits them, not just to tie in with a government target.
Focus on future mothers
Helping a young woman quit smoking is likely to be a multiple success. If she does stop in the long-term, not only she, but all her future children will gain health benefits.
Every time a young woman who smokes comes to see me, I tell her about the support and treatment options available to help her give up, and I explain how much more effective they are than trying to give up by will-power alone.
For any smoker it is important not to tell them to stop because most know they should. What they need, but do not know, is how best to stop - that is, with treatment from a trained smoking-cessation adviser.
For the record, giving up by will-power alone works in about 2-3 per cent of cases, while giving up with the help of treatments and support from a trained smoking-cessation adviser is up to 10 times as effective. As GPs, we see smokers several times each year, and if we take this positive approach each time they come in for a consultation, there is a very good chance of catching them at the right moment, when they are most ready to give up.
Raising the issue need not take more than a few seconds at the end of a consultation, but is probably the most effective use of time in general practice.
This 'right moment' might often come when a woman is planning to have a child, because women at this stage are often a highly motivated group and may be very interested in smoking cessation.
A special advantage in this group is that if their partner also smokes there is a ready-made 'quit buddy' who can try to stop at the same time.
This is known to improve chances of success, and if they do go on to have a child you have effectively treated three people at the cost in effort and NHS money of a single quit attempt.
Rewards for the GP
I find helping young women to give up smoking before they become pregnant is one of the most satisfying things I do in general practice.
Some of the rewards are obvious: the children suffer less from the problems associated with smoking in pregnancy and after birth.
Another, less obvious reward is that patients are often most grateful to the person who helped them through the difficult task of giving up, which leads to an excellent long-term relationship.
Dr Bobak is a GP with a special interest in smoking cessation in Wandsworth, London
September is pregnancy health month. For more information see www.tommys.org
This article was originally published in MIMS Women's Health. To register go to www.healthcarerepublic.com/womenshealth