‘Opt-out’ referrals after identifying pregnant smokers using exhaled air carbon monoxide: impact on engagement with smoking cessation support

Abstract

BackgroundIn the UK, free smoking cessation support is available to pregnant women; only a minority accesses this. ‘Opt-out’ referrals to stop smoking services (SSS) are recommended by UK guidelines. These involve identifying pregnant smokers using exhaled carbon monoxide (CO) and referring them for support unless they object.MethodsTo assess the impact of ‘opt-out’ referrals for pregnant smokers on SSS uptake and effectiveness, we conducted a ‘before–after’ service development evaluation. In the 6-month ‘before’ period, there was a routine ‘opt-in’ referral system for self-reported smokers at antenatal ‘booking’ appointments. In the 6-month ‘after’ period, additional ‘opt-out’ referrals were introduced at the 12-week ultrasound appointments; women with CO≥4 ppm were referred to, and outcome data were collected from, local SSS.ResultsApproximately 2300 women attended antenatal care in each period. Before the implementation, 536 (23.4%) women reported smoking at ‘booking’ and 290 (12.7%) were referred to SSS. After the implementation, 524 (22.9%) women reported smoking at ‘booking’, an additional 156 smokers (6.8%) were identified via the ‘opt-out’ referrals and, in total, 421 (18.4%) were referred to SSS. Over twice as many women set a quit date with the SSS after ‘opt-out’ referrals were implemented (121 (5.3%, 95% CI 4.4% to 6.3%) compared to 57 (2.5%, 95% CI 1.9% to 3.2%) before implementation) and reported being abstinent 4 weeks later (93 (4.1%, 95% CI 3.3% to 4.9%) compared to 46 (2.0%, 1.5% to 2.7%) before implementation).ConclusionsIn a hospital with an ‘opt-in’ referral system, adding CO screening with ‘opt-out’ referrals as women attended ultrasound examinations doubled the numbers of pregnant smokers setting quit dates and reporting smoking cessation.

Barriers and facilitators to smoking cessation in pregnancy and in the post‐partum period: The health care professionals’ perspective

“…Some pregnant smokers with experience of an opt‐out referral have reported being unhappy with the lack of choice with some even describing powerlessness and resentment (Sloan et al ., 2016). Yet opt‐out pathways have been shown to increase support, access, and abstinence (Bell et al ., 2017; Campbell et al ., 2017). Informing health care professionals of the potential benefits of opt‐out over opt‐in referrals, including emphasizing that many pre‐implementation concerns do not emerge post‐implementation (Campbell et al ., 2016), could help with adoption and delivery (Jordan et al ., 2006).…”

“…This should also help improve the consistency of health messages around smoking delivered to pregnant smokers. Training of antenatal staff can increase the assessment of smoking and provision of support to pregnant women (Althabe et al ., 2016), even when part of opt‐out referral pathways (Campbell et al ., 2017). …”

“…In the absence of any objection, those identified as smokers are automatically referred to specialist cessation support. Where this pathway has been implemented, both staff and pregnant women considered it broadly acceptable (Campbell et al ., 2017) although less so the automatic referral component (Sloan et al ., 2016). Despite growing implementation of the opt‐out protocol, comparatively little is known about the views of health care professionals on this intervention.…”

“…Despite growing implementation of the opt‐out protocol, comparatively little is known about the views of health care professionals on this intervention. While the implementation of an opt‐out pathway has been associated with a twofold increase in support access and cessation during pregnancy (Bell et al ., 2017; Campbell et al ., 2017), only a minority of pregnant smokers ultimately have access to this pathway (Health and Social Care Information Centre, 2015). Therefore, it is important to increase our understanding of interactions between health care professionals and pregnant smokers generally, as well as those connected with opt‐out referrals.…”

Pregnant Women’s Experiences and Views on an “Opt-Out” Referral Pathway to Specialist Smoking Cessation Support: A Qualitative Evaluation: Table 1.

“…Routine CO testing of all pregnant women and an 'opt-out' referral pathway were introduced within one UK hospital trust; qualitative work reported here was part of a 6-month service evaluation of this pathway 13 . Patients who experienced the pathway were invited to participate in an interview about their experience.…”