Nanny NICE?

I’m a big fan of the work of the National Institute for Health and Clinical Excellence. Someone has to make the hard decisions about which treatments are sufficiently cost-effective to provide on the NHS. I’m glad the decisions are, by and large, made by committees of experts, after careful appraisal of the evidence.

You can hear the ‘but’ hanging in the air. A series of pronouncements in recent weeks has started the alarm bells ringing.

First up, a minimum price for alcohol, as part of a guideline to prevent hazardous and harmful drinking. Hmm, maybe. There’s evidence it would cut the amount the nation drinks at a population level, but it could be a pretty blunt tool to cut the amount imbibed by problem drinkers.

Next, pronouncements about how much salt and saturated fat we eat (too much, predictably). This guideline (on the prevention of cardiovascular disease) ranged widely in its recommendations, taking in the banning of takeaway outlets near schools, food labelling and advertising, catering guidelines for the public sector, and increasing physical activity. 

I began to be suspicious when I read the blithe announcement in the press release that ‘most consumers don’t even notice any difference in taste’ when salt is reduced. Hmm, then why do food companies use so much of it? And why does a GP friend hate telling people to switch to a low-salt diet, ‘because it makes them so bloody miserable.’

But the one that had me muttering into my (salt-free) porridge this morning was the recommendation (part of the guideline on quitting smoking in pregancy and after childbirth) that midwives should administer a carbon monoxide test to all pregnant women, to see whether they smoked or not.

I can imagine how that conversation might go. ‘Can you just blow into this monitor for me?’ ‘What’s it for?’ ‘To see if you smoke.’ ‘But I’ve already told you I don’t.’ ‘Ah, but you might be lying.’ No doubt that’ll do wonders for the midwive-patient relationship.

Now, clearly, smoking in pregnancy causes all sorts of damage to mother and baby, and I’m a pretty rabid anti-smoker myself. But it’s one more example of how pregnant women are treated as feckless, stupid or mendacious, until proven otherwise.

It’s rather sad, because NICE actually stood up for the evidence when the previous government decided that pregnant women should abstain completely from alcohol, in case they were too dim to know the difference between the occasional glass of wine and a full-on White Lightning binge.

The trouble with these recent forays into public health guidelines is that the evidence is much less strong than that which NICE considers when deciding whether or not to recommend a specific treatment for NHS funding.

So what’s the evidence that administering a CO test to all pregant women will result in more pregnant women quitting smoking? Has there been a randomised controlled trial, comparing cotinine levels of women at the end of pregnancy between those who had a CO test and midwife advice, with those who simply had advice? No, of course not.

The guideline instead reports studies that show some women who claim to have quit still have biochemistry suggesting they haven’t. That’s hardly a surprise, and its a flimsy basis on which to introduce a new public health initiative.

I did a quick PubMed search on smoking cessation and pregancy. Of 146 studies, two looked at incorporating biochemical testing as part of a study of smoking cessation. Neither of them used CO as a measure. So much for evidence-based policy making.

But it can’t do any harm, can it? And surely it’s worth it, if it means just one woman, caught Marlborough-redhanded, gives up in time to have a bouncy baby? Well, maybe. But it brands the rest of the pregnant population as untrustworthy idiots, who can’t be expected to do the right thing for their child without being checked up on by Nanny NICE. And of those who are smoking, what’s the odds that they’ll skip the next midwifery appointment, to avoid the embarrassment of being tested and ‘found out’? That sounds like harm to me.

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