Search

Introduction: China faces the dual challenge of high air pollution and an increasing burden of cardiovascular disease (CVD). We aimed to estimate the healthcare costs associated with CVD and the quality-adjusted life years (QALYs) under scenarios of improved air quality in China., Methods: A health prediction model was developed to estimate 10-year CVD-related costs and QALY associated with PM2.5 levels in 2015, as well as two hypothetical improved air quality scenarios: (1) the China national PM2.5 target of 35 µg/m³, and (2) the World Health Organization's (WHO) PM2.5 guideline of 5 µg/m³. Population CVD risks were estimated from the 2015 China Health and Retirement Longitudinal Study. Hazard ratios from WHO risk curves were subsequently applied to baseline cardiovascular risks to predict national 10-year estimates of ischaemic stroke and coronary heart disease-related healthcare expenditures and QALYs for individuals aged 45-85 under the three air quality scenarios., Results: Under PM2.5 levels in 2015, we estimated a cumulative 10-year incidence of 35.40 million CVD events, resulting in healthcare costs of US$96.12 billion and 4.44 billion QALYs. Under the national target of 35 µg/m³, the projected 10-year CVD incidence was 31.92 million cases, resulting in cost savings of US$9.29 billion and 3.43 million QALY gains compared with 2015 levels. If PM2.5 concentration levels meet the WHO's guideline of 5 µg/m³, the projected number of CVD events would decrease to 24.18 million, translating to cost savings of approximately US$30.10 billion and gains of 11.29 million QALYs., Conclusion: Our findings indicate that achieving the WHO recommended PM2.5 concentration level of 5 µg/m³ could lead to over threefold greater health and economic benefits than those achievable under national standards of 35 µg/m³. This underscores the potential need for stricter future national PM2.5 standards. Our findings also inform other low- and middle-income countries in establishing effective long-term PM2.5 targets., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Smoking during pregnancy is harmful to unborn babies, infants and women. Nicotine replacement therapy (NRT) is offered as the usual stop-smoking support in the UK. However, this is often used in insufficient doses, intermittently or for too short a time to be effective. This randomised controlled trial (RCT) explores whether a bespoke intervention, delivered in pregnancy, improves adherence to NRT and is effective and cost-effective for promoting smoking cessation., Methods and Analysis: A two-arm parallel-group RCT was conducted for pregnant women aged ≥16 years and who smoke ≥1 daily cigarette (pre-pregnancy smoked ≥5) and who agree to use NRT in an attempt to quit. Recruitment is from antenatal care settings and via social media adverts. Participants are randomised using blocked randomisation with varying block sizes, stratified by gestational age (<14 or ≥14 weeks) to receive: (1) usual care (UC) for stop smoking support or (2) UC plus an intervention to increase adherence to NRT, called 'Baby, Me and NRT' (BMN), comprising adherence counselling, automated tailored text messages, a leaflet and website. The primary outcome is biochemically validated smoking abstinence at or around childbirth, measured from 36 weeks gestation. Secondary outcomes include NRT adherence, other smoking measures and birth outcomes. Questionnaires collect follow-up data augmented by medical record information. We anticipate quit rates of 10% and 16% in the control and intervention groups, respectively (risk ratio=1.6). By recruiting 1320 participants, the trial should have 90% power (alpha=5%) to detect this intervention effect. An economic analysis will use the Economics of Smoking in Pregnancy model to determine cost-effectiveness., Ethics and Dissemination: Ethics approval was granted by Bloomsbury National Health Service's Research Ethics Committee (21/LO/0123). Written informed consent will be obtained from all participants. Findings will be disseminated to the public, funders, relevant practice/policy representatives, researchers and participants., Trial Registration Number: ISRCTN16830506., Protocol Version: 5.0, 10 Oct 2023., Competing Interests: Competing interests: FN is an unpaid member of the scientific committee for the Smoke Free app, a smoking cessation app unrelated to this project. All other authors have declared that they have no competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Objectives: Postpartum return to smoking (PPRS) is an important public health problem. E-cigarette (EC) use has increased in recent years, and in a contemporary UK pregnancy cohort, we investigated factors, including ECs use, associated with PPRS., Design: Secondary analyses of a longitudinal cohort survey with questionnaires at baseline (8-26 weeks' gestation), late pregnancy (34-36 weeks) and 3 months after delivery., Setting: 17 hospitals in England and Scotland in 2017., Participants: The cohort recruited 750 women who were current or recent ex-smokers and/or EC users. A subgroup of women reported being abstinent from smoking in late pregnancy (n=162, 21.6%), and of these 137 (84.6%) completed the postpartum questionnaire and were included in analyses., Outcome Measures: Demographics, smoking behaviours and beliefs, views and experience of ECs and infant feeding., Results: 35.8% (95% CI 28% to 44%) of women reported PPRS. EC use in pregnancy (adjusted OR 0.34, 95% CI 0.13 to 0.85) and breast feeding (adjusted OR 0.06, 95% CI 0.02 to 0.24) were inversely associated with PPRS, while household member smoking at 3 months post partum was positively associated with PPRS (adjusted OR 11.1, 95% CI 2.47 to 50.2)., Conclusion: EC use in pregnancy could influence PPRS. Further research is needed to confirm this and investigate whether ECs could be used to prevent PPRS., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Objective: The first observational study to investigate the impact of early supported discharge (ESD) on length of hospital stay in real-world conditions., Design: Using historical prospective Sentinel Stroke National Audit Programme (SSNAP) data (1 January 2013-31 December 2016) and multilevel modelling, cross-sectional (2015-2016; 30 791 patients nested within 55 hospitals) and repeated cross-sectional (2013-2014 vs 2015-2016; 49 266 patients nested within 41 hospitals) analyses were undertaken., Setting: Hospitals were sampled across a large geographical area of England covering the West and East Midlands, the East of England and the North of England., Participants: Stroke patients whose data were entered into the SSNAP database by hospital teams., Interventions: Receiving ESD along the patient care pathway., Primary and Secondary Outcome Measures: Length of hospital stay., Results: When adjusted for important case-mix variables, patients who received ESD on their stroke care pathway spent longer in hospital, compared with those who did not receive ESD. The percentage increase was 15.8% (95% CI 12.3% to 19.4%) for the 2015-2016 cross-sectional analysis and 18.8% (95% CI 13.9% to 24.0%) for the 2013-2014 versus 2015-2016 repeated cross-sectional analysis. On average, the increased length of hospital stay was approximately 1 day., Conclusions: This study has shown that by comparing ESD and non-ESD patient groups matched for important patient characteristics, receiving ESD resulted in a 1-day increase in length of hospital stay. The large reduction in length of hospital stay overall, since original trials were conducted, may explain why a reduction was not observed. The longer term benefits of accessing ESD need to be investigated further., Trial Registration Number: http://www.isrctn.com/ISRCTN15568163., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Integration of smoking cessation (SC) into lung cancer screening is essential to optimise clinical and cost effectiveness. The most effective way to use this 'teachable moment' is unclear. The Yorkshire Enhanced Stop Smoking study will measure the effectiveness of an SC service integrated within the Yorkshire Lung Screening Trial (YLST) and will test the efficacy of a personalised SC intervention, incorporating incidental findings detected on the low-dose CT scan performed as part of YLST., Methods and Analysis: Unless explicitly declined, all smokers enrolled in YLST will see an SC practitioner at baseline and receive SC support over 4 weeks comprising behavioural support, pharmacotherapy and/or a commercially available e-cigarette. Eligible smokers will be randomised (1:1 in permuted blocks of random size up to size 6) to receive either an enhanced, personalised SC support package, including CT scan images, or continued standard best practice. Anticipated recruitment is 1040 smokers (January 2019-December 2020). The primary objective is to measure 7-day point prevalent carbon monoxide (CO) validated SC after 3 months. Secondary outcomes include CO validated cessation at 4 weeks and 12 months, self-reported continuous cessation at 4 weeks, 3 months and 12 months, attempts to quit smoking and changes in psychological variables, including perceived risk of lung cancer, motivation to quit smoking tobacco, confidence and efficacy beliefs (self and response) at all follow-up points. A process evaluation will explore under which circumstances and on which groups the intervention works best, test intervention fidelity and theory test the mechanisms of intervention impact., Ethics and Dissemination: This study has been approved by the East Midlands-Derby Research Ethics Committee (18/EM/0199) and the Health Research Authority/Health and Care Research Wales. Results will be disseminated through publication in peer-reviewed scientific journals, presentation at conferences and via the YLST website., Trial Registration Numbers: ISRCTN63825779, NCT03750110., Competing Interests: Competing interests: PAJC has received consultation fees and share options from Everest Detection., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Objective: To investigate relationships between maternal smoking status in pregnancy and infant development. The largest randomised controlled trial of nicotine replacement therapy (NRT) for smoking cessation in pregnancy, the smoking, nicotine and pregnancy (SNAP) trial, found that at 1 month after randomisation, smoking cessation rates were doubled in the NRT group compared with the placebo group. At delivery, there was no significant difference in cessation rates between groups. Surprisingly, infants born to women randomised to NRT were more likely to have unimpaired development at 2 years. We hypothesised that this apparently protective effect was due to smoking cessation caused by NRT and so, investigate this relationship using the same cohort., Design: Secondary analysis of a randomised controlled trial., Setting: Seven antenatal hospitals in the Midlands and North-West England., Participants: Eight hundred and eighty-four pregnant smokers randomised to receive either NRT patches or visually-identical placebo in the SNAP trial. Participants' smoking behaviour were recorded at randomisation, 1 month after their target quit date and at delivery., Methods: Using logistic regression models, we investigated associations between participants' smoking measures and infant development (assessed using the Ages and Stages questionnaire) at 2 years., Main Outcome Measures: 2 year infant development., Results: Developmental impairment was reported for 12.7% of study 2 year olds. Maternal heaviness of smoking at randomisation (OR: 1.26, 95% CI: 0.82 to 1.96, p=0.091), validated smoking abstinence recorded at 1 month after a quit date (OR: 1.02, 95% CI: 0.60 to 1.74, p=0.914) and validated smoking abstinence recorded at both 1 month after a quit date and at the end of pregnancy (OR: 1.52, 95% CI: 0.81 to 2.85, p=0.795) were not independently associated with infant developmental impairment at 2 years., Conclusion: We found no evidence that NRT treatment improved infants' developmental outcomes through smoking cessation., Trial Registration Number: CTA03057/0002/001-0001; Post-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Objectives: Venous thromboembolism (VTE) is a serious, potentially traumatic, life-threatening condition and a major cause of mortality and morbidity. The aim of this study was to obtain detailed understandings of the impact of VTE and examine individual's experiences over the first year since a first-time VTE., Design: A longitudinal qualitative interview study using inductive thematic analysis. This study presents follow-up data for 11 participants, first interviewed 6 months following a first-time VTE., Setting: Outpatients recruited from a community haematology clinic in a UK District General Hospital., Participants: Eleven participants (seven females and four males) recruited from a community haematology clinic. Participants had experienced a first-time VTE and participated in qualitative interviews 3 months previously., Intervention: Audio-recorded semistructured interviews with a sample of 11 participants who experienced a first-time deep vein thrombosis or pulmonary embolism within the previous year. Interviews were transcribed and analysed using inductive thematic analysis., Results: Four overarching themes were identified: life changing and forever changed, the trauma of care, 'thrombo-neuroses' and through adversity comes growth. Theme content varied according to age and developmental stage, presence of VTE symptoms and the experience of diagnosis., Conclusions: The data demonstrate the psychosocial impact of VTE and its diagnosis as physically and psychologically challenging, and individuals reported being forever changed by the experience. Participants' reported continued high levels of trauma and anxiety symptoms, triggered by physical (eg, symptoms) and psychological (eg, health anxiety, negative emotions) reminders of VTE. Wider primary care service issues including misdiagnosis maintained negative emotions and health anxiety with implications for relationships with professionals. Targeted clinical interventions to better identify and support individuals at risk of distress and enhance psychological well-being and reduce distress are discussed., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: This protocol describes a study of a quality improvement collaborative (QIC) to support implementation and delivery of comprehensive geriatric assessment (CGA) in UK care homes. The QIC will be formed of health and social care professionals working in and with care homes and will be supported by clinical, quality improvement and research specialists. QIC participants will receive quality improvement training using the Model for Improvement. An appreciative approach to working with care homes will be encouraged through facilitated shared learning events, quality improvement coaching and assistance with project evaluation., Methods and Analysis: The QIC will be delivered across a range of partnering organisations which plan, deliver and evaluate health services for care home residents in four local areas of one geographical region. A realist evaluation framework will be used to develop a programme theory informing how QICs are thought to work, for whom and in what ways when used to implement and deliver CGA in care homes. Data collection will involve participant observations of the QIC over 18 months, and interviews/focus groups with QIC participants to iteratively define, refine, test or refute the programme theory. Two researchers will analyse field notes, and interview/focus group transcripts, coding data using inductive and deductive analysis. The key findings and linked programme theory will be summarised as context-mechanism-outcome configurations describing what needs to be in place to use QICs to implement service improvements in care homes., Ethics and Dissemination: The study protocol was reviewed by the National Health Service Health Research Authority (London Bromley research ethics committee reference: 205840) and the University of Nottingham (reference: LT07092016) ethics committees. Both determined that the Proactive HEAlthcare of Older People in Care Homes study was a service and quality improvement initiative. Findings will be shared nationally and internationally through conference presentations, publication in peer-reviewed journals, a graphical illustration and a dissemination video., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Research into interventions to improve health and well-being for older people living in care homes is increasingly common. Health-related quality of life (HRQoL) is frequently used as an outcome measure, but collecting both self-reported and proxy HRQoL measures is challenging in this setting. This study will investigate the reliability of UK care home staff as proxy respondents for the EQ-5D-5L and HowRu measures., Methods and Analysis: This is a prospective cohort study of a subpopulation of care home residents recruited to the larger Proactive Healthcare for Older People in Care Homes (PEACH) study. It will recruit residents ≥60 years across 24 care homes and not receiving short stay or respite care. The sample size is 160 participants. Resident and care home staff proxy EQ-5D-5L and HowRu responses will be collected monthly for 3 months. Weighted kappa statistics and intraclass correlation adjusted for clustering at the care home level will be used to measure agreement between resident and proxy responses. The extent to which staff variables (gender, age group, length of time caring, role, how well they know the resident, length of time working in care homes and in specialist gerontological practice) influence the level of agreement between self-reported and proxy responses will be considered using a multilevel mixed-effect regression model., Ethics and Dissemination: The PEACH study protocol was reviewed by the UK Health Research Authority and University of Nottingham Research Ethics Committee and was determined to be a service development project. We will publish this study in a peer-reviewed journal with international readership and disseminate it through relevant national stakeholder networks and specialist societies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Scaling the Peaks is a cross-disciplinary research study that draws on medical ethnography, human geography and Geospatial Information Science (GIS) to address the issues surrounding the design and delivery of dementia-friendly services in rural communities. The research question seeks to understand the barriers and drivers to the development of relevant, robust, reliable and accessible services that make a difference among older rural families affected by dementia., Methods and Analysis: This mixed methods study recruits both families affected by dementia who reside within the Peak District National Park, Derbyshire, and their service providers. The study explores the expectations and experiences of rural dementia by adopting a three-part approach 1 : longitudinal ethnographic enquiry with up to 32 families affected by dementia (aged 70 years plus) who identify themselves as rural residents 2 ; ethnographic semistructured interviews and systematic observations of a range of statutory, third sector, private and local community initiatives that seek to support older people living with dementia 3 ; and geospatial visual mapping of the qualitative and quantitative data. The ethnographic data will be used to explore the ideas of belonging in a community, perceptions of place and identity to determine the factors that influence everyday decisions about living well with dementia and, for the providers, working in a rural community. The geospatial component of the study seeks to incorporate quantitative and qualitative data, such as types, locations and allocation of services to produce an interactive web-based map for local communities to determine the future design and delivery of services when considering dementia-friendly services., Ethics and Dissemination: The study is approved by the Leeds and Humberside Health Research Authority 16/YH/0163. The study is also approved by other participating organisations as required by their own governance procedures. The study includes people with dementia and as such adheres to the ethical considerations when including people with dementia. A publicly available interactive visual map of the findings will be produced in relation to current services related to location and, by default, identify gaps in provision. Formal reports and dissemination activities will be undertaken in collaboration with the study advisory group members., Study Progress: The recruitment began in September 2016. The data analysis commenced June 2017, using 59 provider interviews and 27 family participants. Data collection will be completed June 2018., Note on Terminology: Please note that the term 'families affected by dementia' is the preferred term of usage by the family members of the Scaling the Peaks Study Advisory Group. The group wish to emphasise that they consider this term to be more representative of their lives than the term living with dementia., Trial Registration Number: NIHR IRAS 188103; Pre-results., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objectives: Evidence from the US Truth campaign suggests that interventions focusing on tobacco industry practices and ethics may be effective in preventing youth smoking uptake. We developed, piloted and evaluated a school-based intervention based on this premise., Methods: Exploratory study students in years 7-8 (aged 11-13) in two UK schools received Operation Smoke Storm , comprising three 50 min classroom-based sessions in year 7, an accompanying family booklet and a 1-hour classroom-based booster session in year 8. We compared the risk and odds of ever smoking and susceptibility to smoking in year 8 students in study schools postintervention with students in control schools. Focus groups and interviews with students, teachers and parents evaluated the acceptability of the intervention., Results: In intervention schools, the combined prevalence of ever smoking and susceptibility increased from 18.2% in year 7 to 33.8% in year 8. There was no significant difference in the odds of a year 8 student in an intervention school being an ever smoker or susceptible never smoker compared with controls (adjusted OR (aOR) 1.28, 95% CI 0.83 to 1.97, p=0.263) and no significant difference in the odds of ever smoking (aOR 0.82, 95% CI 0.42 to 1.58, p=0.549). Teachers highlighted differences by academic ability in how well the messages presented were understood. Use of the family component was low but was received positively by parents who engaged with it., Conclusions: Operation Smoke Storm is an acceptable resource for delivering smoking-prevention education, but it does not appear to have reduced smoking and susceptibility., Competing Interests: Competing interests: LLJ receives personal fees from the National Centre for Smoking Cessation and Training, outside the submitted work., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objectives: Cancer-associated thrombosis (CAT) complex condition, which may present to any healthcare professional and at any point during the cancer journey. As such, patients may be managed by a number of specialties, resulting in inconsistent practice and suboptimal care. We describe the development of a dedicated CAT service and its evaluation., Setting: Specialist cancer centre, district general hospital and primary care., Participants: Patients with CAT and their referring clinicians., Intervention: A cross specialty team developed a dedicated CAT service , including clear referral pathways, consistent access to medicines, patient's information and a specialist clinic., Primary and Secondary Outcome Measures: The service was evaluated using a mixed-methods evaluation , including audits of clinical practice, clinical outcomes, staff surveys and qualitative interviewing of patients and healthcare professionals., Results: Data from 457 consecutive referrals over an 18-month period were evaluated. The CAT service has led to an 88% increase in safe and consistent community prescribing of low-molecular-weight heparin, with improved access to specialist advice and information. Patients reported improved understanding of their condition, enabling better self-management as well as better access to support and information. Referring clinicians reported better care standards for their patients with improved access to expertise and appropriate management., Conclusions: A dedicated CAT service improves overall standards of care and is viewed positively by patients and clinicians alike. Further health economic evaluation would enhance the case for establishing this as the standard model of care., Competing Interests: SN served in the advisory boards of Leo Pharma and Pfizer and in the speakers bureau for Leo Pharma and Pfizer; no honorarium was received. RA served in the advisory boards of Pfizer, Leo Pharma, Bristol Myers Squibb and Bayer and in the speakers bureau for Leo Pharma, Pfizer and Bayer., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objective: To identify and critically assess previous economic evaluations of smoking cessation interventions delivered during pregnancy., Design: Qualitative review of studies with primary data collection or hypothetical modelling. Quality assessed using the Quality of Health Economic Studies checklist., Data Sources: Electronic search of 13 databases including Medline, Econlit, Embase, and PubMed, and manual search of the UK's National Institute of Health and Care Excellence guidelines and US Surgeon General., Eligibility Criteria for Selecting Studies: All study designs considered if they were published in English, evaluated a cessation intervention delivered to pregnant women during pregnancy, and reported any relevant economic evaluation metric (eg, cost per quitter, incremental cost per quality adjusted life year)., Results: 18 studies were included. 18 evaluations were conducted alongside clinical trials, four were part of observational studies, five were hypothetical decision-analytic models and one combined modelling with within-trial analysis. Analyses conducted were cost-offset (nine studies), cost-effectiveness (five studies), cost-utility (two studies), and combined cost-effectiveness and cost-utility (two studies). Six studies each were identified as high, fair and poor quality, respectively. All interventions were demonstrated to be cost-effective except motivational interviewing which was dominated by usual care (one study). Areas where the current literature was limited were the robust investigation of uncertainty, including time horizons that included outcomes beyond the end of pregnancy, including major morbidities for the mother and her infant, and incorporating better estimates of postpartum relapse., Conclusions: There are relatively few high quality economic evaluations of cessation interventions during pregnancy. The majority of the literature suggests that such interventions offer value for money; however, there are methodological issues that require addressing, including investigating uncertainty more robustly, utilising better estimates for postpartum relapse, extending beyond a within-pregnancy time horizon, and including major morbidities for the mother and her infant for within-pregnancy and beyond., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objectives: Children's exposure to secondhand smoke (SHS) is causally linked to childhood morbidity and mortality. Over 38% of English children (aged 4-15) whose parents are smokers are exposed to SHS in the home. Little is known about the prevalence of SHS exposure in the homes of young infants (≤3 months). This study aimed to estimate maternal self-reported prevalence of SHS exposure among infants of women who smoked just before or during pregnancy, and identify factors associated with exposure., Setting: Primary Care, Nottingham, England., Participants: Current and recent ex-smoking pregnant women (n=850) were recruited in Nottingham, England. Women completed questionnaires at 8-26 weeks gestation and 3 months after childbirth. Data on smoking in the home 3 months after childbirth was available for 471 households., Primary and Secondary Outcome Measures: Maternal-reported smoking in the home 3 months after childbirth., Results: The prevalence of smoking in the home 3 months after childbirth was 16.3% (95% CI 13.2% to 19.8%) and after multiple imputation controlling for non-response 18.2% (95% CI 14.0% to 22.5%). 59% of mothers were current smokers; of these, 24% reported that smoking occurred in their home compared to 4.7% of non-smokers. In multivariable logistic regression, mothers smoking ≥11 cigarettes per day were 8.2 times (95% CI 3.4 to 19.6) more likely to report smoking in the home. Younger age, being of non-white ethnicity, increased deprivation and less negative attitudes towards SHS were also associated with smoking in the home., Conclusions: This survey of smoking in the home 3 months after childbirth found a lower prevalence than has been reported in older children. Interventions to support smoking mothers to quit, or to help them restrict smoking in the home, should target attitudinal change and address inequality relating to social disadvantage, younger age and non-white ethnic groups., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To explore the psychological consequences of experiencing symptomatic pulmonary embolism (PE)., Design: Qualitative interview-based study using interpretative phenomenological analysis., Setting: Outpatients who attended an anticoagulation clinic in a district general hospital., Participants: Patients attending an anticoagulation clinic following hospital admission for symptomatic PE were approached to participate. A total of 9 (4 women, 5 men) of 11 patients approached agreed to be interviewed. Participants were aged between 26 and 72 years and had previously experienced a PE between 9 and 60 months (median=26 months, mean=24 months)., Intervention: Audiotaped semistructured qualitative interviews were undertaken to explore participants experiences of having a PE and how it had affected their lives since. Data were transcribed and analysed using interpretative phenomenological analysis to identify emergent themes., Results: Three major themes with associated subthemes were identified. Participants described having a PE as a life-changing experience comprising initial shock, followed by feeling of loss of self, life-changing decisions and behaviour modification. Features of post-traumatic stress disorder (PTSD) were described with flashbacks, hypervigilance and intrusive thoughts being most prevalent. Participants identified several areas of support needed for such patients including easier access to support through information giving and emotional support., Conclusions: Long-term consequences of venous thromboembolism go beyond the physical alone. Patients describe experiencing symptomatic PE to be a life-changing distressing event leading to behaviour modification and in some PTSD. It is likely that earlier psychological intervention may reduce such long-term sequelae.