Smokefree pregnancy referral pathway

LTP Priority: Respiratory

Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service

Type of Interventions: Smokefree pregnancy referral pathway

Major driver of health inequalities in your area of work

Smoking in pregnancy is the main modifiable risk factor for a range of negative outcomes for both mother and baby. Women who smoke during pregnancy are twice as likely to experience a stillbirth, up to 32% more likely to miscarry, and babies born to smokers are three times more likely to suffer from Sudden Infant Death Syndrome. Smokers who access behavioural support to quit, combined with stop smoking medication, are 3 times as likely to quit as those without support. However, women from priority populations (especially those from lower socio-economic groups) are less likely to seek or access this support.

The current national measure of maternal smoking is the rate of women smoking at time of delivery (SATOD), and the latest annual figure for England is 10.8% in 2017/18. However, this average figure masks significant variation in maternal smoking rates amongst key populations, and associated health inequalities. Causes of variation include:

  • There is a near threefold variation in maternal smoking rates from the lowest commissioning region (London at 5%) to the highest (The North at 14.3%). At CCG level the disparity is even greater, ranging from 1.8% in NHS Westminster to 26% in NHS Blackpool.
  • Smoking at time of booking shows a near fivefold variation in smoking rates from the youngest age group (Under 18s at 28.3%) to the oldest age group (Over 40s at 5.9%)
  • A fivefold difference in smoking at booking rates between the most deprived decile (19.8%) and the least deprived decile (3.7%)
  • Young white women (18-34) are more likely to smoke (18.6%) than the average for all women that age group (16.3%)

Despite moderate declines in SATOD rates over the last decade, there has been a plateauing of this decline over the last 3 years. Current estimates also indicate that nearly a quarter of UK women (23.3%) smoke at some point during pregnancy, which is amongst the highest rates in the EU15+. Women from higher socio-economic groups are less likely to smoke in pregnancy, but those that do are significantly more likely to quit before their booking appointment.

In addition to the direct health inequalities of maternal smoking, there is also a compounding factor, whereby children born into smoking households are three times more likely to start smoking themselves, compared to children raised in non-smoking households.

Target groups

Deprivation and protected characteristics – age and pregnancy


Smokefree pregnancy referral pathway: Service


Embed local stop smoking in pregnancy referral pathways within maternity services, by ensuring that all pregnant women are routinely tested for levels of carbon monoxide (CO), receive Very Brief Advice (VBA) on smoking and those who smoke are referred into behavioral support to stop smoking on an opt-out basis.

Establish this smokefree pregnancy referral pathway within maternity services, by:

  1. Training all relevant maternity staff to conduct CO testing, deliver VBA, have a brief and meaningful conversation on smoking, and refer into behavioral support. E-learning for healthcare provides an online training module (the same training is also available through RMC ilearn and the National Centre for Smoking Cessation and Training). The Smoking in Pregnancy Challenge Group provides further resources to support maternity teams to develop and deliver effective pathways for stop smoking support
  2. Routinely testing all women for levels of carbon monoxide (CO) at their first booking antenatal appointment (and at relevant subsequent appointments). This includes ensuring that CO monitors and associated consumables (for example, mouthpiece and wipes) are available onsite. CO results should be recorded on maternity information systems and included in the MSDS submission to NHS Digital.
  3. Providing Very Brief advice on smoking to women with a raised CO levels (4 ppm)
  4. Establishing effective pathways from maternity services into specialist stop smoking support AND referring all pregnant women with raised CO levels (4 ppm) into these services on an opt-out basis.

Implementation of this intervention will be an enabler for the delivery of the NHS Long Term Plan commitment to offer NHS-fund tobacco addiction and stop smoking support to all pregnant women who smoke.

(Implementation of VBA during Health Checks or in Healthy Living Pharmacies, or use of QOF to encourage use of VBA, can also support referral of pregnant women who smoke into behavioural support to help them quit)

What outcomes is it expected to lead to?

Implementation of this smokefree pregnancy referral pathway will lead to:

  • Universal CO testing of pregnant women
  • Improved identification of pregnant women who smoke, using objective methods


Implementing a systematic approach to identifying and referring pregnant smokers is underpinned by recommendations within NICE guidance PH26 (Stopping smoking in pregnancy and after childbirth), with the first two recommendations aimed at midwives and others in the public, community and voluntary sectors to use appointments with pregnant women to establish if they smoke, provide VBA on smoking, and an opt-out referral into support to quit.

The latest summary report of the Smoking in Pregnancy Challenge Group reiterates the need to address variation in the way that NICE guidance PH26 is implemented locally, and to increase the proportion of the maternity workforce trained to address smoking in pregnancy.

Saving babies lives Care Bundle Version 2 aims to deliver a national ambition to halve the rates of stillbirths, neonatal and maternal deaths and intrapartum brain injuries by 2025. One of the five key elements within the bundle to help achieve this is reducing rates of smoking in pregnancy. SBLCB Vs.2 offers a practical approach to reducing smoking in pregnancy which will be achieved by, “offering carbon monoxide (CO) testing for all women at the antenatal booking appointment, and as appropriate throughout pregnancy, to identify smokers (or those exposed to tobacco smoke) and offer them a referral for support from a trained stop smoking advisor”.

A review of Saving Babies Lives Care Bundle Version 1 highlighted that only 70% of pregnant women reported being asked to undertake CO monitoring, with over 99% agreeing to do so. Nationally, we should strive to achieve 100% of pregnant women being offered a CO reading at booking and at other key points during the pregnancy pathway.

The evaluation of the North East regional babyClear approach was published in the BMJ in 2017 concludes that “implementation of routine carbon monoxide monitoring and opt-out referral of pregnant smokers to smoking cessation services increases referral rates”. This approach, which trained community midwifery staff in VBA and provided them with CO equipment, showed a more than twofold increase in the number of pregnant women being referred to stop smoking support in the year post-implementation, compared to the previous year. This evaluation also showed a near doubling in the number of pregnant smokers at booking who had successfully quit by the time that they gave birth.

Guidance for Commissioners