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Smoking in pregnancy


Smoking during pregnancy causes up to 2,200 premature births, 5,000 miscarriages and 300 perinatal deaths every year in the UK. It also has an impact on long-term physical growth and intellectual development.

It is the single biggest modifiable risk factor and a major cause of inequality in child and maternal health. Prevalence varies significantly across communities and social groups, resulting in those from lower socio-economic groups being at much greater risk of complications during and after pregnancy. Therefore, reducing the number of women who smoke prior to conception, during pregnancy and postnatally, is a very important public health measure.

Nationally, over 10% of pregnant women smoke, whereas in South Gloucestershire, 9% of pregnant women smoke, the second lowest rate in the South West. The National Tobacco Plan has set an ambitious new goal of reducing smoking amongst pregnant women to 6% by the end of 2022. This is critical to ensure children have the best start in life.

South Gloucestershire Public Health & Wellbeing Division commission a dedicated stop smoking service for pregnant women who smoke, which is delivered through a specialist community midwife working for North Bristol NHS Trust.

This Joint Strategic Needs Assessment (JSNA) considers ‘Smoking in Pregnancy’ only. ‘Smoking in Adults’ and ‘Smoking in Children and Young People’ are considered separately in other sections.


Recommendations for Consideration

Develop effective digital communication strategies for pregnant smokers; Implement NICE guidance; Maintain a robust referral pathway for smoking cessation for pregnant smokers; Collect service user feedback on need, quality and gaps; Deliver a rolling programme of training for healthcare professionals; Work with third sector community organisations to provide smoking cessation support; Implement evidence-based behaviour change techniques; Improve access and sharing of ward and cluster level data; Reduce children’s exposure to second-hand smoke; Work in partnership with Commissioners and Providers of children services to ensure every child has the best start in life; Implement harm reduction interventions, including e-cigarettes.


1.  Who Is At Risk and Why?

Smoking is the leading modifiable risk factor for poor birth outcomes. In 2015, the stillbirth rate in England and Wales was the lowest it had been since 1992, at 4.5 per 1000 total births (Office for National Statistics, 2016). However, in global comparisons, the UK’s annual rate of reduction has been 1.4% per year since 2000, compared with 4.5% in Poland and 6.8% in the Netherlands. In 2015, the UK stillbirth rate ranked 24th out of 49 high income countries (Flenady et al, 2016).

Smoking in pregnancy is also associated with increased perinatal and neonatal deaths (Pineles et al, 2015) and increases the risk of miscarriage by approximately one quarter in some studies (Pineles, Park & Samet, 2014) or double in others (Baba et al, 2011). Smoking is associated with a significant reduction in birthweight (Suzuki et al, 2014). This is a risk factor for stillbirth, as well as long term health conditions later in life such as; increased risk of obesity, diabetes and cardiovascular disease (Jornayvaz et al, 2016). Preterm birth is also increased in pregnant women who smoke, with some studies estimating the risk to be as much as doubled (Kyrklund-Blomberg, Granath & Cnattingius, 2005). If no women smoked during pregnancy, an estimated 7.1% of stillbirths could be avoided (Flenady et al, 2011).

Smoking is now the leading risk factor for sudden infant death syndrome (cot death), (Fleming et al, 2007) with some evidence that the increase may be as high as four-fold. It has also been linked to specific birth defects (Hackshaw, Rodeck, & Boniface, 2011), behavioural problems (McCrory & Layte, 2012 & Tanaka et al, 2016), asthma (Den Dekker et al, 2015) and other disorders.

Maternal health is also affected by smoking as it is the leading preventable cause of morbidity and mortality. Around half of smokers will die from a cause related to smoking, and on average smokers die 10 years earlier than non-smokers (Jha et al, 2013). This clearly has significance for both women who smoke and their families.

Second hand smoke also has a harmful effect on health, particularly for children in whom increases in lower respiratory tract infections, asthma, wheezing, middle ear infections, sudden unexpected death in infancy and invasive meningococcal disease have been reported (Action on Smoking and Health, 2014). This has implications for both new-born babies and existing children of women who smoke.

Engagement of pregnant women who smoke with specialist stop smoking services can be poor, with standard rates of access to these services being as low as 12 – 20% (Campbell et al, 2017). Reasons for this are complex. Low referral rates by staff have been reported (Bell et al, 2017), difficulties in identifying smokers due to under-reporting by women caused by the stigma associated with smoking in pregnancy, and other barriers for women, such as personal worries or discomfort associated with using such services (Ussher, Etter & West, 2006).

Smoking is estimated to cost the economy in excess of £11 billion per year. Of this cost, £2.5 billion falls to the NHS, £5.3 billion falls to employers, and £4.1 billion falls to wider society. Smoking related ill-health leads to increased costs for the adult social care system and additional costs are incurred from smoking related fires, tobacco litter, illicit tobacco and organised crime (DoH, 2017). In contrast, estimated savings to the NHS from smoking cessation interventions aimed at reducing smoking in pregnancy is highly cost effective at £4, for every £1 spent (NCSCT, 2017).

Pregnant women respond better to advice and support that is framed around their health as well as that of their baby. Interventions which employ cognitive behavioural approaches to stopping smoking have been shown to be effective, such as those delivered by local smoking cessation services. Self-help interventions and financial incentives also have the potential to be effective with this smoking population. However, the UK evidence for this is limited, and therefore may not be directly applicable (NCSCT, 2017).


2. The Level of Need and Inequalities in the Local Population

Smoking at Time of Delivery (SATOD) prevalence in South Gloucestershire is currently estimated at 9% (an estimated 237 women in 2015-16), against an England average of 10.5%, and a South West average of 11.2%. Of those areas for which data is collected, South Gloucestershire has the second lowest rate for SATOD in the South West.


Figure 1: SATOD 2015-16 in Local Authorities in the South West

Source: Local Tobacco Control Profiles:


In England, SATOD rates have been declining from 13.5% in 2010/11 to 10.6% in 2015-16. Progress has stagnated with a rate of 10.5% in 2016-17. In South Gloucestershire, SATOD rates have also seen a decline; 11% in 2010-11 to 9% in 2015-16 (Local Tobacco Control Profiles, 2017). There is a need to be working towards the national ambition of SATOD rates of 6% or below.


Figure 2: SATOD Trends for South Gloucestershire

Recent trend:

Period South Gloucestershire (%) South West (%) England (%)
2010/11         Ο 11.0 13.5 13.5
2011/12         Ο 11.0 13.1 13.2
2012/13         Ο 9.7 13.3 12.7
2013/14         Ο 9.3 13.0 12.0*
2014/15         Ο 9.1 11.9 11.4*
2015/16         Ο 9.0 11.2 10.6*
Source: NHS Digital

Source: Local Tobacco Control Profiles:

In 2015, low birth weight of term babies’ rates for South Gloucestershire were at 2.5 per 1,000 (an estimated 69 women in 2015-16), against an England average of 2.8 per 1,000, and a South West average of 2.7 per 1,000 (Local Tobacco Control Profiles, 2017).


Figure 3: Low Birth Weight Trends for South Gloucestershire
Recent trend:
Period South Gloucestershire (%) South West (%) England (%)
2010      Ο 2.3 2.4 2.9
2011      Ο 2.4 2.4 2.8
2012      Ο 2.3 2.5 2.8
2013      Ο 1.6 2.4 2.8
2014      Ο 2.0 2.5 2.9
2015      Ο 2.5 2.7 2.8
Source: Office for National Statistics

Source: Local Tobacco Control Profiles:

In 2016, still birth rates for South Gloucestershire were at 0.4 per 1,000 (an estimated 12 stillbirths), against an England average of 4.6 per 1,000 and a South West average of 3.7 per 1,000 (Local Tobacco Control Profiles, 2017). In 2016, neonatal death rates for South Gloucestershire were at 2.3 per 1,000 (an estimated 130 neonatal deaths).


Figure 4: Still Birth Rate Trends for South Gloucestershire

Recent trend:–

Period South Gloucestershire per 1000 South West per 1000 England per 1000
2010 – 12     Ο 4.2 4.4 5.0
2011 – 13     Ο 4.0 4.2 4.9
2012 – 14     Ο 4.7 4.0 4.7
2013 – 15     Ο 3.5 3.7 4.6
Source: Office for National Statistics

Source: Local Tobacco Control Profiles:

South Gloucestershire Ward Level Data for SATOD

This will be added when available.

Smoking in pregnancy is a leading cause of health inequality; it has been estimated to account for 38% of the inequality in stillbirth and 31% of the inequality in infant deaths (Gray et al, 2009). Mothers aged 20 or under are six times more likely than those aged 35 and over, to have smoked throughout pregnancy (35% and 6% respectively).

Mothers in routine and manual occupations are five times more likely to have smoked throughout pregnancy, compared to women in managerial and professional occupations (20% and 4% respectively) (NHS Digital, 2010), meaning those from lower socio-economic groups are at a much greater risk of complications during and after pregnancy (Royal College of Physicians, 2010). Children who grow up with a smoking parent are also more likely to become smokers themselves (Leonardi-Bee, Jere, & Britton, 2011), further perpetuating the cycle of inequality and affecting their life chances.


3.  Current Services and Assets in Relation To Need

In line with NICE Guidance PH26, there is an established Care Pathway for smoking cessation in pre-conception and pregnancy. Midwives are asked to:

  • Assess the woman’s exposure to tobacco smoke through discussion and use of a carbon monoxide (CO) assessment.
  • Refer all women who smoke (including those who smoke lightly or infrequently), have stopped in the last 2 weeks, or have a CO reading indicative of smoking to stop smoking services. This is done electronically using an online secure database ‘Quit Manager’.
  • Help women who do not smoke but register CO levels of 3 parts per million (ppm) or more to identify the source of CO and take further action as appropriate.
  • If a person declines help to stop smoking, leave the offer open. At subsequent contacts, offer the support again.
  • Ensure all actions, discussions and decisions related to stop smoking advice, referrals or interventions are recorded in the person’s records (preferably computer-based).
  • The Care Pathway is reviewed annually (last review October 2017) and disseminated to midwives and other health professional groups.

Electronic referrals via ‘Quit Manager’ can also be made by other professional groups (pharmacists, children centre staff and health visitors) that have trained as Stop Smoking Advisors and participated in continuous professional development sessions, as required. There is potential for other professional groups (GPs, practice nurses, family nurses, obstetricians, paediatricians, ultra-sonographers, other

members of the maternity team, those working in youth and teenage pregnancy services, social services and those working in fertility clinics, dental practices, community pharmacies and voluntary and community organisations) who come into contact with a pregnant smoker to make referrals.

Nicotine Replacement Therapy (NRT) is available for immediate administration on all wards and clinics at St Michael’s hospital and Southmead hospital, with the exception of the maternity wards and clinics, which means there is an inequitable service and non-adherence to NICE guidance which recommends immediate access to NRT products for women on all wards.

The Public Health and Wellbeing Division’s (PHWBD) primary focus is to help pregnant women stop their tobacco use through evidence-based stop smoking support and quitting aids, or where this is not possible, advocate a ‘harm-reduction approach’ by encouraging pregnant smokers to switch to safer ways of using nicotine. E-cigarettes, as an aid to stopping smoking, could lead to greater quit rates among those pregnant smokers accessing stop smoking services. For pregnant smokers not ready to quit smoking, e-cigarettes are a cheaper alternative to tobacco smoking. Therefore, there is potential to reduce child poverty, and the number of smoking role models for young people, thus de-normalising smoking (Action on Smoking and Health, 2016).

The Tobacco Control Lead for South Gloucestershire commissions a Specialist Midwife (2 days a week) to support and meet the needs of women who present as smokers at the time of booking. All women referred to the local stop smoking service are contacted within one working day and with the aim of being seen at their home within one week. This intensive support programme is available up to the point of delivery, and up to two months post-partum (or longer if appropriate to prevent relapse). Evidence shows 43% of women who enroll for smoking cessation support, restart within six months of giving birth.

In 2016-17, a total of 257 pregnancy referrals (from health visitors and midwives) were made to Smokefree South Gloucestershire, a decrease of 0.77% (259) from 2015-16. The total number of pregnant women successfully quitting has decreased from 50% in 2015-16 to 42% in 2016-17. The Department of Health (DoH) recommends a quit rate of 30% or above. The most prolific source of midwifery referrals have been from Priority Neighbourhoods including Yate (23%), followed by Kingswood (18%). In 2016-17, midwives contributed an average of 64 referrals per quarter.


Figure 5: 2016-17 Pregnancy Referrals and Outcomes to Smokefree South Gloucestershire

Total Referrals From Midwives and Health Visitors:


Accessed Outcomes
Agreed In Principle Declined Service Unable To Contact Closed: No Outcome Accessed Service Quit Date Set Quit Date Not Set 4 Week Quit CO Verified 4 Week Not Quit 4 Week Lost To Follow Up
16 18 75 13 135  



49 36 34 15 25
Source: Quit Manager Referral and Outcome Report (2017)

Of the 135 pregnant smokers who accessed the Smokefree Service, the Specialist Midwife actively engaged with 64% of these. 41% were classed as ‘Routine and Manual Workers’. All clients set a quit date, with 45% successfully quitting at 4-weeks, 95% of these were CO Verified. 16% had not quit, and 27% were lost to follow up. 12% were not reported.

The Specialist Midwife service has consistently achieved above the DoH targets (quit rate of 30% or above and 85% CO verified quits) with an average quit rate over 4 years of 47%, and an average CO verification rate of 97%.

The Specialist Midwife has engaged on average with 49% of pregnant women classified in routine and manual occupations. Therefore, playing a vital role in helping to reduce the cycle of inequality and giving every child the best start in life, as evidence shows that mothers in routine and manual occupations are five times more likely to smoke throughout pregnancy, and children who grow up with a smoking parent are more likely to become smokers themselves.


4. Projected Service Use and Outcomes in the Next 5 Years and 5-10 Years

Office of National Statistics (ONS) population projections suggest the population of South Gloucestershire is set to increase a further 20% by 2039. However, these predictions do not take into account the significant housing developments taking place, and with approximately 17,000 new homes planned to be built between 2014 and 2024, this will likely swell the population beyond the ONS predictions.

The number of babies born to residents of South Gloucestershire rose from approximately 2,600 in 2003 to a peak of 3,500 in 2012 – an increase of over 30%. However, the baby boom has started to show signs of decline with the number of resident births falling by 17% between 2012 and 2016. In the period to 2037, there is projected to be a 6% increase in births.

Figure 6: South Gloucestershire Birth Projections 2015-2039

Source: Public Health Intelligence and Evidence Team, 2017

Figure 7 shows the projected number of births in South Gloucestershire up until 2039. It is estimated that there will be a 16% increase in births over this period across maternal age groups. With regard impact on service demand in the immediate future, projections indicate an increase of around 8% over the next 5 years between 2017 and 2022, and an increase of around 9% over the next 10 years, between 2017 and 2027. In real terms, this accounts for an additional 190 births per year after 5 years, and an additional 230 births per year after 10 years.

If the proportion of mothers smoking at time of delivery remains consistent with the current rate (9.0% – 2015-16), we can expect the number of mothers smoking at time of delivery to increase by around 17 after 5 years, and around 20 after 10 years. It should be noted that this is a conservative estimate as these projections do not include dwelling led projections which seem to suggest the population of children will increase at a greater rate than official ONS estimates suggest.

SATOD prevalence is decreasing as indicated by the Local Tobacco Control data. However, prevalence in some parts of South Gloucestershire continues to be at a higher rate than the England average. Future provision will need to target pregnant smokers within each ward more effectively than current providers.


5. Evidence of What Works

There is a wide range of evidence and guidance on supporting factors and barriers to smoking cessation in pregnancy. Key guidance is provided in:

  • ‘Towards A Smokefree Generation: A Tobacco Control Plan for England’ (2017) – This contains the Government’s national ambition to reduce rates of smoking in pregnancy to 6% or less by the end of 2022. It also includes commitments to analyse current practice in maternity services, assess the use of CO monitoring and the implementation of smokefree policies across England (Department of Health, 2017).
  • ‘Smokefree Skills: An Assessment of Maternity Workforce Training’ (2017) – This report has been produced by Action on Smoking and Health (ASH) in collaboration with the Smoking in Pregnancy Challenge Group. It seeks to identify the current barriers to full training of the maternity workforce to enable them to deliver NICE guidance on smoking in pregnancy and sets out recommendations for change (Smoking In Pregnancy Challenge Group, 2017).
  • ‘Better Births’ (2016) – This refers to the risks associated with smoking in pregnancy and supports the stillbirth care bundle. The recommendations from Better Births are being implemented through the Maternity Transformation Programme, led by NHS England. Supporting an increase in smokefree pregnancies and better multi-professional working between midwives, obstetricians and other professionals is specifically incorporated into the work stream (National Maternity Review, 2016).
  • ‘Saving Babies Lives: A Care Bundle for Reducing Stillbirths’ (2016) – This recognises evidence-based or best practice to support a reduction in still births and early neonatal death. Element one focuses on reducing smoking in pregnancy (Connor, 2016).
  • ‘NCSCT Smoking Cessation: A Briefing for Midwifery Staff’ (2016) – This is written for the midwifery team to maximise the opportunity for pregnant women who smoke to get support (McEwen, 2016).
  • ‘Smoking Cessation in Pregnancy: A Call to Action’ (2013) – This report outlines recommendations for commissioners, providers, royal colleges, government bodies, training organisations and third sector organisations specifying what action is required in order to reduce the prevalence of smoking during pregnancy (ASH, 2013).
  • The National Institute of Health and Care Excellence (NICE) Guidance – There is various NICE guidance concerning the actions that should be taken to address smoking in pregnancy:
    • PH48: ‘Smoking Cessation in Secondary Care: Acute, Maternity and Mental Health Services’ (2013) – This promotes smokefree policies and services and recommends effective ways to help people stop smoking or to abstain from smoking while using or working in secondary care settings (NICE, 2013).
    • PH26: ‘Smoking: Stopping in Pregnancy and After Childbirth’ (2010) – This covers support to help women stop smoking during pregnancy and in the first year after childbirth (NICE, 2010).
    • PH10: ‘Stop Smoking Services’ (2008) – This aims to reduce the number of people who smoke by ensuring that stop smoking services are as effective as possible and seeks to raise awareness of the range and types of support available (NICE, 2008).
    • PH14: ‘Preventing the Uptake of Smoking by Children and Young People’ (2008) – This covers anti-smoking mass-media campaigns and measures to prevent tobacco being sold to children and young people. The aim is to help prevent children and young people from taking up smoking (NICE, 2008).


6. User Views (On Need, Services/Assets and Gaps)

A social marketing report looking at smoking in pregnancy and early years found there are many barriers that prevent pregnant mothers from stopping smoking which include; time involved in attempting to stop, effort involved in stopping, peer pressure from family and friends who smoke, influence of other women who continued to smoke during pregnancy and gave birth to healthy babies, and the overall enjoyment of smoking.

Perceived benefits include; self-esteem – taking control of their lives, stress management which would include building in ‘me time’ to their lives, feeling good, looking good, and saving money

Pregnant women would like a stop-smoking service that can be very locally based, be in an informal, supportive and non-judgmental environment, invite them  to participate in the service – not force or push them into going, avoiding words like ‘refer’, run through the day and/or early evenings to enable them to attend outside of the times when their children need them most, promote ‘me time’ which would be crucial in terms of how the service was ‘sold’, offer group sessions which were relaxed, informal and based on ‘slimming world’ or ‘weight watchers’ concept, with  ‘role model’ clients who would share experiences and who had been in similar situations, be flexible in response to their individual needs and provide a choice of groups, one-to-one  contact – or combination of methods (Richardson, 2009)

The ‘NCSCT Service Provider Review – Smokefree South Gloucestershire’ (2016) found that for client satisfaction of the Smokefree service provided in GP surgeries, 99% reported that they were happy with the service they received. Furthermore, all verified contacted clients said they would recommend the service to another smoker. For the Smokefree service provided in Pharmacies, 92% of contacted clients were extremely satisfied with the service. Only 8% of clients reported being unsatisfied or very unsatisfied. All but one of the verified contacts would happily recommend the service to another smoker. For the Specialist Midwife Smokefree service, 94% were extremely satisfied with the service. Only 6% of clients reported being unsatisfied. All of the verified contacts would recommend the service to another smoker.

All contacted clients were asked “Do you have any comments that might help improve the service that Smokefree South Gloucestershire provides?” with a number of positive comments received. Many clients reported how happy they were with the service; paying particular attention to the excellent support they received, particularly from the nurses who they found non-judgemental and compassionate. Many clients found that the structure of the support was useful in helping them address issues and eventually quit.


Figure 7: Client Comments from the NCSCT Service Provider Review 2016:


In March 2017, Bristol, North Somerset and South Gloucestershire (BNSSG) jointly held a Smoking in Pregnancy workshop to identify ways in which midwives and health visitors can work with public health smoking cessation colleagues to increase uptake and completion of stop smoking support for pregnant women, new mothers, and their families.

Figure 9 shows that health Professionals predominately felt that the services across all areas should have equal provision and a standard of support. There is a need for inter-professional working, quarterly feedback reports, access to resources and availability of continuous professional development and training. There are gaps in the ways health professionals can communicate with clients and how different interventions may be delivered (apps/social media).


Figure 8: What Are The 2 Things That You Will Take Away With You And Put Into Practice?

7.  Equalities

The information presented within this chapter provides evidence of needs in respect of diverse
groups. Consideration of these needs has resulted in the identification of priority issues to be
addressed within South Gloucestershire as follows:

  • Pregnant smokers who are categorised as routine and manual workers
  • Disadvantaged groups (e.g. younger mothers, those living on the poverty line.)
  • Localities where prevalence remains high
  • Routine collection of more detailed data around ethnicity


8. Unmet Needs and Service Gaps

A range of services are provided to reduce smoking in pregnancy rates. However, local issues and gaps remain and a number of improvements are required:

  1. A more accurate picture of the numbers and demographics of local women who are smoking during pregnancy.
  2. Identification of which stop smoking strategies are obtaining the best outcomes.
  3. Further insight is required regarding what prevents women from stopping smoking during their pregnancy, particularly amongst high risk groups.
  4. Feedback from users on their experience of the stop‐smoking service to improve our understanding of what has motivated and enabled women to quit smoking and what prevented women from being able to stop smoking in their pregnancy.
  5. The numbers of pregnant women who are smoking, with partners who smoke and what success is achieved with this group of smokers in referral and quit rates.
  6. Need to monitor trends in demographic changes to the local population closely as the new communities develop in South Gloucestershire, which could result in an increased proportion of women smoking during pregnancy.
  7. Nicotine Replacement Therapy available for immediate administration on all wards and clinics at St Michael’s hospital and Southmead hospital ensuring an equitable service and adherence to NICE guidance.
  8. Targeted services for those in areas of deprivation and in lower social economic classes with the aim to reduce health inequalities.


9. Recommendations for Consideration by Commissioners

Recommendations for commissioning activity are based on the identified local issues and gaps:

  • Develop digital communication strategies that are the most effective and cost-effective for women who smoke during pregnancy.
  • Investigate the extent to which NICE guidance has been implemented locally, and support areas found not to have acted on the recommendations.
  • Work in partnership with other professional groups to ensure that there is an effective and robust referral pathway for pregnant smokers.
  • Develop a mechanism for formal service user feedback on service need, quality and gaps.
  • Deliver a rolling programme of training for hospital midwives and other professional groups achieving full NCSCT certification on smoking in pregnancy, recording of data, NRT use and electronic cigarettes and short opportunistic interventions.
  • Develop close working links and cross referral pathways with third sector organisations at community level who provide on-going support and advice to young families and young women.
  • Understand behaviour change techniques for smoking cessation in pregnancy, particularly which types of these techniques are effective, including e-cigarettes.
  • Ensure data on smoking prevalence at time of booking is shared with public health.
  • Ensure prevalence of SATOD and at time of booking is available at ward and cluster level. Clinical Commissioning Groups (CCG’s) should include this requirement in service specifications for maternity services.
  • Ensure NRT is directly accessible and provided to all women on Southmead maternity wards and clinics.
  • Develop interventions to reduce the exposure of children to second-hand smoke in different settings, including in the home and outdoor areas, and assist with reducing the number of children that start smoking as a result of living in a smoking home and family.
  • Aspire to work more closely with Commissioners and Providers of children services to ensure every child has the best start in life.
  • Ensure interventions include harm-reduction methods, such as the use and availability of electronic cigarettes.


10. Recommendations for Needs Assessment Work

Recommendations for Needs Assessment Work are:

  • Smoking prevalence data available at ward and cluster level.
  • The need to strengthen the quality of service user engagement and feedback.
  • The consideration of recommendations to be included into the Bristol North Somerset and South Gloucestershire (BNSSG) action plan and local Tobacco Control Strategy.
  • Health equity audits are required to understand which population groups and geographical areas with high smoking prevalence are accessing services, and if there is an inequity amongst outcomes.


Key Contacts



Action on Smoking and Health (ASH) (2013) ‘Smoking Cessation in Pregnancy: A Call to Action’. (Online) Available From:

Action on Smoking and Health (ASH) (2014) ‘Second-hand Smoke: The Impact on Children Key Findings of this Report’. Pg.: 1–20.

Baba, S, et al. (2011) ‘Risk Factors of Early Spontaneous Abortions among Japanese: A Matched Case-Control Study’. Human Reproduction, 26, (2), pg.: 466–72.

Bell, R., et al. (2017) ‘Evaluation of a Complex Healthcare Intervention to Increase Smoking Cessation in Pregnant Women: Interrupted Time Series Analysis with Economic Evaluation’. Tobacco Control.

Campbell, K.A., et al. (2017) ‘Opt-Out Referrals After Identifying Pregnant Smokers Using Exhaled Air
Carbon Monoxide: Impact on Engagement with Smoking Cessation Support’
. Tobacco Control, 26, (3), pg.: 300-6

Connor, D.O. (2016) ‘Saving Babies’ Lives A Care Bundle for Reducing Stillbirth’. NHS England, pg.: 1–30.

Den Dekker, H.T., et al. (2015) ‘Tobacco Smoke Exposure, Airway Resistance, and Asthma in School-age Children’. Chest, 148, (3), pg.: 607–17.

Department of Health (DoH) (2017) ‘Towards a Smokefree Generation – A Tobacco Control Plan for England’. (Online) Available From:


Fleming, P, et al. (2007) ‘Sudden Infant Death Syndrome and Parental Smoking’. Early Human Development, 83, (11), pg.: 721–5.

Flenady, V. et al. (2011) Major Risk Factors for Stillbirth in High-Income Countries: A Systematic Review and Meta-Analysis. Lancet (London, England) 377, pg.: 1331–40.

Flenady, V, et al. (2016) ‘Stillbirths: Recall to Action in High-Income Countries’. The Lancet, 387, (10019), pg.: 691-702.

Gray, R., et al. (2009) ‘Contribution of Smoking During Pregnancy to Inequalities in Stillbirth and Infant Death in Scotland 1994-2003: Retrospective Population Based Study Using Hospital Maternity Records’. British Medical Journal, 339

Hackshaw A., Rodeck C., & Boniface, S. (2011) ‘Maternal Smoking in Pregnancy and Birth Defects: A Systematic Review Based on 173,687 Malformed Cases and 11.7 Million Controls’. Human Reproduction Update, 1; 17, (5), pg.: 589–604.

Jha, P., et al. (2013) ‘21st-Century Hazards of Smoking and Benefits of Cessation in the United States’. The New England Journal of Medicine, 368, pg.: 341–50.

Jornayvaz, F.R, et al. (2016) ‘Low Birth Weight Leads to Obesity, Diabetes and Increased Leptin Levels in Adults: the CoLaus Study’. Cardiovascular Diabetology, 3, 15, pg.: 73.

Kyrklund-Blomberg, N.B, Granath, F., & Cnattingius, S. (2005) ‘Maternal Smoking and Causes of Very Preterm Birth’. Acta Obstetricia Gynecologica Scandinavica, 84, (6), pg.: 572–7.0  mmmmmmmj nn  m

Leonardi-Bee, J., Jere, M.L., & Britton J. (2011) ‘Exposure to Parental and Sibling Smoking and the Risk of Smoking Uptake in Childhood and Adolescence: A Systematic Review and Meta-Analysis’. Thorax, 66, pg.: 847-855.

Local Tobacco Control Profiles (2017) ‘Smoking Prevalence in Adults: Smoking Status at Time of Delivery 2015-16’. (Online) Available From:

McCrory, C., & Layte, R. (2012) ‘Prenatal Exposure to Maternal Smoking and Childhood Behavioural Problems: A Quasi-Experimental Approach’. Journal of Abnormal Child Psychology, 40, (8), pg.: 1277–88.

McEwen, A. (2016) ‘NCSCT Smoking Cessation: A Briefing for Midwifery Staff’. (3rd Edition) (Online) Available From:

National Centre for Smoking Cessation and Training (NCSCT) (2017) ‘Pregnancy and the Post-Partum Period’. (Online). Available From:

National Maternity Review (2016) ‘Better Births: Improving Outcomes of Maternity Services in England’. (Online) Available From:

National Institute for Health and Care Excellence (NICE) (2013) ‘PH48: Smoking: Acute, Maternity and Mental Health Services’. (Online) Available From:

National Institute for Health and Care Excellence (NICE) (2010) ‘PH26: Smoking: Stopping in Pregnancy and After Childbirth’. (Online) Available From:

National Institute for Health and Care Excellence (NICE) (2008) ‘PH10: Stop Smoking Services’. (Online) Available From:

National Institute for Health and Care Excellence (NICE) (2008) ‘PH14: Preventing the Uptake of Smoking by Children and Young People’. (Online) Available From:

NHS Digital (2010) ‘Infant Feeding Survey UK 2010’. (Online) Available From:

Office for National Statistics (ONS) (2016) ‘Births in England and Wales: 2015’. (Online) Available From:

Pineles, B.L, Park, E., and Samet, J.M. (2014) ‘Systematic Review and Meta-Analysis of Miscarriage
and Maternal Exposure to Tobacco Smoke During Pregnancy’
. American Journal of Epidemiology, 179, (7), pg.: 807–23.

Pineles, B.L, et al. (2015) ‘Systematic Review and Meta-Analyses of Perinatal Death and Maternal
Exposure to Tobacco Smoke During Pregnancy’
. American Journal of Epidemiology, 184, (2), pg.:87–97.

Richardson, D. (2009) Smoking in Pregnancy and Early Years: Social Marketing Project Report’. (Online) Available From:

Royal College of Physicians (2010) ‘Passive Smoking and Children Report’. (Online) Available From:

Smoking in Pregnancy Challenge Group (2017) ‘Smokefree Skills: An Assessment of Maternity Workforce Skills’. (Online) Available From:

Suzuki, K, et al. (2014) ‘Effect of Maternal Smoking Cessation Before and During Early Pregnancy on Foetal and Childhood Growth’. Journal of Epidemiology, 24, (1), pg.: 60–6.

Tanaka, K, et al. (2016) ‘Perinatal Smoking Exposure and Behavioural Problems in Japanese Children Aged 5 Years: The Kyushu Okinawa Maternal and Child Health Study’. Environmental Research, 151, pg.: 383–8.

Ussher M., Etter J-F., & West R. (2006) ‘Perceived Barriers to and Benefits of Attending a Stop Smoking Course during Pregnancy’. Patient Education and Counselling, 61, (3), pg.: 467-72.