Specifying services for quitting smoking in pregnancy and following childbirth
The key components of services for quitting smoking in pregnancy are:
- identifying and referring all pregnant women who smoke
- contacting women who have been referred and offering initial and ongoing support from specialist advisers
- developing high-quality services for quitting smoking in pregnancy and following childbirth.
Commissioners should note that service components will impact on working practice within maternity services and other services (identifying and referring) as well as on NHS Stop Smoking services (contacting women). Therefore, service components apply to more than one service specification and a range of providers.
Commissioners should work with a range of service providers including midwives, GPs, practice nurses, health visitors and family nurses as well as obstetricians, paediatricians, sonographers and other members of the maternity team, those working in youth and teenage pregnancy services, children's centres and social services, fertility clinics, dental practices and community pharmacies to ensure that all women who smoke are identified and referred to NHS Stop Smoking Services. Commissioners may also wish to consider including referral procedures in all provider contracts for pregnant women who smoke. Commissioners should ensure that pregnant women who smoke have access to services and are referred in accordance with the referral recommendations in NICE public health guidance PH26.
NICE recommends that midwives take action at first maternity booking and subsequent appointments to assess the woman's exposure to tobacco smoke through discussion and through use of a carbon monoxide (CO) test. This is because people can get a high CO reading simply from being around other people that smoke. Midwives should explain that the CO test will allow her to see a physical measure of her smoking and her exposure to other people's smoking. Commissioners should take note that the aim of the test is not to check whether women are telling the truth - or to make them feel guilty if they smoke. Rather, it is to see if carbon monoxide is an issue for them (and, as a result, their unborn child).
NICE also recommends that midwives explain that it is normal practice to refer all pregnant women who smoke for help to quit and that a specialist midwife or adviser will phone and offer her support. Therefore commissioners need to ensure that the appropriate referral pathways are in place and there is sufficient capacity within NHS Stop Smoking Services to receive and follow up all women referred by midwives at first maternity booking and subsequent appointments, and where appropriate, at any earlier initial meetings.
Contacting women who have been referred and offering initial and ongoing support from specialist advisers
When commissioning NHS Stop Smoking Services, commissioners need to ensure that there are sufficient resources to enable specialist advisers to contact women who have been referred into the NHS Stop Smoking Service. Commissioners should ensure that there are sufficient resources to enable specialist advisers to ring referred women twice, follow up with a letter and invite them to use the service.
NICE public health guidance PH26 recommends that attempts to see those who cannot be contacted by telephone should be made. This could happen during a routine antenatal care visit (for example, when they attend for a scan).
When specifying a service for initial and ongoing support, commissioners should note that studies have shown that effective interventions in helping women who are pregnant to stop smoking are:
- cognitive behaviour therapy
- motivational interviewing
- structured self-help and support from NHS Stop Smoking Services.
Pregnant women who smoke should be provided with intensive and ongoing support (brief interventions alone are unlikely to be sufficient) throughout pregnancy and beyond.
Women with partners who smoke find it harder to stop smoking and are more likely to relapse if they do manage to stop smoking. Commissioners should also ensure that capacity is available within NHS Stop Smoking Services to enable the partners of pregnant women and others in the household who smoke to have access to support to stop smoking. Interventions that are effective with the general population will not necessarily work with the partners of women who are pregnant. Therefore commissioners should refer to the recommendation for partners and others in the household who smoke in NICE public health guidance PH26.
Commissioners should be aware that there is mixed evidence on the effectiveness of Nicotine Replacement Therapy (NRT) in helping women to stop smoking during pregnancy. Therefore commissioners need to ensure that specialist advisers are competent and practicing in line with the NICE recommendations that relate to NRT including the following:
- Discuss the risks and benefits of NRT with pregnant women who smoke, particularly those who do not wish to accept other help from NHS Stop Smoking Services. Use only if smoking cessation without NRT fails. If they express a clear wish to receive NRT, use professional judgement when deciding whether to offer a prescription.
- Only prescribe NRT for use once they have stopped smoking (they may set a particular date for this). Only prescribe 2 weeks of NRT for use from the day they agreed to stop. Only give subsequent prescriptions to women who have demonstrated on reassessment that they are still not smoking.
NICE public health guidance PH26 recommends that neither varenicline nor buproprion should be offered to pregnant or breastfeeding women.
Developing high-quality services for quitting smoking in pregnancy and following childbirth
NICE public health guidance PH26 on Quitting smoking in pregnancy and following childbirth recommends that NHS Stop Smoking Services provide services that meet the needs of disadvantaged pregnant women who smoke.
Commissioners should ensure that NHS Stop Smoking Services provide the following:
- Services should be delivered in an impartial, client-centred manner. They should be sensitive to the difficult circumstances that many women who smoke find themselves in.
- Services should take into account other socio-demographic factors such as age and ethnicity and ensure provision is culturally relevant. This includes making it clear how women who are non-English speakers can access and use interpreting services.
- Services should collaborate with the family nurse partnership pilot and other outreach schemes to identify additional opportunities for providing intensive and ongoing support. (Note: family nurses make frequent home visits).
- Services should work in partnership with agencies that support women who have complex social and emotional needs. These include substance misuse services, youth and teenage pregnancy support and mental health services.
NICE public health guidance PH26 also recommends training to deliver interventions.
Commissioners should therefore ensure that training to deliver interventions that help pregnant women stop smoking reflects the recommendations in NICE public health guidance PH26. They should also ensure the following:
- All midwives who deliver intensive stop-smoking interventions (one-to-one or group support) are trained to the same standard as NHS stop-smoking advisers. The minimum standard for these interventions is set by the NHS centre for smoking cessation and training. They should also be provided with additional, specialised training and offered ongoing support and training updates.
- Midwives who are not specialist stop-smoking advisers are trained to assess and record people's smoking status and their readiness to stop smoking. They should also know about the health risks of smoking and the benefits of quitting - and understand why it can be difficult to stop. In addition, they should know about the treatments that can help people to stop and how to refer them to local services for treatment. (Acquisition of this knowledge and skill set is part of level 1 training in brief stop-smoking interventions. Commissioners should note that midwives are not advised to carry out brief interventions with pregnant women. However, they are advised to use these skills to initiate a referral to NHS Stop Smoking Services.)
- All healthcare and other professionals who work with pregnant women are trained in the same skills - and to the same standard - as those required of midwives who are not specialist smoking cessation advisers.
Commissioners may wish to note that NICE public health guidance PH26 recommends brief stop-smoking interventions and intensive one-to-one and group support to stop smoking are incorporated into pre- and post-registration midwifery training and midwives' continuing professional development, as appropriate.
Commissioners may wish to consider commissioning services for quitting smoking in pregnancy in a number of different ways. Mixed models of provision may be appropriate in some localities. This may include non-NHS services that offer help to stop smoking (that operate to the same standard as NHS Stop Smoking Services), and maternity services with midwives who have been specially trained to help pregnant women to stop smoking.
General examples include:
- routine referrals of all pregnant women who smoke from maternity services to local NHS Stop Smoking Services
- specialist stop-smoking provision within maternity services or other settings where midwives are trained to deliver local specialist support
- Integrated smoking cessation as part of routine antenatal care.
(Please note - these examples are offered to share good practice and NICE makes no judgement on the compliance of these services with its guidance).
Commissioners should consider making resources available for stop-smoking interventions in the immediate postnatal period in line with passive smoking and children: a report by the tobacco advisory group of the Royal College of Physicians and the Healthy Child Programme: pregnancy and the first five years of life. They should also consider the needs of their whole population when commissioning stop-smoking services, including women who are planning a pregnancy and their partners and families.
Commissioners may wish to consider using the Commissioning for Quality and Innovation payment framework as a lever for influencing change where there are perceived barriers. Examples may include the number of referrals from maternity services to NHS Stop Smoking Services.
Commissioners should collaborate with clinicians, local stakeholders, and service users when determining what is needed from services for quitting smoking in pregnancy in order to meet local needs and the needs of hard to reach groups including pregnant teenage young women who smoke. The service should be client-centred and integrated with other elements of care for women who are pregnant such as Sure start children's centres and non-statutory organisations.
The service specification needs to consider:
- the scope of service in relation to local prevalence of smoking during pregnancy
- the rationale for the service
- the required competencies of - and training for - staff responsible for providing the service (see training standards at www.ncsct.co.uk)
- the expected number of referrals of pregnant women, partners and others in the household who smoke (this should take into account how quickly any changes in service provision are likely to take place)
- ease of access, service location, times and type of delivery (for example, home visits or other venues if it is difficult for women to attend specialist services) ensuring that services can be tailored to meet individual needs and are flexible and coordinated; commissioners should engage with service users and other relevant individuals and organisations locally
- care and referral pathways to ensure that all opportunities are maximised to refer to NHS Stop Smoking Services, and to encourage pregnant women who smoke to stop
- providing structured self-help materials or support via a telephone helpline for women who are reluctant to attend the clinic
- links with other services such as contraceptive services, fertility clinics and antenatal and postnatal mental health services so that everyone working in those organisations knows about local NHS Stop Smoking Services and is promoting maternal smoking cessation
- measuring outcomes and performance indicators including percentage of women with their smoking status recorded at booking and delivery, and the percentage of women referred to local NHS Stop Smoking Services
- information and audit requirements, including establishing and maintaining data collection systems, IT support and infrastructure
- planned service development setting out any productivity improvements including redesign, quality and equitable access
- address any safeguarding concerns and promote the welfare of children and vulnerable adults
- service monitoring criteria.
Useful sources of information may include:
- ‘Brief interventions and referral for smoking cessation in primary care and other settings' (NICE public health guidance PH1), ‘Workplace interventions to promote smoking cessation' (NICE PH5) and ‘Smoking cessation services' (NICE public health guidance PH10).
- ‘Behaviour change' (NICE public health guidance PH6) and ‘Identifying and supporting people most at risk of dying prematurely' (NICE public health guidance PH15).
- The NICE shared learning database offers examples of how organisations have implemented NICE guidance locally and implementation advice on stopping smoking in pregnancy (NICE public health guidance PH26).
- NHS stop smoking services: service and monitoring guidance 2010/11.
- Department of health tobacco control national support team (TCNST) and Excellence in tobacco control: 10 high impact changes to achieve tobacco control. An evidence-based resource for local alliances.
- Action on smoking and health (ASH).
- The NHS smokefree pregnancy campaign and The NHS Smoking helpline.
- Tackling health inequalities: targeting routine and manual smokers in support of the public service agreement smoking prevalence and health inequality targets.
- The standard NHS contracts for acute hospital, mental health, community and ambulance services and supporting guidance
- NHS networks: learning from practice database offers examples of innovative commissioning across the NHS and its partners.
- Local Government Improvement and Development supports improvement and innovation in local government.
- Total Place: better for less looks at how a ‘whole area' approach to public services can lead to better services at less cost.
- Every child matters is a Green paper that aims to strengthen preventative services by focusing on supporting families and carers.
- Teenage parents next steps: guidance for local authorities and primary care trusts and Teenage parents: who cares? A guide to commissioning and delivering maternity services for young parents.
- National guidelines for maternity services liaison committees (MSLCs): MSLCs are for maternity service users, providers and commissioners of maternity services to come together to design services that meet the needs of local women, parents and families. See also website of the maternity service liaison committees.
 For the national standard for level 1 see ‘Standard for training in smoking cessation treatments' or future updates from the NHS Centre for smoking cessation and training. Note: ‘Standard for training in smoking cessation treatments' is due to be superseded by the new NCSCT training standard from the end of March 2010.
This page was last updated: 02 March 2012
- Quitting smoking in pregnancy and following childbirth
- Commissioning services for quitting smoking in pregnancy and following childbirth
- Specifying services for quitting smoking in pregnancy and following childbirth
- Determining local service levels for quitting smoking in pregnancy and following childbirth
- Assumptions used in estimating a population benchmark
- The commissioning and benchmarking tool
- Ensuring corporate and quality assurance