Smoking

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Implementation support toolkit

The challenge

Stopping smoking in pregnancy is important for the health of the woman or pregnant person and their baby. Identifying women and pregnant people, and their partners, who smoke at routine antenatal appointments enables those who have not engaged with specialist support, or who have relapsed, to be identified and (re-)referred for stop-smoking support and treatment.

Recommendation 1.18 in NICE's guideline on tobacco: preventing uptake, promoting quitting and treating dependence recommends providing routine carbon monoxide (CO) testing at the first antenatal appointment and at the 36-week appointment to assess maternal exposure to tobacco smoke during pregnancy.

Nationally, the proportion of booking appointments that included a record of a CO test in 2024/25 was just over 62%.

Insight provided to NICE from the healthcare system indicates that some of the reasons for the variation recorded, may be:

the test was carried out, but not recorded
there may not be enough CO monitors available for use in the clinic, or there are no disposable mouthpieces to use with the monitor
the kit may be damaged, not available for use at the time of the appointment, or not sufficiently charged to take a reading (if battery powered)
newer staff may not be trained, or feel comfortable, in using the kits, or in having the conversation about CO testing and smoking
lack of time in the appointment.

What support is available

Support from NICE

NICE has produced a guideline on tobacco: preventing uptake, promoting quitting and treating dependence, which makes recommendations on treating tobacco dependence during pregnancy. These can be used alongside the recommendations in NICE's antenatal care guidelines.
NICE has published a case study by the Manchester Foundation Trust on supporting pregnant people to stop smoking which outlines their comprehensive approach to helping pregnant people stop smoking. It highlights the use of CO screening during antenatal care, staff training, referral pathways, and financial incentives to support smoking cessation. The initiative has led to improved referral rates and quit outcomes, contributing to better maternal and infant health across Greater Manchester.
There is a pregnant or breastfeeding scenario within the smoking cessation clinical knowledge summary on the NICE website. It covers:
- how to manage pregnant or breastfeeding woman who want to stop smoking
- what practical advice to give pregnant or breastfeeding women to help them stop smoking
- which sources of information and support should be given to pregnant or breastfeeding women who wish to stop smoking
- what drug treatment should be prescribed for a woman who is pregnant or breastfeeding to help her stop smoking
- how to follow up pregnant or breastfeeding women who want to stop smoking.

Support from our partners

Element 1: reducing smoking in pregnancy in NHS England's Saving Babies Lives (version 3) contains excellent information on interventions, continuous learning, process and outcome indicators, rationale, implementation, and resources.
The NHS England maternity services dashboard aims to bring together maternity information from a range of different sources including the NHS England Maternity Services Data Set (MSDS). The dashboard includes data on smoking at booking and at delivery and enables providers of maternity services to compare their performance with their peers on a series of national indicators (including those from the NICE indicators menu) for the purposes of identifying areas that may need local clinical quality improvement.
Action on Smoking and Health (ASH) produce annual briefings for integrated care systems showing the impact of smoking, using data at ICS level. The briefings include national data on maternal smoking and other clinical areas broken down to ICS level, and signposts to current resources and information.
The Smoking in Pregnancy Challenge Group's evidence into practice briefing supports commissioning incentive schemes and gives both commissioners and practitioners a set of 'lessons for practice' to consider before launch. It sets out:
- impacts of smoking in pregnancy
- evidence for smokefree pregnancy incentive schemes
- 'lessons for practice' based on schemes that have been implemented, including requirements for successful implementation.
The Royal College of Midwives i-learn programme provides a training module on delivering very brief advice on smoking (VBA) to pregnant women, which includes CO screening.

Please see the section on addressing ethnic health inequalities for further advice in relation to this topic.

Note that external websites and resources have not been produced by NICE. NICE has not made any judgement about the methodology, quality or usability of the websites or resources.

This page was last updated: 09 October 2025