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All pregnant women should be encouraged to have their carbon monoxide levels tested to determine whether they smoke, thereby ensuring that pregnant smokers receive appropriate support to quit for the good of their unborn baby. This change to current clinical practice is one of a number of recommendations in new guidance published recently by the National Institute for Health and Clinical Excellence (NICE), to help women and their families give up smoking during and after pregnancy.

Smoking during pregnancy can increase the risk of miscarriage, premature birth, still-birth and sudden unexpected death in infancy1. Exposure to smoke in the womb is also associated with psychological problems in childhood such as attention and hyperactivity problems2. Meanwhile, children of parents who smoke tend to suffer from more respiratory problems like asthma or bronchitis and have problems of the ear, nose and throat, compared to children in non-smoking households. Nearly half of all children in the UK are exposed to tobacco smoke at home3.

It is thought to cost the NHS between £20 million and £87.5 million each year to treat mothers and small infants under 12 months old with problems caused by smoking in pregnancy4.

To tackle this issue, new NICE guidance calls on midwives to assess every woman’s carbon monoxide levels at their first antenatal appointment by encouraging women to have a special breath test. High carbon monoxide levels can be seen amongst active and passive smokers, so by testing the levels of all pregnant women, those who smoke or who are regularly exposed to second-hand smoke will see a physical measure of their exposure. The guidance also recommends that women who smoke and are either pregnant or have recently given birth, are offered a range of options to help them quit, including automatic referral to smoking cessation services and sensitive and non-judgemental support by professionals.

Professor Mike Kelly, Director of the Centre for Public Health Excellence at NICE, said: “We’ve known for many years that smoking and passive smoking can cause serious illnesses like lung cancer. During pregnancy, smoking puts the health of the women and her unborn baby at great risk both in the short and long-term, and small children who are exposed to second-hand smoke are more likely to suffer from respiratory problems.

“One of our recommendations is for midwives to encourage all pregnant women to have their carbon monoxide levels tested and discuss the results with them. This isn’t to penalise them if they have been smoking, but instead will be a useful way to show women that both smoking and passive smoking can lead to having high levels of carbon monoxide in their systems. It will also alert non-smokers with high carbon monoxide levels to possible CO poisoning, which can be caused by a faulty boiler or car emissions.”

In 2005, almost one third of mothers smoked before or during pregnancy5. Despite nearly half (49%) of these women giving up before the birth of their baby, three in ten were smoking again less than a year after childbirth6. Younger women aged under 20 are five times more likely to smoke while pregnant than women over 35 years old7. Smoking during pregnancy is also more common in women who are less educated, are not homeowners and are either single or live with a partner who smokes.

The guidance contains recommendations for GPs, midwives, health visitors and others involved in antenatal and postnatal services, as well as other professionals including dentists, pharmacists and those working in smoking cessation services, fertility clinics, children’s centres, voluntary organisations and local authorities.

Professor Catherine Law, Professor of Public Health and Epidemiology at UCL Institute of Child Health and Chair of NICE’s Public Health Interventions Advisory Committee, said: “This guidance aims to protect the health of children by encouraging and supporting women and their families to give up smoking during or after pregnancy and for the long-term. We know quitting can be difficult, which is why the guidance calls for a multi-disciplinary approach to provide a network of support to help expectant mums, or those who have a small child, quit for good. If they can do this, both they and their children can look forward to healthier futures”

Key recommendations of the guidance include:

• Assessing a pregnant woman’s exposure to tobacco smoke through discussion and use of a CO test at their first antenatal appointment and subsequent appointments
• Routinely referring women who smoke to NHS Stop Smoking services and providing women with the NHS Pregnancy Smoking Helpline number
• Suggesting to partners who smoke that they contact NHS stop Smoking Services for help to quit
• Formal training for healthcare and smoking cessation staff to ensure advice is offered in a non-judgmental way
• Offering women personalised help, support and information on how to stop smoking.

The guidance also includes recommendations for NHS Stop Smoking Services when considering the use of nicotine replacement therapy (NRT), such as:

• Discussing the risks and benefits of NRT with pregnant women who smoke, use only if smoking cessation without NRT fails and use professional judgement when deciding whether to offer a prescription.
• Only prescribing NRT for use when a woman has stopped smoking. Only two weeks of treatment should be prescribed at any one time with subsequent prescriptions only given to women who can demonstrate they are still not smoking.

Jane Brewin, Chief Executive of baby charity Tommy’s, said:"The sooner women who are pregnant can give up smoking, the better. Every baby deserves the best start in life and those born to smokers tend be smaller and weaker than other infants. However, it’s important pregnant women feel supported if they make the decision to quit, and are aware of the stop smoking services available to them."

NICE has produced a range of tools to help organisations and health, childcare and smoking cessation professionals implement this new guidance. These can be downloaded from the NICE website; www.nice.org.uk.

Deborah Arnott, Chief Executive of Action on Smoking and Health (ASH), said: “Only a very small proportion of women smokers carry on smoking after getting pregnant, but those who do tend to be the heaviest and most addicted smokers who need support and help from healthcare professionals to quit. We welcome the NICE guidance which is designed to be practical and encouraging and not to condemn pregnant smokers for their addiction.”

Commenting on the role of NHS Stop Smoking services, Dr Elin Roddy, Chair of the British Thoracic Society Tobacco Specialist Advisory Group, said: “Pregnancy is a vital time to encourage smoking cessation as it improves not only maternal health but reduces the chances of premature birth and birth complications. Stop smoking services make a significant and indeed cost-effective improvement to health and Stop Smoking Practitioners, based both within primary and secondary care, provide an essential contribution to the NHS. We encourage national policy-makers at all levels to continue to support stop smoking services to ensure that all those who wish to stop smoking receive the necessary advice and support”.

NICE has produced a range of tools to help organisations and health, childcare and smoking cessation professionals implement this new guidance. These can be downloaded from the NICE website.

Notes to Editors

About the guideline

• The NICE guidance on “Quitting smoking in pregnancy and following childbirth”, including a version for patients and carers, and corresponding implementation tools are available from the NICE website at: http://guidance.nice.org.uk/PH26 (from Wednesday 23 June 2010).
• The total annual cost to the NHS of smoking during pregnancy is estimated to range between £8.1 and £64 million for treating the resulting problems for mothers and between £12 million and £23.5 million for treating infants (aged 0-12 months)8.
• The guidance was developed by the Public Health Interventions Advisory Committee (PHIAC) on behalf of NICE. The recommendations were developed following a thorough review of available evidence, economic modelling, expert advice, stakeholder comments and fieldwork.
• The recommendations mainly cover interventions to help pregnant women who smoke to quit. No specific recommendations have been made for those planning a pregnancy or who have recently given birth. This is due to the lack of evidence available on stop-smoking interventions for these groups and does not constitute a judgement on whether or not such interventions are effective or cost effective.
• The baby charity, Tommy’s, is currently developing a guide for professionals who work with pregnant teens. The resource, “Talking about smoking in pregnancy”, will aim to help professionals encourage pregnant teens to quit smoking and engage with stop smoking services. It will be available from October 2010.

About NICE

• The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.
• NICE produces guidance in three areas of health:
  • public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
  • health technologies - guidance on the use of new and existing medicines, treatments and procedures within the NHS
  • clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

1 Royal College of Physicians (1992) Smoking and the young. London: Royal College of Physicians

2 Button TMM, Maughan B, McGuffin P (2007) The relationship of maternal smoking to psychological problems in the offspring. Early Human Development 83 (11): 727-32

3 Jarvis MJ, Goddard E, Higgins V et al. (2000) Children’s exposure to passive smoking in England since the 1980s: cotinine evidence from population surveys. BMJ 321: 343-5

4,8 Godfrey C, Pickett KE, Parrot S et al. (2010) Estimating the costs to the NHS of smoking in pregnancy for pregnant women and infants. York: Department of Health Sciences, The University of York

5,6,7 British Market Research Bureau (2007) Infant feeding survey 2005. A survey conducted on behalf of the Information Centre for Health and Social Care and the UK Health Departments. Southport: The Information Centre