Reducing smoking in pregnancy in England—a public health success story

In recent years rates of smoking in pregnancy in England have declined, from 11.7% of pregnant women in 2014/15, to 5.9% in quarter 3 2024/25, according to the latest smoking at the time of delivery (SATOD) figures.1 This is remarkable progress and suggests that a target set in the 2017 Tobacco Control Plan for England2—to reduce rates of smoking to less than 6% of pregnant women and other pregnant people by 2022—has finally been met. The last few years have seen an acceleration in declines that has not been mirrored in smoking rates in the general adult population.3

What factors have contributed to this progress? We believe it is a combination of sustained multi-agency working and system change, including embedding a comprehensive approach to stopping smoking during pregnancy as part of the “Saving Babies Lives” care bundle and NHS Long Term Plan.

Multi-agency working began at pace in 2012 when the then conservative public health minister, Anne Milton, posed a “challenge” to the health community to identify new ways to tackle smoking in pregnancy, which is a major cause of preventable morbidity and mortality for mothers and babies. This resulted in the formation of the Smoking in Pregnancy Challenge group (SPCG)4 convened by Action on Smoking and Health (ASH) and involving members from medical Royal Colleges, public health, primary, secondary, and community care and academia. Since then, the SPCG has ensured a sustained focus on maternal smoking, developing materials for practitioners and patients, convening networks and meetings, promoting evidence-based training and lobbying for investment to embed smoking cessation support in the maternity pathway. This sustained approach and the community of committed professionals it has built has undoubtedly helped to influence the rapid observed decline in rates of smoking during pregnancy.

The smoking cessation offers championed by the SPCG, and gradually implemented in the NHS, includes dedicated and targeted smoking cessation support from a trained advisor throughout the maternity care pathway. This is an opt out treatment approach, providing behavioural support and stop smoking medications. This approach has been embedded through the “Saving Babies Lives” care bundle—a set of clinical recommendations for reducing perinatal mortality. Introduced in 2016, the care bundle has driven a shift from largely voluntary, inconsistent uptake of best practice to a more systematic approach. Since 2019, it has been enhanced by dedicated funding for NHS tobacco dependence treatment services, enabling trusts to embed cessation support within maternity services.

This comprehensive offer has recently been further strengthened through the addition of a national financial incentives scheme built on clear evidence of effectiveness5 and cost effectiveness,6 alongside support during pregnancy to switch to vaping as a reduced harm option for smoking cessation. This follows emerging evidence of the effectiveness of vaping for smoking cessation in this population.7 Maternity services working in partnership with local authorities have been able to apply to the “swap to stop” scheme—the first worldwide to offer free vapes for switching away from tobacco smoking.8 This combination of government investment, a systematic evidence-led approach, and innovative solutions to reach those who may struggle to quit means that we now see the possibility of a smokefree future for generations of people entering pregnancy, and for their families.

Despite this positive news, the battle against smoking as a leading cause of poor birth outcomes is not yet won. Continued investment is needed to sustain the current rate of progress and tackle longstanding inequalities in maternal smoking rates. Those from more deprived backgrounds are still much more likely to smoke during pregnancy than those from more affluent backgrounds. Targeted action is needed to close this gap and engage with those who may not be well served by existing interventions, such as when they lack adequate access to maternity services, are marginalised, or living in poverty. This must be a key focus of future policy efforts—alongside tackling high rates of relapse to smoking postnatally—to ensure every child has a smokefree start in life.