Smoking in pregnancy has fallen to a record low. Here's what the rest of the health system can learn

New NHS data shows that smoking during pregnancy has fallen to a record low in England. 

The latest NHS data show that smoking at the time of delivery has fallen to 4.2% in 2025/26, down from 9.6% in 2020/21. Behind the statistics are thousands of women and babies experiencing better outcomes. 

Since 2020, these declines in smoking during pregnancy are estimated to have prevented 70 stillbirths, neonatal deaths and sudden infant deaths, as well as 2,000 fewer babies being born preterm or with low birthweight.

This progress is worth celebrating. It is also an opportunity to reflect on what has made it possible.

The decline in smoking during pregnancy was not inevitable, and for several years, national progress had largely stalled. 

Change was not driven by a single campaign, intervention or policy and was not simply the result of increased availability of stop smoking support. Progress accelerated only when smoking cessation became embedded within a wider system of care, accountability and support. 

A number of factors came together to create the conditions for success.

The Saving Babies' Lives Care Bundle established a clear model for delivery, bringing together a small number of evidence-based interventions – including opt-out stop smoking support – and setting out what should happen, when it should happen and who was responsible. This created a standardised approach that made smoking cessation a routine and auditable part of maternity care. Smoking status was routinely measured through Smoking at Time of Delivery (SATOD), providing a visible and meaningful measure of progress. Accountability was strengthened through the Clinical Negligence Scheme for Trusts, while sustained NHS investment has enabled specialist support to be embedded within maternity pathways.

Together these elements created a system in which supporting patients to quit smoking became the norm and could be delivered at scale.

Before these changes, stop smoking support in maternity care was often delivered inconsistently. While many women received advice to quit, identification of smoking status, referral into support and access to treatment varied significantly between services, and the gold standard of opt-out support embedded within usual care was the exception, not the norm.

Since then, smoking cessation has become a routine part of maternity care. Smoking status is systematically identified through carbon monoxide monitoring. Women who smoke are offered opt-out referral to behavioural support and treatment which is typically embedded within maternity services rather than sitting outside them.

Rather than expecting women to navigate an entirely separate system, with many inevitably being lost to follow up, support has become part of the pathway they are already accessing. 

This has driven a wider culture change where smoking cessation is now positioned as a core component of maternity care rather than an optional lifestyle discussion. Maternity professionals have been supported to see smoking cessation as a core part of their role, equipped with the skills to have effective conversations, and given clear referral pathways so that identifying smoking led to action rather than being an unsupported discussion.

This approach has been strengthened by the introduction of the national smokefree pregnancy incentive scheme, building on the work done in areas like Greater Manchester and South Tyneside. This is a highly cost-effective way of increasing the number of people who engage with quit support, while also driving wider improvements in the delivery of stop smoking support in maternity services.

The success of this approach matters not only because of the lifesaving improvements it has delivered for women and babies, but because it demonstrates what is possible.

Smoking rates in the general population have fallen dramatically over recent decades, but progress has not been shared equally. Some groups continue to experience smoking rates that would have been familiar half a century ago.

People with severe mental illness are a striking example. Smoking remains the single largest contributor to the 10–20 year life expectancy gap experienced by this group, and prevalence remains around 40% in mental health inpatient settings.

Reducing smoking is one of the biggest opportunities to improve both physical and mental health outcomes for this population.

There are enabling foundations already in place. Most mental health trusts now have inpatient tobacco dependence treatment services – mirroring those in maternity services – while annual physical health checks provide an established point in care for identifying those who smoke and connecting them with treatment.

The challenge is ensuring these elements are brought together into a coherent system.

As maternity services have demonstrated, lasting change can be achieved when smoking cessation is embedded within routine care, supported by clear pathways, robust data, accountability and sustained investment.

If we are serious about reducing health inequalities, and shifting healthcare towards prevention, then the lessons from maternity should not remain confined to maternity services. They should help shape the future of tobacco dependence treatment across the health system.