Background and challenges to implementation:
In 2011/12, more pregnant women smoked at delivery in North East England (population 2.6 million) than the national average (21% vs 13%). Work with midwives across the region identified barriers to implementing national guidance for universal carbon monoxide (CO) screening and referral for smoking cessation (SC) support. These included lack of equipment, and midwives' concerns that quit advice was not worthwhile and might undermine relationships with women.

Intervention or response:
A system wide approach, babyClear©, was commissioned across 12 local government areas involving eight NHS hospital maternity services and associated smoking cessation services. The intervention provided equipment and training for universal CO monitoring, opt-out referral to SC services and enhanced support to quit. Independent evaluation assessed effectiveness and implementation. Service data for more than 37,000 deliveries in 2013-14, including 10,500 smokers, was analysed for impact on quit rates. Interviews with more than 90 healthcare staff were conducted. Routine smoking at delivery data for local commissioning areas was monitored 2012-2017.

Results and lessons learnt:
Quit rates nearly doubled (aOR 1.8, 95% CI 1.5-2.2) and referrals for SC support increased by 2.5 fold (95% CI 2.2-2.8) after initial implementation (Bell et al, 2017). There was variation in effectiveness between maternity services. Process evaluation indicated that effective SC advice was deliverable within routine maternity care and acceptable to women and maternity staff. Diversity of SC service delivery models, variable resourcing and organisational stability influenced implementation. Regional smoking at delivery rates declined steadily from 21% to 16% 2012-2017, but some localities experienced recent increases, suggesting variable sustainability.

Conclusions and key recommendations:
The intervention improved quit rates through system wide training and action to improve identification and referral of pregnant smokers. Local contexts have a critical role to play in both implementing and sustaining such initiatives into practice. Identifying core intervention ingredients and potential for flexibility and tailoring is recommended.