Implementation of routine biochemical validation and an ‘opt out’ referral pathway for smoking cessation in pregnancy Linda Bauld 1,5 , Lucy Hackshaw 2 , Janet Ferguson 1,5 , Tim Coleman 3,5 , Gordon Taylor 4 & Ruth Salway 4 School of Management, University of Stirling, Stirling, UK, 1 The Institute of Work Health and Organisations, University of Nottingham, Nottingham, UK, 2 Divison of Primary Care, University of Nottingham, Nottingham, UK, 3 Department for Health, University of Bath, Bath, UK 4 and UK Centre forTobacco Control Studies, UK 5 ABSTRACT Aims To introduce an ‘opt out’ referral pathway for smoking cessation in pregnancy and to compare different methods for identifying pregnant smokers in maternity care. Design Pilot study that analysed routine data from maternity and smoking cessation services with biochemical validation of smoking status. Setting Dudley and South Birmingham, England. Participants A total of 3712 women who entered the referral pathway—1498 in Dudley and 2214 in South Birmingham. Measurements Routine monitoring data on smoking at maternity booking, referral to smoking cessation services, number of women who set quit dates set and short-term (4-week) self-report smoking status. Comparison of self-report, carbon monoxide (CO)-validated and urinary cotinine-validated smoking status for a subsample (n = 1492) of women at maternity booking. Findings In Dudley 27% of women who entered the opt out referral pathway were identified as smokers following CO testing. Of those referred to the smoking cessation services, 19% reported stopping smoking at 4-week follow-up. In South Birmingham 17% were smokers at booking, with 5% of those referred recorded as non-smokers at 4 weeks. The number of women quitting did not increase during the study when compared with the previous year, despite higher referral rates in both areas. An optimum cut-off CO measure- ment of 4 parts per million (p.p.m.) was identified for sensitivity and specificity. Conclusion The introduction of an opt out referral pathway between maternity and stop smoking services resulted in more women being referred for support to quit but not higher numbers of quitters, suggesting that automatic referral may include women who are not motivated to stop and who may not engage with services. Routine carbon monoxide monitoring introduced as part of a referral pathway should involve a cut-off of 4p.p.m. to identify smoking in pregnancy. Keywords Carbon monoxide, cotinine, pilot, pregnancy, referral, smoking cessation. Correspondence to: Professor Linda Bauld, School of Management, University of Stirling, Stirling FK9 4LA, UK. E-mail: Linda.Bauld@stir.ac.uk Submitted 18 March 2012; initial review completed 4 April 2012; final version accepted 28 August 2012 INTRODUCTION Reducing smoking in pregnancy is a health policy prior- ity in the United Kingdom, as in many other developed countries [1]. Maternal smoking in pregnancy causes substantial harm, increasing the risk of miscarriage, still- birth, prematurity, low birth weight, perinatal morbidity and mortality, neonatal or sudden infant death, asthma [2–5], attention deficit hyperactive disorder, learning difficulties [6], obesity and diabetes [7]. While many women in the United Kingdom stop smoking before becoming pregnant or soon after, one in four women smoke for part of pregnancy and one in eight smoke throughout [8]. Compared to women in advan- taged circumstances, women in disadvantaged circum- stances are four times more likely to smoke prior to pregnancy and are half as likely to quit in pregnancy; disadvantaged women are also more likely to resume smoking after birth [9]. However, there are interventions known to be effective in promoting cessation in pregnancy. The most recent Cochrane Review of smoking cessation interventions pooled results from 72 trials and concluded that cessation interventions in early pregnancy can reduce smoking in RESEARCH REPORT doi:10.1111/j.1360-0443.2012.04086.x © 2012 The Authors, Addiction © 2012 Society for the Study of Addiction Addiction, 107 (Suppl. 2), 53–60