title: 'Opt-out' referrals after identifying pregnant smokers using exhaled air carbon monoxide: impact on engagement with smoking cessation support.
abstract: In the UK, free smoking cessation support is available to pregnant women; only a minority accesses this. 'Opt-out' referrals to stop smoking services (SSS) are recommended by UK guidelines. These involve identifying pregnant smokers using exhaled carbon monoxide (CO) and referring them for support unless they object.
  
  
  
  To assess the impact of 'opt-out' referrals for pregnant smokers on SSS uptake and effectiveness, we conducted a 'before-after' service development evaluation. In the 6-month 'before' period, there was a routine 'opt-in' referral system for self-reported smokers at antenatal 'booking' appointments. In the 6-month 'after' period, additional 'opt-out' referrals were introduced at the 12-week ultrasound appointments; women with CO≥4 ppm were referred to, and outcome data were collected from, local SSS.
  
  
  
  Approximately 2300 women attended antenatal care in each period. Before the implementation, 536 (23.4%) women reported smoking at 'booking' and 290 (12.7%) were referred to SSS. After the implementation, 524 (22.9%) women reported smoking at 'booking', an additional 156 smokers (6.8%) were identified via the 'opt-out' referrals and, in total, 421 (18.4%) were referred to SSS. Over twice as many women set a quit date with the SSS after 'opt-out' referrals were implemented (121 (5.3%, 95% CI 4.4% to 6.3%) compared to 57 (2.5%, 95% CI 1.9% to 3.2%) before implementation) and reported being abstinent 4 weeks later (93 (4.1%, 95% CI 3.3% to 4.9%) compared to 46 (2.0%, 1.5% to 2.7%) before implementation).
  
  
  
  In a hospital with an 'opt-in' referral system, adding CO screening with 'opt-out' referrals as women attended ultrasound examinations doubled the numbers of pregnant smokers setting quit dates and reporting smoking cessation.
authors.affiliation: Division of Primary Care, School of Medicine, UK Centre for Tobacco and Alcohol Studies, University of Nottingham, Nottingham, UK.
authors.forename: Katarzyna A
authors.identifier: 0000-0001-7453-9138
authors.initials: KA
authors.lastname: Campbell
authors.affiliation: Division of Primary Care, School of Medicine, UK Centre for Tobacco and Alcohol Studies, University of Nottingham, Nottingham, UK.
authors.forename: Sue
authors.identifier: 0000-0002-1994-6395
authors.initials: S
authors.lastname: Cooper
authors.affiliation: Division of Primary Care, School of Medicine, UK Centre for Tobacco and Alcohol Studies, University of Nottingham, Nottingham, UK.
authors.forename: Samantha J
authors.identifier: 0000-0002-2013-6154
authors.initials: SJ
authors.lastname: Fahy
authors.affiliation: Division of Primary Care, School of Medicine, UK Centre for Tobacco and Alcohol Studies, University of Nottingham, Nottingham, UK.
authors.forename: Katharine
authors.identifier: 0000-0002-9033-0884
authors.initials: K
authors.lastname: Bowker
authors.affiliation: Division of Epidemiology and Public Health, School of Medicine, UK Centre for Tobacco and Alcohol Studies, University of Nottingham, Nottingham, UK.
authors.forename: Jo
authors.initials: J
authors.lastname: Leonardi-Bee
authors.affiliation: National Centre for Smoking Cessation and Training (NCSCT), London, UK.
authors.forename: Andy
authors.initials: A
authors.lastname: McEwen
authors.affiliation: Division of Primary Care, School of Medicine, UK Centre for Tobacco and Alcohol Studies, University of Nottingham, Nottingham, UK.
authors.forename: Rachel
authors.initials: R
authors.lastname: Whitemore
authors.affiliation: Division of Primary Care, School of Medicine, UK Centre for Tobacco and Alcohol Studies, University of Nottingham, Nottingham, UK.
authors.forename: Tim
authors.identifier: 0000-0002-7303-4805
authors.initials: T
authors.lastname: Coleman
mesh_terms: D000328:Adult; D002248:Carbon Monoxide / Q000032:analysis; D005260:Female; D006801:Humans; D011247:Pregnancy; D011248:Pregnancy Complications / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control*; D011295:Prenatal Care / Q000458:organization & administration*; D012017:Referral and Consultation / Q000458:organization & administration / Q000706:statistics & numerical data; D016540:Smoking Cessation / Q000379:methods*; D000074606:Smoking Prevention; D006113:United Kingdom; D055815:Young Adult
chemical_list: D002248:Carbon Monoxide
keywords: Cessation; Health Services; Priority/special populations