Background and challenges to implementation:
An intervention to encourage and support pregnant women to stop smoking by implementing National Institute of Health and Clinical Excellence guidance (2010) was introduced across north east England, a region with almost 30 000 births per year.

Intervention or response:
Comprised provision of equipment for universal, routine carbon monoxide (CO) monitoring, opt-out referral and enhanced follow-up. Positive impact was reported in Bell et al (2017). The current paper reports findings from qualitative interviews with pregnant smokers which aimed to ascertain the acceptability of the intervention. Women from the four areas where full implementation had taken place were interviewed individually face-to-face, initially at around 16 weeks of pregnancy (n=17) and again 4-10 weeks later (n=8) or postpartum (n=3). Interviews were recorded, transcribed then analysed thematically.

Results and lessons learnt:
Universal CO monitoring and opt-out referral appeared acceptable and the former motivated women to quit. When linked to a professional discourse of caring and concern, the intervention prompted women to take action. Where women continued to smoke or failed to attend smoking cessation services (SCS) appointments, they received a risk perception intervention (RPI), visually demonstrating the immediate, negative effects of CO on the foetus. Most women accepted the need for this hard-hitting approach, and although distressing, they expressed gratitude for it. Having this risk message personalised raised awareness and sometimes led to setting a quit date; however some resented the approach. Women generally found the RPI and enhanced follow up supportive and also benefited from greater family inclusion. Where maternity services were either less focused on prioritising the smoking cessation message, or less well integrated with SCS or where maternity staff were not as adept at delivering the RPI women found the intervention less acceptable.

Conclusions and key recommendations:
The intervention proved to be acceptable to pregnant women smokers interviewed during and shortly after pregnancy. Wider application is recommended.