Women who quit smoking during pregnancy may be significantly more likely to remain smoke-free after childbirth when relapse-prevention support is delivered by trained health visitors, according to a large study led by researchers at the University of East Anglia (UEA). The findings suggest that the period immediately after birth—often marked by sleep deprivation, emotional strain, changing routines and renewed exposure to smoking within social networks—represents a critical window for preventing a return to tobacco use. The research evaluated BabyBreathe, a complex intervention designed to extend smoking-cessation support beyond pregnancy and into the first year of a child’s life. Unlike conventional cessation programmes, which often focus on helping pregnant women stop smoking but provide limited follow-up after delivery, BabyBreathe was designed around the biology and behavioural dynamics of relapse.
The programme combines personalised, one-to-one guidance from trained health visitors with digital and practical support. Women received access to text-message prompts, a dedicated website, a mobile application and a relapse-prevention kit sent after the birth of their baby. The intervention also included advice on managing cravings, identifying situations that could trigger smoking, and finding alternatives when urges emerged. Partners and other family members were included in the support strategy because smoking behaviour is strongly influenced by household environments. Exposure to cigarettes, tobacco use by partners, and the stress associated with caring for a newborn can all undermine a woman’s confidence in remaining abstinent. BabyBreathe therefore treated postpartum smoking relapse as a continuing health and behavioural risk rather than as a failure of the original quit attempt.
A total of 886 women in England and Scotland took part in the multicentre randomised controlled trial. All participants had successfully stopped smoking before or during pregnancy, making them a group with an immediate and measurable risk of relapse rather than a population seeking initial cessation. Participants were randomly assigned either to receive BabyBreathe alongside usual maternity and health-visiting services or to receive usual care alone. In the control group, women were not offered a dedicated programme focused on preventing a return to smoking. Randomisation was intended to balance important characteristics between the groups, allowing researchers to estimate the effect of the intervention more reliably than would be possible through observational comparisons. The study followed participants for 12 months after childbirth, a period in which postpartum relapse is known to be common.
BabyBreathe was intended to begin near the end of pregnancy and continue through routine health visitor appointments after delivery. Health visitors provided tailored conversations about the woman’s smoking history, current confidence, likely triggers and available coping strategies. This type of support is technically different from simply reminding someone not to smoke: it is based on relapse-prevention principles, which identify high-risk situations before they occur and encourage people to develop specific responses. A participant might, for example, be helped to plan what to do during an intense craving, how to respond if a partner smokes at home, or how to manage stress without using tobacco. The digital elements were designed to reinforce those conversations between appointments, while the mailed kit provided a tangible reminder of the commitment to remain smoke-free.
The researchers reported that 57.6 per cent of women who received the intervention as intended remained smoke-free 12 months after giving birth, compared with 49.9 per cent of women receiving usual care. This difference of 7.7 percentage points suggests that consistent health visitor involvement could prevent relapse for a meaningful proportion of women who had already overcome the difficult process of quitting. The result is particularly important because smoking cessation during pregnancy is often treated as the endpoint of care, even though the protective effect can be lost if smoking resumes after delivery. Remaining abstinent not only reduces a mother’s future risk of cardiovascular disease, lung disease and cancer, but also lowers the likelihood that infants and children will be exposed to second-hand smoke.
The trial also revealed a major challenge in translating a promising intervention into routine healthcare. BabyBreathe was not delivered as planned to approximately one in five participants. Missed appointments, administrative problems and pressures on the health visitor workforce meant that some women did not receive the full package of support. This distinction matters scientifically. The study’s analysis of participants who received BabyBreathe as intended indicated a clear benefit, while incomplete delivery reduced the intervention’s apparent effectiveness when the programme was considered across the entire assigned group. In implementation research, this difference is often described as the gap between efficacy and real-world effectiveness: a programme may work when delivered reliably, yet produce a smaller population-level effect if staffing, training or service organisation prevent consistent delivery.
The study’s authors argue that health visitors are particularly well positioned to close this gap because they already maintain contact with families during the months when relapse risk may rise. Health visiting services can identify women who stopped smoking during pregnancy, acknowledge the achievement and continue monitoring smoking status without treating the subject as closed. Professor Caitlin Notley of UEA’s Norwich Medical School said that health visitors previously had little or no specialist training in smoking relapse prevention, meaning that women who had made a major health behaviour change could leave pregnancy without structured encouragement to maintain it. Training could allow professionals to use routine visits more effectively, integrating relapse-prevention advice into broader assessments of maternal wellbeing, infant health, household smoking and social stress.
The potential benefits extend beyond tobacco exposure in the home. Women who stop smoking and remain abstinent can gradually reduce their risk of smoking-related disease toward that of people who have never smoked, although the speed and extent of risk reduction vary according to smoking history and individual health. For infants, a smoke-free environment reduces exposure to toxic particles and gases that can persist indoors even after a cigarette has been extinguished. Children raised in households without smoking may also be less likely to adopt smoking later in life, making postpartum relapse prevention relevant to the next generation as well as to the mother. By combining behavioural counselling, household advice and digital reminders, BabyBreathe attempts to address the social and environmental mechanisms through which smoking can return after pregnancy.
The researchers caution that the findings should not be interpreted without considering the study’s limitations. Engagement with some components of the programme was low, and incomplete intervention delivery affected the primary analysis. In addition, the participating women were generally more highly educated and less socioeconomically deprived than the wider population. That difference may have influenced their access to digital resources, ability to attend appointments or likelihood of maintaining abstinence, limiting how confidently the results can be applied to communities facing greater financial hardship or more intense tobacco exposure. Further research will be needed to determine how BabyBreathe performs when embedded across overstretched health visiting systems, how much training is required, and which elements—face-to-face contact, digital support, family involvement or the relapse-prevention kit—produce the greatest benefit.
The BabyBreathe programme was developed over more than a decade through collaboration among women, families, health professionals and researchers. UEA led the research with the University of Edinburgh, City St George’s, University of London, the University of Exeter, the University of Stirling, Glasgow Caledonian University, the Institute of Health Visiting and the Norfolk 0–19 Healthy Child Service. The findings point to a practical change in the way smoking cessation around pregnancy could be understood: quitting before birth may be the first stage of treatment, not the final one. If health visitors are trained, adequately staffed and supported to provide relapse-prevention care after delivery, a larger number of mothers may remain smoke-free, protecting their own long-term health while reducing tobacco exposure for babies and families.
Subject of Research: People
Article Title: BabyBreathe trial: protocol for a randomised controlled trial of a complex intervention to prevent postpartum return to smoking
News Publication Date: 19-Aug-2026
Web References: https://doi.org/10.1136/bmjopen-2023-076458; https://www.uea.ac.uk/about/norwich-medical-school
References: University of East Anglia; National Institute for Health and Care Research; Institute of Health Visiting; BMJ
Keywords: BabyBreathe, smoking cessation, postpartum relapse, pregnancy, health visitors, maternal health, infant health, second-hand smoke, public health, randomised controlled trial
