Exploring how smoking cessation services delivered in pregnancy in England can produce equity promoting outcomes for underserved groups.

Background Smoking in pregnancy increases the risk of adverse pregnancy and birth events including miscarriage, stillbirth and low birthweight. Advancements in evidence and availability of psychosocial interventions delivered by smoking cessation services in England have contributed to declining rates of smoking in pregnancy over the last thirty years. However, disparities in rates persist between different groups. Existing evidence indicates that psychosocial interventions are similarly effective for participating groups characterised by socioeconomic status and ethnicity. However, there are gaps in understanding how interventions can be tailored to improve reach, engagement and smoking cessation outcomes for underserved groups. This is vital to increasing the rate of reduction which will realise the UK Government's ambition of a smokefree England ( Methods This research will explore how smoking cessation services delivered in pregnancy in England can produce equity promoting outcomes for underserved groups. The research will answer: 1) What are the pathways to intervention effectiveness for underserved groups? 2) How do rates of smoking at time of booking and delivery vary according to multiple, intersecting sociodemographic characteristics? 3) How do services tailor support to underserved groups, and what are the barriers and facilitators to doing so? 4) How are services experienced by pregnant people from underserved groups, and how does this relate to service engagement, beliefs and motivations about smoking, smoking outcomes, and prenatal health and wellbeing? 5) What are the processes that services work by to affect behaviour change for smoking cessation in underserved groups? The project will be conducted over three linked studies using qualitative comparative analysis (QCA), multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) and qualitative methods comprising semi-structured interviews, focus groups, creative participatory research methods and grounded theory. Impact and dissemination The research will support local maternity and neonatal systems to deliver on their equity action plans and to support smoking cessation services to more effectively tailor interventions for underserved groups. Research outputs will include a research summary for stakeholders of the pathways developed by the QCA, an interactive dashboard of the characteristics of those who smoke at time of booking and deliver, and a services guide to understanding and responding to the needs of underserved groups. This will include some of the visual and narrative data analysed, approaches for embedding of involvement and engagement in service planning and delivery, and a framework that draws together findings to propose a model for how services can create the conditions for equity generating outcomes. Outputs will primarily be disseminated through the NHS treating tobacco dependency national community of practice and the Office for Health Improvement and Disparities tobacco control networks. An advisory group comprising people with lived experience of smoking in pregnancy from underserved groups and professionals will oversee the research to ensure it is designed, delivered and disseminated to maximise relevance and impact. The project will be delivered from 2025 - 2031 with the first output, the research summary entering the health, social and care system by March 2027.