To investigate whether 1) pregnant smokers with mental disorders are less likely to accept referrals to smoking cessation services compared to pregnant smokers without disorders; 2) they experience specific barriers to smoking cessation.

Cohort study supplemented by cross-sectional survey and nested qualitative study.

Three maternity services, London, UK

Pregnant smokers with and without mental disorders.

Case notes were examined on a cohort of 400 consecutive pregnant smokers; data were triangulated with routinely collected data on 845 pregnant smokers at 2 other sites; 27 pregnant smokers were interviewed using qualitative methods.

Acceptance of referral to smoking cessation services; Perceived barriers to quitting.

Pregnant smokers with a mental disorder recorded by midwives were a quarter of the cohort (97, 23%), were more likely to accept referral to smoking cessation services (69% vs 56%, AOR 1.70), but more likely to still smoke at delivery (69% vs 56% AOR 2.63). Discussion about smoking was documented in 7.7% of subsequent antenatal visits in women with or without mental disorders. Pregnant smokers with diagnosed mental disorders reported that they and health practitioners did not prioritise smoking advice due to concern about adversely impacting mental health.

Pregnant women with mental disorders appear more motivated, yet find it more difficult, to stop smoking. Prioritisation of mental health over smoking may thus lead to increasing health inequality for this group. Research into effective smoking cessation interventions is required for those with mental disorders.