ObjectiveTo investigate whether 1) pregnant smokers with mental disorders are less likely to accept referrals to smoking cessation services compared with pregnant smokers without disorders; 2) they experience specific barriers to smoking cessation.DesignCohort study supplemented by cross-sectional survey and nested qualitative study.SettingThree maternity services, London, UK.PopulationPregnant smokers with and without mental disorders.MethodsCase notes were examined on a cohort of 400 consecutive pregnant smokers; data were triangulated with routinely collected data on 845 pregnant smokers at two other sites; 27 pregnant smokers were interviewed using qualitative methods.Main outcome measuresAcceptance of referral to smoking cessation services; perceived barriers to quitting.ResultsPregnant smokers with a mental disorder recorded by midwives were one-quarter of the cohort (97, 23%), were more likely to accept referral to smoking cessation services (69% versus 56%, adjusted odds ratio 1.70, 95% confidence interval 1.03–2.79), but more likely to still smoke at delivery (69% versus 56%, adjusted odds ratio 2.63, 95% confidence interval 1.41–4.92). 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 because of concern about adversely impacting mental health.ConclusionsPregnant women with mental disorders appear more motivated, yet find it more difficult, to stop smoking. Prioritisation of mental health over smoking may therefore lead to increasing health inequality for this group. Research into effective smoking cessation interventions is required for those with mental disorders.

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The aim of this article is to analyse the roots of the Catalonia health reform, whose first projects on reform have been documented since 1917. This historical process set-up, in Catalonia, a hospital-centric model involving three sets of regenerating and mutually reinforcing institutions: financial resources were being disproportionally distributed to hospitals, high-quality medical professionals were largely concentrated in hospitals and large outpatient departments were incorporated in hospitals, which functioned as a first point of care for many patients. Based on these premises, the intention is to contribute to the understanding of the initiatives that, during much of the 20th century, took place in Catalonia with the aim of bringing access to hospital services to the population. These same organising principles also had decisive influence on hospital planning in the rest of Spain. As such, we develop an historical approach to public policies that have been shaping the current imbalance between hospitals and primary care providers in Catalonia by combining two methodologies. On the one hand, an overview of the existing literature on this topic. On the other, an accumulation of case studies –which does not claim to be exhaustive– the result of this very research and that of other specialists in the object of study.As Catalonia still has a hospital-centric health system seeded throughout the 20th century, these findings can inform the framing of contemporary options for primary care strengthening. Without addressing these deep regenerating causes using a whole-system approach, Catalonia is unlikely to achieve a primary care orientation for health system development.

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