Financial incentives for smoking cessation in pregnancy: randomised controlled trialBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h134 (Published 27 January 2015) Cite this as: BMJ 2015;350:h134
All rapid responses
Tappin et al in their well designed study provide evidence of the effectiveness of financial incentives in supporting pregnant women in quitting smoking. If corroborated by further studies and if found to be cost effective, financial incentives to quit smoking may well be worth incorporating into health policy.
The authors acknowledge, however, the potential for unintended consequences and for "gaming" when financial incentives such as those in this study are offered. Should such an intervention become policy, it could create an incentive for non-current smokers to start smoking, in order to qualify for the financial incentives. It may well be that recommencing smoking in this context would be intended to be short term. A proportion of such smokers could end up dependant in the long term. Such an outcome would be very concerning. This question may be worthy of further study.
Competing interests: No competing interests
A larger context for considering the Tappin et al. report on financial incentives for smoking cessation in pregnant and newly postpartum women
We commend Dr. Tappin and colleagues on an important study and report. As is carefully reviewed in their report, smoking during pregnancy and postpartum is associated with many serious adverse maternal and infant health outcomes. Yet after almost 30 years of treatment development research in this area, there remains a tremendous need for more effective interventions. The Tappin et al. report provides additional evidence from a relatively large and rigorously controlled trial that financial incentives in the form of vouchers exchangeable for retail items increase abstinence rates several fold above cessation rates achieved with other psychosocial and pharmacological interventions.
We want to contribute several points of information not mentioned by Tappin and colleagues that warrant consideration regarding the potential merits of this treatment approach, often referred to as Contingency Management in the substance abuse literature. First, there is a large body of experimental evidence in the form of rigorously controlled randomized clinical trials and meta-analyses supporting the efficacy of this treatment approach for increasing abstinence from a wide range of different abused drugs including cocaine, marijuana, methamphetamine, opioids, and tobacco.1,2 Indeed, a NICE Guidelines report appeared in the BMJ in 2007 recommending implementation of this treatment approach in community substance abuse treatment centers in the United Kingdom.3 When considered in this larger context, the accumulating evidence supporting the efficacy of this approach with pregnant cigarette smokers is not surprising.
Second, there is increasing evidence that the intervention improves important health outcomes among pregnant and newly postpartum women and their infants. For example, there are two randomized controlled clinical trials demonstrating that this treatment approach increases sonographically estimated fetal growth in the third trimester.4,5 Results from several studies that combined data sets across controlled trials conducted in the same clinic along with appropriate statistical adjustments for doing so, suggest that the intervention can increase mean birth weight and decrease percent of low birth weight deliveries6, increase the duration of breastfeeding7, and decrease postpartum depressive symptomatology in depression-prone women.8
Third, the large literature on the use of voucher-based incentives in treatment of substance abuse allows us to glean some evidence-based guideposts. One such guidepost is that the size of the treatment effect generally increases as an orderly function of the monetary amount of the incentive provided.2 Tappin and colleagues used a smaller maximal incentive value than has been used in several prior trials with pregnant smokers (£400 versus ~$1,100). As expected, treatment effect size also appears to be relatively smaller, with absolute late-pregnancy abstinence levels of 22% in the Tappin et al report versus an average of 35-45% in the prior efficacy trials that used the $1,100 value and differences above control levels of 13.9% in the Tappin et al. report versus ~25% in the prior reports.4,5,9 This is certainly not a criticism of the abstinence outcomes achieved by Tappin and colleagues, which were 2.6-fold greater than control levels. Instead, the intent of this comment is to get this important information on the relationship between incentive value and treatment effect size into the conversation about where to set intervention parameters when using this treatment with pregnant smokers. The likelihood of impacting birth and other health outcomes mentioned above can also be expected to vary by the size of the treatment effect on smoking abstinence as can the likelihood of significantly impacting longer-term maternal abstinence rates and related risk of second-hand smoke exposure among the children, etc. Future parametric trials examining the impact of varying incentive value on abstinence and related health outcomes in pregnant women and their infants, along with associated cost-effectiveness analyses, would be very helpful in answering this important parametric question. There are also other important parametric questions to be addressed regarding the optimal frequency of clinic contact and different ways of scheduling voucher delivery that also merit serious consideration.10,11
A fourth and final point has to do with predictors of individual differences in response to voucher-based incentives that we feel underscores the importance of ongoing dialogue among investigators in this area. Tappin et al. report that baseline socioeconomic indicators (Scottish Index of Multiple Deprivations) and nicotine dependence levels (selected individual items and average scores from Fagerstrom questionnaire) did not predict treatment response. In prior research on this same topic, years of educational attainment and cigarettes smoked per day pre-pregnancy or at first antepartum prenatal care visit were robust predictors of end-or-pregnancy abstinence within the incentives condition.11,12 We did not see either of these potential predictors mentioned by Tappin and colleagues, but they are worth examining if they are available in this data set.
1. Higgins ST, Silverman K, Heil SH, editors. Contingency management in substance abuse treatment. New York: The Guilford Press; 2008.
2. Lussier JP, Heil SH, Mongeon JA, Badger GJ, Higgins ST. A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction. 2006;101:192–203.
3. Pilling S, Strang J, Gerada C. Psychosocial interventions and opioid detoxification for drug misuse: summary of NICE guidelines. BMJ. 2007; 335: 203-205.
4. Heil SH, Higgins ST, Bernstein IM, Solomon LJ, Rogers RE, Thomas CS, Badger GJ, Lynch ME. Effects of voucher-based incentives on abstinence from cigarette smoking and fetal growth among pregnant women. Addiction. 2008;103:1009-18.
5. Higgins ST, Washio Y, Lopez AA, Heil SH, Solomon LJ, Lynch ME, Hanson JD, Higgins TM, Skelly JM, Redner R, Bernstein IM.. Examining two different schedules of financial incentives for smoking cessation among pregnant women. Prev Med. 2014;68:51-7.
6. Higgins ST, Bernstein IM, Washio Y, Heil SH, Badger GJ, Skelly JM, Higgins TM, Solomon LJ. Effects of smoking cessation with voucher-based contingency management on birth outcomes. Addiction. 2010;105:2023-30.
7. Higgins TM, Higgins ST, Heil SH, Badger GJ, Skelly JM, Bernstein IM, Solomon LJ, Washio Y, Preston AM. Effects of cigarette smoking cessation on breastfeeding duration. Nicotine Tob Res. 2010;12:483-8.
8. Lopez AA, Skelly JM, Higgins ST. Financial incentives for smoking cessation among depression-prone pregnant and newly postpartum women: effects on smoking abstinence and depression ratings. Nicotine Tob Res. In press.
9. Higgins ST, Heil SH, Solomon LJ, Bernstein IM, Lussier JP, Abel RL, Lynch ME, Badger GJ. A pilot study on voucher-based incentives to promote abstinence from cigarette smoking during pregnancy and postpartum. Nicotine Tob Res. 2004;6:1015-20.
10. Donatelle R, Hudson D, Dobie S, Goodall A, Hunsberger M, Oswald K. Incentives in smoking cessation: status of the field and implications for research and practice with pregnant smokers. Nicotine Tob Res. 2004;6 Suppl 2:S163-79.
11. Higgins ST, Washio Y, Heil SH, Solomon LJ, Gaalema DE, Higgins TM, Bernstein IM. Financial incentives for smoking cessation among pregnant and newly postpartum women. Prev Med. 2012;55 Suppl:S33-40.
12. Higgins ST, Heil SH, Badger GJ, Skelly JM, Solomon LJ, Bernstein IM. Educational disadvantage and cigarette smoking during pregnancy. Drug Alcohol Depend. 2009; 1;104 Suppl 1:S100-5.
Competing interests: No competing interests
What is social about a deadly addiction?
The recent study by Tappin et al 1 analysing the effects of financial incentives on smoking cessation rates in pregnancy is a clear example of the radical changes that continue to be made in our understanding of, and attitudes towards, both active and passive smoking. The early research demonstrating the causal relationship between smoking and the risk of lung cancer and other pathologies has resulted in far-reaching public health initiatives such as enforced smoke-free environments, tax increases and advertisementrestrictions that have been implemented with profoundly positive outcomes. Smoking rates have declined markedly in the UK and other developed nations. Furthermore, we now enter an era of plain packaging and potentially, financial stop-smoking incentives.
However, in my experience and in spite of the aforementioned successes in tobacco control, the majority of the medical fraternity continue to isolate this potentially deadly addiction to the somewhat elusive, and, at times, omitted section of their patient's consultation and health record: the social history or Shx. Considering society's improvement in attitude and awareness towards smoking and its repercussions, it seems evident that doctors have in fact been left behind with regard to their attitude, advocacy and practice. This comes in spite of the pivotal role that they play in establishing a tobacco free society. Such an approach to patients' smoking status and smoking history leads to inertia and, alarmingly, compromises patient care and clinical outcome.
The de-prioritisation of smoking history stands in direct contradiction to the emphasis placed on two of society’s other important addictions: intravenous drug use and alcoholism. Both entities are commonly seen and correctly noted and addressed as active and serious medical problems with significant associated morbidity and mortality. Furthermore, a recent study published in the New England Journal of Medicine 2 has demonstrated that our current understanding of the number of diseases and magnitude of excess mortality caused by smoking are likely to be gross underestimates. Indeed, behavioural patterns are believed to be the dominant determinant of preventable death and smoking is the leading behavioural cause contributing to premature deaths. 3
If we hope to continue to succeed in our efforts to combat smoking and its effects and to realise our aim of a smoke-free generation as aspired to by the World Health Organisation and UK health and research institutes, all health professionals should acknowledge their pivotal role. They should use their knowledge and tools to improve the health of their patients and spare them from years of poor health and premature death. Achieving a smoke-free society will take time and involve a combination of both large policies and small interventions that will have an incremental impact. In my opinion, one such intervention would be for doctors to remove their patient’s smoking status from a one word social entity confined to the Shx. It ought to be regarded as a serious medical issue deserving of a detailed timeline and treatment history in the all important section of a patient's medical consultation and health record - the Medical History or Mhx. Although seemingly trivial in nature, such a change in attitude and practice has the potential to be highly impactful for the health of our patients.
1. Tappin D, Bauld L, Purves D, Boyd K, Sinclair L, MacAskill S, et al. Financial incentives for smoking cessation in pregnancy: randomised controlled trial. BMJ 2015; 350: h134.
2. Carter BD, Abnet CC, Feskanich D, Freedman ND, Hartge P, Lewis CE, et al. Smoking and mortality--beyond established causes. The New England journal of medicine 2015; 372(7): 631-40.
3. Schroeder SA. Shattuck Lecture. We can do better--improving the health of the American people. The New England journal of medicine 2007; 357(12): 1221-8.
Competing interests: No competing interests
Authors reply: Criticisms can be political rhetoric and poor science
We thank the authors of two recent rapid responses for taking the time to respond to some of the issues raised in our article.
In terms of a response, it is helpful to start by emphasing that our trial (1) was a phase II therapeutic exploratory trial. ‘Phase II is usually considered to start with the initiation of studies in which the primary objective is to explore therapeutic efficacy in patients.’(2) ‘Additional objectives of clinical trials conducted in Phase II may include evaluation of potential study endpoints.’ We think it is important for all to understand that, although it had striking findings, this trial (1) was not designed as a phase III definitive trial and the critique offered by Braillon and Bewley (3) seems to miss this point entirely.
An additional focus of the responses is the validity of the primary outcome. We believe this is robust and provide further detail here.
The primary outcome was self-report of smoking cessation in late pregnancy corroborated by cotinine in saliva or urine (Russell Standard) (4). All participants were contacted in late pregnancy by specialist advisers from the NHS Stop Smoking Helpline call centre. These same advisers had gained telephone consent from participants to take part in the trial and provided concealed random allocation. At that time the study database randomly allocated a date from 34-38 weeks gestation from which advisers would start to try to contact the participant for follow up. This date was not known to the adviser or the participant so, although participants knew they would be followed up within a 4 week window, they did not know exactly when they would be phoned and asked about smoking status for primary outcome assessment. Women who self reported as quit were visited by a research nurse to collect a urine and saliva sample to test for cotinine and validate their reports. Additionally, for the final 200 participants, with a change of consent after a substantial ethics amendment, we performed a second validation of women’s self-reported smoking by testing residual routine blood samples taken, during routine ante natal care over the last 10 weeks of pregnancy. This extra, second validation was reassuring; we found that, in the intervention group, 4 / 18 (20%) women who, by our research processes were considered as quitters, had a blood cotinine level which indicated they were actually smoking but the figure in the control group was very similar, 1 / 5 (20%). This suggests that any bias in primary outcome assessment affected intervention and control group outcomes to a similar degree and will not have impacted on the relative difference in cessation outcomes between trial groups. The primary outcome is therefore quite solid and findings clearly demonstrate that, in this population, incentives were effective in achieving smoking cessation in pregnancy, at least. Relatively few trials of smoking cessation interventions in pregnancy have followed women up for long after pregnancy and we agree that, for incentives, as for other interventions, evidence for longer term efficacy is needed. Participants lost to follow-up were also examined using residual routine blood samples from late pregnancy assayed for cotinine and all tested in both intervention and control groups were smokers.
Cope (5) suggests using a quick test for cotinine rather than carbon monoxide breath testing to decide if self report quitters should receive financial incentives. We are familiar with his work and sympathetic to the need for more routine affordable biochemical validation of smoking status. Indeed, we have tried to apply this in one of our previous studies (6) which was a pragmatic observational study looking at ways of identifying smoking in pregnancy and routine referral to cessation services. However a key challenge is that existing stop smoking services in the UK (and maternity services) are simply currently not set up to use quick cotinine tests to verify abstinence. Instead they use CO testing which has some limitations as we acknowledge, but still provides manageable and very useful biochemical validation of smoking status. It is worth emphasising CO testing was not used to define the primary outcome of this study, which utilised cotinine validation.
With regards to Nicotine Replacement Therapy (NRT) in pregnancy, Braillon and Bewley cite an observational study which has findings which differ from those derived from RCTs; two large randomised placebo controlled trials (7, 8) in pregnancy both showed no significant difference in quit rate and the second titrated NRT to saliva cotinine levels prior to the quit attempt. The second study showed an increase in diastolic blood pressure associated with NRT. There is at present no evidence of the efficacy of NRT during pregnancy, however well it works in the non-pregnant population.
‘Is the improvement of healthcare providers’ motivational interviewing skills really so difficult?’ (3) We (Tappin) have significant firsthand experience of implementing a randomised controlled trial using motivational interviewing (MI) to help pregnant smokers quit during pregnancy in Glasgow (9). It was a challenge to teach a group of research midwives motivational interviewing skills (10) but with the support of a great teacher (Jeff Allison) who spent 8 days full time teaching the midwives and then 1 day per month honing their skills by discussing difficult cases the midwives became good practitioners. To make sure that the motivational interviewing skills were implemented, every intervention interview (625 undertaken in participants’ homes) was digitally recorded. A random 1 in 10 sample (63) were transcribed and sent with the audio recording to a motivational interviewing rating house at the Center on Alcoholism, Substance Abuse and Addictions(CASAA), at the University of New Mexico. The ratings indicated that the midwives could be described as “experts” at providing motivational interviewing in this setting. Outcome assessment for the trial, which included 762 pregnant smokers 351 intervention and 411 controls, was self report of quit in late pregnancy corroborated by cotinine estimation in residual routine late pregnancy blood samples. 4% of pregnant smokers had quit in the control group and 4% had quit in the intervention group. On the basis of our previous well conducted motivational interviewing (9) and NRT (7) trials in pregnancy we therefore take particular exception to the jibe that ‘Financial incentives look more akin to lazy bribery’ (3).
We do however agree that the case for implementing financial incentives across the NHS is far from proved, and that a phase III definitive trial of financial incentives to support smoking cessation during pregnancy should be carried out in the UK. Financial incentives are potentially a highly cost effective intervention to help pregnant smokers stop and to improve the health and wealth of the poorest in our society. It is important that this potentially highly effective health promoting intervention is not lost in a haze of political rhetoric and poor science.
David Tappin, Linda Bauld and Tim Coleman, on behalf of the CPIT study team.
1 Tappin D, Bauld L, Purves D, et al. Financial incentives for smoking cessation in pregnancy: randomised controlled trial. BMJ 2015 27;350:h134.
2 International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use. General considerations for clinical trials, 1997.
Guideline E8, section 126.96.36.199. http://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/Guidelines/Eff...
3 Braillon A, Bewley S. Neither carrots nor sticks should replace fairness and autonomy. http://www.bmj.com/content/350/bmj.h134/rr-3
4 West R, Hajek P, Stead L, Stapleton J. Outcome criteria in smoking cessation trials: proposal for a common standard. Addiction 2005;100:299-303.
5 Cope GF. Re: Financial incentives for smoking cessation in pregnancy: randomised controlled trial http://www.bmj.com/content/350/bmj.h134/rr-2
6 Bauld, L. Hackshaw, L, Ferguson, J et al. Implementation of routine biochemical validation and an ‘opt out’ referral pathway for smoking cessation in pregnancy, Addiction, 107, S2: 53-60.
7 Coleman T, Cooper S, Thornton JG, et al. A randomized trial of nicotine-replacement therapy patches in pregnancy. N Engl J Med 2012;366:808–18.
8 Berlin I, Grange G, Jacob N, Tanguy ML. Nicotine patches in pregnant smokers: randomised, placebo controlled, multicentre trial of efficacy. BMJ 2014;348:g1622.
9 Tappin DM, Lumsden MA, Gilmour WH, et al. Randomised controlled trial of home based motivational interviewing by midwives to help pregnant smokers quit or cut down. BMJ 2005;331:373-7.
10 Tappin D. Authors Reply: Teaching midwives motivational interviewing for a randomised controlled trial. http://www.bmj.com.ezproxy.lib.gla.ac.uk/rapid-response/2011/10/31/autho...
Competing interests: No competing interests
Increased understanding of the physiological and psychosocial barriers to smoking cessation for pregnant women and interventions to improve cessation is a public health priority. The well-executed RC study by Tappin et al (27th January 2015) assessed the impact of offering financial incentives on smoking cessation rates in pregnant women in Glasgow, UK1. Their primary finding is that pregnant women who were also offered additional financial incentives had a relative risk for not smoking at the end of pregnancy of 2.63 (95% CI: 1.73 – 4.01) compared to those offered only routine smoking cessation management.
We agree that any evidence to support increased smoking cessation for pregnant women is encouraging, however we would like to comment on some aspects of this paper.
There is an implicit assumption that deprivation is a primary reason for the smoking behaviour of these women, given that the incentive was financial in nature. While this assumption may be valid, it should be emphasised that the psychosocial context of smoking behaviour is complex and for many women, smoking behaviour is driven by other factors such as social approval or family smoking even in affluent communities2.
Additionally, risk factors known to be associated with failure to stop smoking were not assessed in their baseline analysis or adjusted for in primary analysis, such as partner/family smoking status or number of previous pregnancies (including whether the mother smoked during these pregnancies)3. Inclusion of these risk factors may have altered patterns of association.
As the authors rightly mention, the issue of potential public resistance to financial incentives is indeed very real4,5. Commonly, it is debated whether such schemes are a suitable use of public money, however the stated cost of £482/QALY is cheaper for the tax-payer (and less time-consuming) than many alternative options, including intensive counselling or CBT6.
Furthermore, the focus of smoking cessation efforts in pregnancy should be on the health of the unborn baby. While there may be public misgivings about paying women to do things that most people think they should be doing already, most would surely agree that £400 is a small cost to pay to facilitate massive reduction in health risks to an unborn child.
This reframing from ‘money for the mother’ to ‘money for the baby’ could be reinforced further by offering vouchers specifically targeted at parents, babies and children’s stores. This would bring the scheme more in line with schemes such Healthy Start, Sure Start or tax credits, where public resources are used on interventions directed at pregnant women and new mothers but the benefit is seen by (and the focus is upon) the unborn or newborn baby.
Given the growing emphasis in the health and social system upon early years health and life chances, we would welcome further discussion from the scientific and political community into the practical issues of prioritising children and baby health, as a separate issue from the important yet distracting arguments on moralistic issues or the ‘worthiness’ of some recipients over others in receiving public resources.
1. Tappin D, Bauld L, Purves D, Boyd K, Sinclair L, MacAskill S, (2015). Financial incentives for smoking cessation in pregnancy: randomised controlled trial. BMJ 2015;350:h134
2. Office on Smoking and Health, (2001). Women and Smoking: A Report of the Surgeon General. Centers for Disease Control and Prevention 2001,Mar;Ch4.
3. Raatikainen K, Huurinainen P, Hoinonen S, (2007). Smoking in early gestation of through pregnancy: a decision crucial to pregnancy outcome. Preventive Medicine 2007;44:59-63
4. Marteau T, Ashcroft R, Oliver A, (2009). Using financial incentives to achieve healthy behaviour. BMJ 2009;338:b1415
5. Volpp K, Troxel A, Pauly M, Glick H, Puig A, Asch D, Audrain-McGovern J, (2009). A randomized, controlled trial of financial incentives for smoking cessation. New England Journal of Medicine 2009;360(7):699-709
6. Feenstra T, Hamberg‐van Reenen H, Hoogenveen R & Rutten‐van Mölken M. (2005). Cost‐Effectiveness of Face‐to‐Face Smoking Cessation Interventions: A Dynamic Modeling Study. Value in health 2005, 8(3), 178-190.
Competing interests: No competing interests
Tappin et al investigated the efficacy of financial incentives (£400 of shopping vouchers) for smoking cessation in deprived pregnant women (n=612) and evidenced a 43% quit rate at 4 weeks vs 21% in the control group. The validity and usefulness of the findings are questionable as this apparent ‘success’ contrasts with: (a) a relative risk of premature birth of 1.52 (95% CI 0.95 to 2.39) (p=0.09) in the incentive group (13.4% vs 8.6% in control group); and (b) a non-significant difference in birth weight (3140g vs 3102g; p =0.67).
Firstly, the Fagerstrom questionnaire (assessing severity of nicotine addiction) was higher for all items in controls. Both groups only received a single form of nicotine replacement therapy (NRT) and four weekly support phone calls. Such NRT treatment may have led to inadequate dosing: a previous large randomized controlled trial (n= 3880) found success rates at 4-week follow-up of 16.3% for those without medication and 35.7% for those using a combination of various forms of NRT. Single form of NRT alone showed no benefit.(2)
Second, although Tappin et al reported a 22.5% success for the primary outcome (at 34-38 weeks’ gestation) in the incentive group versus 8.6% in controls, the details are not fully available. Patients in the financial incentive group may be more liable to ‘untruths’ when reporting (e.g. 30 were never contactable for validation vs 23 in the control group) or even ‘cheating’ when tested. The authors considered those who were lost to follow-up for the primary outcome had continued to smoke. For a true an intention-to-treat analysis, this would overestimate the success rate in the incentive group as controls who were lost to follow up and had quit smoking receive no reward from reporting. Can Tappin et al provide: a) the protocol for NRT dosing and for psychological support; b) the number of self-reported non-smokers who were positive for saliva or urine cotinine (for the primary outcome) indicating if the day for testing was planned, how women’s identity was checked for saliva and urine samples, and the number of self-reported non-smokers who were evaluated for saliva and for urine cotinine status in each group?
Third, while financial interventions appear to increase the proportion of smokers who attempt to quit and use treatments there is no evidence yet that smoking cessation shows higher quit rates at six months.(3) Similarly, although financial incentives for professionals increase the provision of cessation advice and referrals to stop smoking services there is not sufficient evidence to show that it leads to reductions in smoking rates.(4)
Lastly, are financial incentives fundamentally flawed? (5,6) There is far too little evidence for long-term efficiency; unsurprising given they do not promote autonomy. Additionally, the approach is far from fair; the most socially deprived citizens deserve better living conditions, an intervention which does work.(7) Financial incentives look more akin to lazy bribery (paying people to act against their wishes) or coercion (compelling people to behave using threats of not being paid). Is the improvement of healthcare providers’ motivational interviewing skills really so difficult? (8)
1 Tappin D, Bauld L, Purves D et al. Financial incentives for smoking cessation in pregnancy: randomised controlled trial. BMJ 2015 27;350:h134.
2 Brose LS, McEwen A, West R. Association between nicotine replacement therapy use in pregnancy and smoking cessation. Drug Alcohol Depend 2013;132:660-4.
3 Reda AA, Kotz D, Evers SM, van Schayck CP. Healthcare financing systems for increasing the use of tobacco dependence treatment. Cochrane Database Syst Rev 2012;6:CD004305.
4 Hamilton FL, Greaves F, Majeed A, Millett C. Effectiveness of providing financial incentives to healthcare professionals for smoking cessation activities: systematic review. Tob Control 2013;22:3-8.
5 Marteau TM, Ashcroft RE, Oliver A. Using financial incentives to achieve healthy behaviour. BMJ 2009;338:b1415.
6 Woolhandler S, Ariely D, Himmelstein DU. Why pay for performance may be incompatible with quality improvement. BMJ 2012;345:e5015
7 Ludwig J, Sanbonmatsu L, Gennetian L et al. Neighborhoods, obesity, and diabetes-a randomized social experiment. N Engl J Med 2011;365:1509-19.
8 Rollnick S, Butler CC, Kinnersley P, Gregory J, Mash B. Motivational interviewing. BMJ 2010 Apr 27;340:c1900.
Competing interests: No competing interests
The report by Tappin et al on the financial incentives for smoking shows an impressive reduction in smoking at the end of pregnancy1. This was a well executed study, with important implications for further initiatives to reduce the damage caused by smoking.
My concern is the over reliance on the use of expired-air carbon monoxide (eCO) as a means to verify self-reported abstinence from tobacco; using a cut off of 7 parts per million for the basis on which to allocate shopping vouchers to the value of more than £200.
The problem is that eCO is increasingly questioned as a reliable means of assessing abstinence from tobacco2. The half-life of CO is about 3 hours, meaning eCO only measures smoking habit for a 6-8 hour period, thus many smokers can abstain perhaps for just a few hours and the test will be negative. This was one point highlighted by the current study, stating ‘a small number of self reported quitters were validated as non-smokers by carbon monoxide breath testing but may have only temporarily abstained’. One study estimated that about 40% of those who smoked within 24 hours had eCO reading below 10 ppm and concluded that an eCO criterion of 5 ppm may be optimal to validate 24-hr cessation and reduce misclassification of smokers as “abstinent.”3.
While the use of eCO is useful as part of the Stop Smoking Services for participants to compare results and to provide feedback about their efforts to quit, more accurate and scientific methods should be employed to biochemically verify abstinence for research projects, and for issuing financial incentives. For example urinary and salivary cotinine testing, which was used in the current study only to verify cessation at 34-38 weeks can be carried out with inexpensive point of care methods4.
This study claimed that ‘A possible unintended consequence of financial incentives was that women were untruthful about their smoking status when asked during the trial, especially at the time of the primary outcome assessment’, yet financial incentives were allotted on the basis of a test which can be deceived by refraining from smoking overnight or less.
1. Tappin D, Bauld L, Purves D et al. Financial incentives for smoking cessation in pregnancy: randomised controlled trial. BMJ 2015; 350: h134 doi: 10.1136/bmj.h134
2. Schober P, Schwarte LA, Loer SA. Exhaled carbon monoxide concentration: a reliable predictor of smoking status? Eur J Anaesthesiol 2011; 28: 146-147
3. Perkins KA, Karelitz JL, Jao NC. Optimal carbon monoxide criteria to confirm 24-hour smoking abstinence. Nic Tob Res 2013; 15: 978-982.
4. Cope GF, Wu HHT, O’Donovan GV, Milburn HJ. A new point of care cotinine test for saliva to identify and monitor smoking habit. Eur Respir J 2012; 40: 496-7
Competing interests: GF Cope is the inventor of a point of care urinary and salivary cotinine test called SmokeScreen and he is a director of the manufacturer, GFC Diagnostics Ltd.
This important and interesting trial concerned only the pregnant women themselves, but it is well known that people with a partner who smokes find it easier to stop smoking if they support each other by stopping together. That is also better for the new baby and for any other children in the household.
It would therefore make sense to encourage and help partners who are smokers to stop at the same time. This should certainly involve personal counselling and follow up, but not necessarily an additional financial incentive. I suggest that future studies building on this one should also collect data on smoking by the prospective fathers.
Competing interests: No competing interests
It’s interesting to read an article done on changing lifestyle by incentivizing individuals to stop smoking.
Its good to know that incentivizing smokers did increase the effective quit rate by further 14%, compared to control group.
As suggested by the author, it will be good to consider doing a multi-centre study covering different regions and varied locality across UK. Also adding another arm for counseling service and NRT, to help us compare the efficacy of counseling / NRT, versus incentivizing individuals and more over adding a follow up few months after delivery, to see if they continue to off smoking
I am not sure in this present day and age, what would be the view of general public is, in spending tax payers money on helping individuals to embrace healthy lifestyles. To have one individual stop smoking, (based on the quit rate in the study) spending approximately £3000/-! Should the money be better spent on health education?
Other question is where to draw a line, how about to incentivize individuals to stop alcohol, to loose weight in obese people, smoking cessation in patients with COPD, being complaint with medications, incentivizing encouraging drug addicts to come off drugs, etc.
In the end patient has to take responsibility and ownership of their lifestyle and condition, instead of we giving them a wrong signal that they are doing us a favour to us by stopping smoking.
Competing interests: No competing interests
The present study findings suggest the effectiveness of incentives in the form of shopping vouchers and cash for cessation of smoking among pregnant women. The number needed to treat is 7.2 and the possible beneficial effect of smoking cessation on the birth weight of the newborns compared with control group is absent. Provision of the incentives seems to be quite high if it is translated into India currency which comes to about Indian rupee 64,000 approximately per pregnant woman. Such an incentive is not acceptable in view of the limited resources. In fact, counseling and provision of free nicotine replacement therapy could be provided depending upon its availability in public hospitals. The need for health hazards associated with smoking and tobacco consumption should be communicated and motivation should be done. Provision of cash and kind incentives may not be the choice in approach for long term cessation of smoking. The study should also find out how many returned back to smoking and after what period of the last smoking episode by further following the cohort. It may than be possible to comment upon the effectiveness of such incentive in the long run.
Competing interests: No competing interests