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Financial incentives for smoking cessation in pregnancy: randomised controlled trial

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h134 (Published 27 January 2015) Cite this as: BMJ 2015;350:h134

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Re: Financial incentives for smoking cessation in pregnancy: randomised controlled trial

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.

References
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

13 February 2015
Dr Andrew KB Liu
Specialty Registrar in Public Health
Dr Charlotte Stevenson, Leanne Jennion, Dr Nicola Schinaia
Cumbria & Lancashire Public Health England Centre, 1st Floor York House, Ackhurst Business Park, Foxhole road, Chorley, UK, PR7 1NY