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Financial incentives for smoking cessation in pregnancy: randomised controlled trial

BMJ 2015; 350 doi: (Published 27 January 2015) Cite this as: BMJ 2015;350:h134

Rapid Response:

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

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

21 February 2015
May C I van Schalkwyk
Medical Doctor
Maidstone District General Hospital
55 Meriden Court, Chelsea, London, UK, SW33TT