Financial rewards for pregnant smokers who quitBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h297 (Published 28 January 2015) Cite this as: BMJ 2015;350:h297
- Deirdre J Murphy, professor of obstetrics
- 1Academic Department of Obstetrics & Gynaecology, Trinity College, University of Dublin, Republic of Ireland
Smoking in pregnancy is associated with a wide range of adverse perinatal outcomes including preterm birth, intrauterine growth restriction, and perinatal death.1 2 3 The associations are almost certainly causal and the risks are modifiable by behavioural change.4 5 6 Although smoking cessation before 15 weeks of gestation yields the greatest benefits, quitting at any point can be beneficial.4 6 The potential benefits of total smoking cessation extend beyond the index pregnancy to risk reduction for sudden infant death syndrome, childhood respiratory illness, and the long term health of the mother.1 7 A Cochrane review of smoking cessation in pregnancy found that financial incentives seemed the most effective intervention, increasing abstinence more than threefold, although data were preliminary.8 The linked paper (doi:10.1136/bmj.h134) by Tappin and colleagues suggests that financial incentives may help women to quit smoking from early through to late pregnancy.9
The risks of smoking in pregnancy are widely understood by women, who are exposed to public health education, antenatal counselling, and warnings on cigarette packaging. Pregnancy seems to motivate women to stop smoking, but there is a persistent cohort of pregnant women (10-15%) who find it difficult to stop or who choose to continue.10 11 Approximately 50-60% of women who quit smoking during pregnancy return to it within one year after delivery.10
The cost of cigarettes is inflated regularly through taxation, to deter unhealthy behaviour and the consequences for individuals and the health service. This financially punitive approach has had limited success. An alternative approach is to incentivise smoking cessation with targeted financial rewards aimed at engagement, initial cessation, and prevention of relapse.12 The theoretical advantage of financial rewards in the context of pregnancy is that it tackles some of the social inequity inherent in the associations between poverty, smoking, and adverse perinatal outcomes. Two important questions arise: do financial incentives work, and is this an appropriate use of public resources? The former is best dealt with by well designed randomised controlled trials, such as Tappin and colleagues’ study,9 and the latter warrants public debate with an ethical dimension.
Cigarette dependence is both physiological and psychological, and cessation techniques include counselling, cognitive and behavioural therapy, hypnosis, acupuncture, and drug treatment.8 Financial incentives to promote behaviour change are more controversial. For the initiatives to work, the targeted groups must be motivated to change their behaviour by the promise of the financial incentives offered. Behaviour change has been divided into “simple” (single actions at a point in time such as adherence to drugs) and “complex” (requiring effort over a sustained period, such as smoking cessation).12 Complex behaviour change requires both sustained effort and typically the adoption of multiple strategies to achieve change.
In the linked paper, Tappin and colleagues recruited pregnant smokers from a deprived inner city population in Scotland. They assessed the efficacy of offering up to £400 of shopping vouchers (awarded at four specific times in response to positive behaviours) added to routine specialist services (behavioural therapy with or without nicotine replacement therapy), compared with routine specialist services alone.9 The primary outcome was cotinine verified cessation of smoking at 34-38 weeks’ gestation. Significantly more smokers who were offered incentives quit than did controls (23% v 9%, number needed to treat 7). There were no differences in birth weight, preterm birth, stillbirths, or miscarriages, and barely half of those who quit smoking remained abstinent at six months postpartum (15% v 4%).
The trial was well designed and well informed by extensive preparatory work, but it proved challenging and labour intensive. Making and maintaining contact with the target population proved difficult, despite additional financial rewards for all participants who provided outcome data. Further analyses suggested that the intervention was cost effective; however, this result was based on a short follow-up period of just 12 months from the initial quit date (usually six months postpartum) (www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736%2814%2962130-9.pdf).
Whether widespread implementation is an appropriate use of public money has yet to be decided. Several ethical issues need to be considered first, such as whether financial incentives are coercive (particularly when targeted at people on a low income), who may do things because they need the money, not because they really want to do them; whether we should be paying people to do things that most people think they should be doing already; and whether financial incentives encourage “gaming” or playing the system.
The authors report that the incentives were acceptable to clients and healthcare professionals, although this finding was based primarily on previous qualitative data.13 In a related survey, they reported that UK public opinions on incentives (for either smoking cessation or breastfeeding in pregnancy) were mixed, with negative opinions more prevalent among women and those with lower educational attainment and support higher among those of childbearing age.13 Finally, there was also some evidence of cheating or “gaming” in Tappin and colleagues’ study, with women providing conflicting information by telephone and in person, and discordant findings between self reported smoking cessation and objective biochemical tests.9
Overall, Tappin and colleagues’ study provides important new evidence suggesting that financial incentives, when added to existing services to help women stop smoking in pregnancy, can increase quit rates. The target effect size was exceeded, but it remains disappointing that 77% of pregnant smokers failed to quit despite the offer of £400 in shopping vouchers.
Further research is required to establish how rates of abstinence can be increased and maintained through successive pregnancies and beyond. Financial incentives were acceptable to participants in Tappin and colleagues’ study, but whether there is public support for this type of intervention to be implemented more widely remains unclear.
Cite this as: BMJ 2015;350:h297
Competing interests: I have read and understood the BMJ policy on declaration of interests and declare the following interests: none.
Provenance and peer review: Commissioned; not externally peer reviewed.