Financial Incentives for Smoking Cessation in Pregnancy

Review                                                                                                

Tappin D, Bauld L, Purves D, et al: Financial Incentives for Smoking Cessation in Pregnancy  BMJ 2015;350:h134


Study Methods

This is a randomized controlled study of 612 pregnant smokers of a low-income, inner city population in the west of Scotland, United Kingdom. Participants were placed in either a control group, receiving routine care (face-to-face counseling, free nicotine replacement for 10 weeks, and support phone calls) or an incentivized group which received routine care and up to £400 (~$615) divided over 4 payments (one payment for meeting to discuss smoking cessation and choosing a quit date, one at 4 weeks post quit date with a negative exhaled carbon monoxide (CO) test , one at 12 weeks post quit date with a negative CO test and a final payment at 34-38 weeks for a negative CO result.   The primary outcome was cessation (proven by negative cotinine levels) at 34-38 weeks’ gestation through saliva or urine. Secondary outcomes included birth weight, engagement, and self reported quit at four weeks.

Results

Significantly more smokers in the incentivized group than the control group ceased smoking: 69 (22.5%) vs 26 (8.6%). There were no harms observed with financial incentives and concerns for “gaming the system” were minimal. The relative risk of not smoking at the end of pregnancy was 2.63 (95% CI 1.73 – 4.01 – P<0.001). The absolute risk difference was 14.5% (95% CI 8.2% - 19.7%) and the number needed to treat (NNT) with a financial incentive to achieve one extra quitter in late pregnancy was 7.2 (95% CI 5.1 – 12.2). The mean birth weight in the two groups was  not significantly different (P=0.67). 

Conclusion

Providing financial incentives for smoking cessation in pregnancy may be an effective method to motivate low income, inner city patients.

Commentary

Smoking during pregnancy can result in many serious complications ranging from low-birth weight, to pre-term labor, to stillbirth or miscarriage.  Traditional smoking cessation efforts continue to have very low success rates. Pregnancy presents a unique opportunity in which to target a specific population for smoking cessation with both short-term and long-term benefits for mother and child.
 
Costs related to smoking during pregnancy the UK National Health Service were outlined in this study as ranging from between £8.1m to £64m ($12.5 – $98.5 million US) for mothers, and £12m to £23.5m ($18.5 -  $36.2 million US) for infants (0-12 months). The American Lung Association estimates that in the US, smoking during pregnancy accounts for roughly 20-30% of low-birth weight babies, 14% of preterm deliveries, and ~10% of all infant deaths resulting in neonatal health-care costs of ~$366 million per year (or ~$704 per maternal smoker per year). [MQM1] These US numbers do not factor in general costs of smoking related to lung cancer, COPD, and vascular/cardiac disease.
 
Though several small trails have examined this topic, this study provides a more robust examination of the effectiveness and feasibility of providing financial incentives to aid in smoking cessation. The study’s strengths include a large sample size, pre-study comprehensive economic analysis, addressing public opinion, validation of lost to follow-up assumptions, and post-natal follow-up.
 
The sample size of 612 participants (>90% power to detect >11.4% increase in quit rate), overall success of randomization, and validation of assumption that those lost to follow-up had continued or resumed smoking all lend credibility to the results. Though the two arms were generally well balanced, the control group did have an initially higher physical nicotine dependence as calculated by Fagerstrom score (http://nicotinefreedom.com/articles/fagerstrom); this was controlled for during statistical analysis.
 
While overall this study was well conducted, a few aspects need to be explored further. As the authors mention, this was a single center study, which limits its applicability. A large, multicenter study is needed to examine additional smoking cessation services and to further investigate financial incentives as a feasible and effective practice tool. Another concern relates to study participants “gaming” the system. Much of the data and follow-up initially relies on self-reporting through phone calls. With the presence of financial incentives, self-reporting affords the possibility participants would not be completely truthful about their smoking behavior. Though the authors found little evidence of this behavior, confirmatory testing is unlikely to happen in an actual clinical setting.
 
While data exists of public acceptance of providing financial incentives to pregnant smokers to stop, considerable ethical issues exist.  Despite the perceptions, providing financial incentives may actually provide an efficient and effective way to motivate pregnant smokers to quit compared to standard approaches.  However, the authors suggest further analysis must be done to address the longer-term cost per quality adjusted life year gained.
 
With the US in the midst of payment reform, large physician practices and networks will likely become increasingly responsible for financing patient interventions.  Insurance providers should be encouraged by the possible cost savings seen with decreasing smoking rates, especially during the critical years of childbearing. Exploring innovative and cost effective ways to motivate patients to engage in healthy lifestyle and behavioral changes is a necessity. This unique approach of aligning incentives for patients, providers, and payers offers many exciting possibilities.


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