Are financial incentives effective for smoking cessation in pregnant patients?

The American College of Obstetricians and Gynecologists recommend the following regarding tobacco and pregnant patients:

Healthcare professionals should inquire about all types of tobacco or nicotine use, including cigarette smoking, use of e-cigarettes or vaping products, hookahs, snus, lozenges, patches, and gum, during the pre-pregnancy, pregnancy, and postpartum periods.

Pregnant women should be advised of the significant perinatal risks associated with tobacco use, including orofacial clefts, fetal growth restriction, placenta previa, abruptio placentae, preterm prelabor rupture of membranes, low birth weight, increased perinatal mortality, ectopic pregnancy, and decreased maternal thyroid function.

Clinicians should individualize care by offering psychosocial, behavioral, and pharmacotherapy interventions. Available cessation-aid services and resources, including digital resources, should be discussed and documented regularly at prenatal and postpartum follow-up visits. [1]

Incentives are effective in promoting smoking abstinence across the general population of smokers as well as substance abusers, adolescents, patients with pulmonary disease, patients with serious mental illness and other subgroups. For pregnant patients, rewards contingent on validated cessation may ensure sustained abstinence into the post‐partum period. Incentives given for abstinence to the end of the pregnancy boost cessation rates compared with routine antenatal care. To develop and implement an effective incentive treatment for smoking, special attention should be paid to biochemical verification of smoking status, incentive magnitude and the schedule of incentive delivery. [2, 3]

A review article assessing six controlled trials consisting of economically disadvantaged pregnant smokers found that financial incentives are efficacious at promoting cessation amongst pregnant and recently postpartum women, and improving fetal birth outcomes. Three of the six trials found that interventions improved sonographically estimated fetal growth, mean birth weight, percent of low-birth-weight deliveries, and breastfeeding duration. [4]

Financial Incentives for Smoking Cessation in Pregnancy

Design

Single-blind, multicenter, randomized, controlled trial

N= 466

Objective

To evaluate the efficacy of financial incentives dependent on continuous smoking abstinence on smoking cessation and birth outcomes among pregnant smokers.

Study Groups

Financial incentive group: n= 231

Control group: n= 229

Inclusion Criteria

18 years or older, smoked ≥5 cigarettes/day or ≥3 roll-your-own cigarettes/day, had a gestation of <18 weeks, were motivated to quit smoking (scored >5 on a visual analogue scale ranging from 0 for not at all to 10 for extremely motivated), were affiliated to the social health insurance system as required by the French law on biomedical research, and had signed the informed written consent and agreed to the collection of the birth characteristics of their offspring.

Exclusion Criteria

Current treatment for a chronic psychiatric disorder using neuroleptics, antidepressants, or anxiolytics, use of tobacco products other than cigarettes, use of either bupropion or varenicline, and use of electronic cigarettes.

Methods

The Financial Incentive for Smoking Cessation in Pregnancy (FISCP) trial was conducted in 18 maternity wards in France.

Patients were randomized into either the control group or the financial incentive group. The patients in the financial incentive group received an initial $23.00 voucher, with progressively increasing vouchers at each study visit.

Pay-offs were based on two principles: a reward for abstinence for the day and a reward for continuous abstinence. For example, if participants were abstinent during six consecutive visits, they could earn up to €520 in vouchers.

Abstinence was defined as a self-report of no smoking in the past seven days and expired air carbon monoxide (eCO) ≤8 ppm measured by a Bedfont Smokelyzer piCO.

Randomization occurred during visit-1, and patients were allowed to set a quit-date within 15 days post randomization. From then, monthly visits (2-6) were planned up to the delivery date.

At each visit, all participants received a minimum10-minute intervention for smoking cessation according to national guidelines, including motivational counselling, support, relapse prevention, and skills training elements for behavioral modifications.

Outcome Measures

Primary outcome:

Continuous smoking abstinence from the first post-quit date visit to visit six, before delivery. The primary outcome was analyzed on an intention-to-treat basis, defined as all randomized pregnant smokers.

Secondary outcomes:

Point prevalence abstinence: self-report of no smoking in the past seven days and eCO level ≤8 ppm, time (days) to the first cigarette after quit date.

Relapse

Total number of cigarettes smoked/day

Craving for tobacco (12 item French Tobacco Craving Questionnaire, FTCQ-12)

Newborn characteristics

Baseline characteristics

Characteristic	Financial incentive group (n= 231)	Control (n= 229)
Mean age (range), years	29 (18-42)	29 (18-42)
Yearly income (Euros):
<10,000	42	40
10,000 to 18,000	51	52
18,000 to 30,000	67	72
30,000 to 54,000	56	50
54,000 to 100,000	6	8
Unsure/unanswered	9	7
Self-reported ethnic origin:
African	10	10
Asian	1	2
European	217	214
Other	3	3
Mean motivation to quit smoking	8.3	8.4
Mean age of first cigarette	14.9	14.8
Mean age of daily smoking	16.6	16.4
Median no. of smoking cessation attempts	1	1
Median no. of cigarettes smoked in past 7 days	56	60
Median no. of previous pregnancies	1	1
Median no. of children	0	0
Median BMI before pregnancy	22.5	23
Median BMI at randomization	23	24
Mean gestational age	13.6	13.7
Maternal health disorder reported at start of pregnancy	20	22

Results

From the 466 patients assessed, 460 were randomized. After allocation to study group, 17 patients from the financial incentive group and the 17 patients from the control group were lost to follow-up or experienced pregnancy termination.

Primary outcome: continuous abstinence rate
	Rate	Odds Ratio	95% CI	P-value
Financial group	16% (38/231)	2.4	1.34 to 4.49	0.004
Control group	7% (17/229)

Secondary Outcomes:
Outcome	Measure	95% CI	P-value
Point prevalence smoking abstinence	Odds ratio = 4.61	1.41 to 15.01	0.011
Median relapse	Finance group: visit 5, range [3-6]	–	<0.001
Median relapse	Control group: visit 4, range [3-6]	–	<0.001
Craving for tobacco	B= -1.81	-3.55 to -0.08	0.04
Cigarettes smoked	Mean difference = -163	-302 to -23	0.022

Nine fetal deaths (4%) occurred in the financial incentives group and 12 (5%) in the control group.

Univariate Analyses of Birth Characteristics in Newborns:
Characteristic	No. in Financial Incentive Group	No. in Control Group	Difference	Estimate 95% CI	P value
Birth weight (g)	202	205	47	-56 to 150	0.374
Length (cm)	191	187	-0.03	-0.6 to 0.5	0.925
Head circumference (cm)	186	185	0.00	-0.4 to 0.4	1.000
Apgar score at 5 min (range 0-10)	199	201	0.05	-0.1 to 0.2	0.497
Gestational age (weeks)	208	209	0.24	-0.14 to 0.63	0.217
Poor neonatal outcome	202	209	14	5 to 23	0.0028

Study Author Conclusions

Financial incentives to reward smoking abstinence compared with no financial incentives were associated with an increased abstinence rate in pregnant smokers. Financial incentives dependent on smoking abstinence could be implemented as a safe and effective intervention to help pregnant smokers quit smoking.

InpharmD^TM Researcher

Critique

The continuous abstinence rate being higher in the incentive group shows promise that financial incentives may aid with smoking cessation in this patient population. However, there is a clear lack of systemic follow up. Additionally, majoirty of the patients were lower income individuals, and while studies show that smoking is higher in such communities, the results of this trial cannot be applied to a general population that differs in that regard at baseline. Furthermore, given that the subjects self-reported data, there is a high risk of bias present. Lastly, it is important to note that this study took place in France, and cultural and clinic settings may make a difference when applying to patients in the U.S.

References:

Berlin I, Berlin N, Malecot M, Breton M, Jusot F, Goldzahl L et al. Financial incentives for smoking cessation in pregnancy: multicentre randomised controlled trial BMJ 2021; 375 :e065217 doi:10.1136/bmj-2021-065217