Rewarding smoking cessation in pregnancy-will women cheat to gain incentives?

Abstract

There is a growing body of research that suggests that financial incentives can encourage health behaviour change, but they remain controversial 1. Some of the most consistently positive evidence is for incentives for smoking cessation in pregnancy, where a recent Cochrane Review found incentives to be the most effective intervention 2. This is to address a harmful health behaviour that is challenging for women to change, and where some approaches that seem to work with other adult smokers have not yet been shown to be effective. The Cochrane Review contained just four small trials conducted in the United States, involving approximately 1200 women. More evidence is needed, particularly in countries such as the United Kingdom, where national targets to reduce smoking in pregnancy have not been met 3. Ierfino and colleagues test incentives in a ‘real world’ setting, offering them alongside existing smoking cessation services in one part of England 4. They found reasonable levels of uptake; most women who signed up to the programme made a quit attempt and 8% were validated as abstinent from smoking at delivery. This is a similar proportion of women who stopped smoking by the end of pregnancy in one recent trial of nicotine replacement therapy (NRT) 5 and higher than a second, similar trial of NRT 6. Unlike some previous studies of incentives for cessation in pregnancy, women in this study were eligible to continue receiving incentives during the postpartum period. Half of those recorded as non-smokers at delivery were not using tobacco at 6 months after the birth, a similar rate of relapse to that observed in population surveys of pregnant smokers who are not engaged in cessation programmes 7, 8. This suggests that incentives did not reduce relapse rates significantly, although the numbers here are very small. Perhaps the key contribution of this study, however, particularly given the authors’ acknowledgement of the limitations of the research design (observational data which cannot tell us a great deal about efficacy) is the careful assessment of ‘gaming’. That participants will cheat to enter or remain in incentive schemes is a common conception. It is cited frequently as a reason not to support incentives for health behaviour change. Ierfino and colleagues found that no women pretended to be smokers to enter the scheme. Voluntarily taking up or restarting smoking to a level that can be detected seems unlikely in pregnancy. Some evidence of cheating during the programme was detected, perhaps once women identified the limitations (smoking in the past day) of the carbon monoxide (CO) breath test. However, here the numbers were still low—with 4% of women (10 participants) managing to ‘game’ the CO breath test. These women were identified when the more robust biochemical validation measure of salivary cotinine was used. Widespread cheating was not observed. This is consistent with the findings of qualitative research, with women and health professionals involved in another recent study of incentives for cessation in pregnancy that we have just completed in Glasgow 9, 10. In our study there were also few reports of gaming. Instead, interviewees emphasized the importance of behavioural support for smoking cessation alongside incentives that was part of our programme, as it was in the Ierfino study. Stopping smoking in pregnancy is not easy for many women 11, and support and trust—rather than blame and questioning—needs to be a part of any cessation programme. The Ierfino study adds to existing evidence that suggests rewarding women for engaging with smoking cessation programmes and for maintaining a quit attempt is a promising strategy. Further research is needed to confirm efficacy in a UK context. A greater challenge may be to address policy makers and public scepticism about such schemes, but monitoring and reporting on gaming can contribute to that. None.