Smoking during pregnancy

Smoking during pregnancy

It’s (not) all about the money: Insights into financial incentives to help pregnant women in a deprived area stop smoking

In our recently published paper (available here) (McCormack et al., 2022), we explored the experiences of pregnant women who took part in a smoking cessation programme that used financial incentives.

Why is this important?

Smoking during pregnancy is a sensitive and controversial topic. Both mother and child can be affected by smoking during pregnancy where toxic chemicals are passed through the placenta. Health risks to babies include increased risk of tissue damage, low-birth weight, and premature birth, with further long-term poorer outcomes linked to learning and memory. Maternal health is also impacted. Mothers are at an increased risk of problems with their placentas, and the development of blood clots and heart and respiratory problems. Reducing the rate of smoking during pregnancy is, therefore, a public health priority.

What do we already know?

Reducing rates of smoking is a challenge, particularly in socio-economic disadvantaged communities. There is growing attention on ‘incentive schemes’. Researchers attempting to measure the effect of financial incentives on smoking cessation have suggested that such programmes can help to reduce smoking rates. A large-scale Cochrane review of 33 studies found that in both general and pregnancy trials, individuals given financial incentives were more likely to stop smoking than those who did not receive incentives (Notley et al., 2019). In more recent research, a reduction in smoking rates was also found in a randomised controlled trial of women receiving financial incentive from maternity units in France (Berlin et al., 2021).

However, such initiatives are often met with controversy, stigma and morally charged questions (from the public, health professionals and media) (see Bauld et al. (2017) for further reading). Framing schemes in this way seems to provoke a certain response about why women need ‘payment’ to stop something that could be harming their unborn child.

What don’t we know?

The studies described often do not capture the experiences and perceptions of pregnant women taking part in smoking cessation programmes. Smoking cessation programmes involving financial incentives generally include a component of ‘support’ from health professionals. But it is unclear whether these other components work with, or separate to, financial incentives. As Mantzari et al. (2012) put it, ‘is it from being paid or from the extra aid?’ Moreover, how do these components interact for women from socio-economically disadvantaged areas, where the need for intervention is greatest? The impact of wider social and economic factors on pregnant women in disadvantaged communities, makes smoking cessation far more complex and challenging. For example, women may be more likely to experience smoking as the ‘norm’ within their friendship and family groups. It is important, therefore, to gain some understanding of the experiences and perceptions of pregnant women taking part in these programmes.

What did we do?

Our study evaluated a smoking cessation programme conducted in a socio-economically deprived urban area. The programme combined financial incentives (vouchers) worth up to a maximum of £260 and ’enhanced support’. This included 4-weekly appointments with smoking cessation advisors, carbon monoxide (CO) monitoring, free nicotine replacement therapy, and the option of identifying a ‘significant other supporter’, ideally an individual close to the mother who would attempt to stop smoking alongside her. They received £40 of vouchers if the mother remained a non-smoker at 12 weeks following the birth of the baby. We spoke to 12 pregnant women who had successfully quit smoking for at least four weeks (two of whom had still quit 12-weeks after giving birth) and three advisors from the programme to find out about their experiences and perceptions of the scheme.

What did we find?

Women were successful in the intervention, not just because of the vouchers, but the combination of incentives and support. Women placed great value on their interactions with specialist advisors and framed incentives as a ‘bonus’ rather than the reason for engaging with the programme. The use of CO monitoring was found to be an ‘incentive’, where the objective measure was used to reaffirm their sense of achievement.

For women experiencing disadvantage, the relationship with their smoking cessation advisors was seen as vital to their success. They appeared to value the advisors’ support and help more than receiving financial incentives. However, the advisors felt that the vouchers were helpful to engage and then reward mothers for their smoking cessation. Surprisingly, the uptake of significant other supporters was low, and further highlighted the importance of the support received from smoking cessation advisors.

For women experiencing socio-economic disadvantage, financial incentives appear helpful when considered as part of a package. It seems that social or peer support might be more important for successful smoking cessation, and in this case, the advisors were the critical sources of such support, given the difficulties in finding support from friends and family. Ultimately, it is crucial that smoking cessation and associated schemes are clearly communicated to pregnant women, and health professionals, especially given the potential stigma and controversy that might be attached to financial incentives.

References