Can Financial Incentives Help Pregnant Patients Quit Smoking?

InpharmD™ Clinical Literature Summaries — S3E7

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On behalf of all of us here at InpharmD, whether you’re listening to this from your home or on the front lines, we hope you’re well and we thank you for the important work you’re doing.

With this podcast, we recap innovative, practice changing studies in ten minutes or less. And remember, nothing here is medical advice; we just present the evidence and our (sometimes hot) takes.

Do Financial Incentives Help Pregnant Patients Quit Smoking?

Show me the money! That’s what our study participants this week have been saying. We’re going to find out if giving cold hard cash to pregnant women can help them quit smoking.

To answer this question, researchers in France took just under 500 pregnant women who 18 years were at least old and randomized them to a financial incentives group or control group.

All women smoked at least 5 classic cigarettes or 3 roll your own cigarettes per day, were under 18 weeks’ gestation, and displayed a motivation to quit smoking. Women already on a smoking cessation medication or being treated for a psychiatric disorder were excluded.

So, here’s how the trial worked: Everybody was given a $23 voucher as a show up fee for visits regardless of which group they were in. Both groups received motivational counseling as well. But here’s where things get interesting. The financial incentives group could earn additional vouchers dependent on abstinence from smoking. They could get vouchers for each visit they were abstinent AND vouchers got larger as they stayed continuously abstinent for longer. Of course, all this was confirmed with drug tests to ensure patient reported abstinence was accurate. Let’s also note that nicotine replacement was allowed, but electronic cigarettes were not.

The primary outcome was continuous abstinence from patient chosen quit date until the last follow up visit 6 months later. The researchers found that 16% of patients in the financial incentives group, compared to only 7% in the control group stayed abstinent. This was a statistically significant difference.

Some of the secondary outcomes were interesting as well. The financial incentives group had a significantly longer time to relapse by about a month, less craving for tobacco and higher rate of abstinence at any point in time. What’s really perked our ears up though was a 7% reduction in risk of poor neonatal outcomes in the financial incentives group. This was a statistically significant number as well.

It’s interesting because it raises the question of how best to approach smoking cessation. There are various schools of thought. Some say to just go cold turkey and stop, others may advocate for pharmacologic options. But what about cold hard cash?

Clearly, we’ve got evidence that this method can work. Sure, this study isn’t perfect. It’s mostly made up of low-income individuals, but these are the people who might benefit most from a financial incentive to quit smoking. The other point to consider here is what happens when the incentive is gone? This study only measured continuous abstinence for 6 months, so it’d be interesting to know the rates of relapse after all the dust settles with the new baby.

It’s probably unrealistic to continuously pay people to stay abstinent from smoking, but pregnancy is a perfect setting for this approach to be studied and implemented. It’s a defined time period where smoking cessation is good for both the mother and the fetus. Implementing this type of an approach for pregnant women has the potential to improve fetal outcomes. Culture and population are crucial to success though. This study was done in France, but would it work in America?

One way to find out would be to put this approach up head-to-head against one of the more traditional approaches like bupropion. Once data like that has been obtained, a cost effectiveness analysis could help inform us if this approach could save the healthcare system money in the long run.

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