Financial Incentives for Smoking Cessation Among Disadvantaged Pregnant Women

Smoking during pregnancy is the leading preventable cause of poor pregnancy outcomes in the
U.S. Most pregnant smokers continue smoking through pregnancy producing serious immediate and
longer-term adverse health consequences for the infant. Smoking during pregnancy is highly
associated with economic disadvantage and a substantive contributor to health disparities.

Efficacious interventions are available, but cessation rates are low (<20%) and improvements
in birth outcomes often modest or absent. Current treatments usually entail relatively brief,
lower-cost interventions (e.g., pregnancy specific quit lines). There is broad consensus that
more effective interventions are sorely needed. This team of investigators has developed a
novel behavioral economic intervention in which women earn financial incentives contingent on
smoking abstinence. In a metaanalysis of treatments for smoking during pregnancy, effect
sizes achieved with financial incentives were several fold larger than those achieved with
lower intensity approaches or medications. The intervention also appears to improve birth
outcomes and increase breastfeeding duration. While highly promising, further research is
needed in at least three areas. (1) The evidence on birth outcomes and breastfeeding is from
studies that combined data across trials rather than a single prospective trial, (2) whether
the intervention produces other postpartum improvements in health has not been investigated,
and (3) the overall cost-effectiveness of this approach has not been examined.

To examine these unanswered questions, the investigators are proposing a randomized,
controlled clinical trial comparing the efficacy and cost effectiveness through one year
postpartum of current best practices for smoking cessation during pregnancy vs. best
practices plus financial incentives among 230 pregnant, Medicaid recipients. A third
condition of 115 pregnant nonsmokers matched to the smokers on sociodemographic and health
conditions will be included as well to compare the extent to which the treatments reduce the
burden of smoking and to estimate how much more might be accomplished by further improvements
in this incentives intervention without exceeding cost-effectiveness.

The investigators hypothesize that best practices plus financial incentives will be more
effective than usual care practices alone, that the incentives intervention will be cost
effective, and that while adding the incentives reduces a greater proportion of the health
and economic burden of smoking than best practices alone, more can be done while remaining
cost effective.

Overall, the proposed study has the potential to substantially advance knowledge on
cost-effective smoking cessation for pregnant women. Importantly, because of the strong
association between smoking during pregnancy and economic disadvantage, the proposed study
also has the potential to contribute new knowledge relevant to reducing the serious
challenges of health disparities.

Inclusion Criteria for two intervention arms:

- report being smokers at the time that they learned of the current pregnancy;

- report smoking in the 7 days prior to the first prenatal care visit with biochemical
verification;

- < 25 weeks gestation;

- English speaking;

- plan on remaining in the geographical area through 12months postpartum.

Inclusion Criteria for never-smoker comparison condition:

- report being nonsmokers at the time they learned of the current pregnancy;

- report no smoking in the past 6 month;

- Biochemical verification of non-smoker status;

- report smoking < 100 cigarettes in their lifetime;

Exclusion criteria:

- > 25 weeks gestation;

- unavailable for routine assessments through 1 year postpartum;

- opioid substitution therapy;

- untreated/unstable serious mental illness