By Eoin Moloney
The recently published results of a trial from a team in Glasgow, showing that pregnant women are more than twice as likely to give up smoking if given financial incentives, has attracted significant media attention. The use of incentives to change negative health behaviours has always been somewhat of a controversial issue, with terms such as ‘bribery’ and ‘unfair reward’ regularly used by those in opposition to the strategy. However, when that behaviour is impacting not only the individual but also the health of their unborn child, the argument on both sides needs to be somewhat more considered. In light of these results, it seems like an appropriate time to consider the prevalence of smoking during pregnancy, the associated health and economic consequences and whether an incentives scheme is the best way to tackle the issue.
First of all, let’s look at the figures which highlight the gravity of the problem in our own area. The smoking in pregnancy rates are higher in the North East of England than in any other part of the country. Smoking at the Time of Delivery (SATOD) statistics reveal that nearly one in five (19%) women giving birth in the North East are smokers, compared to a national average of one in nine (11%). The contrast becomes even bleaker when we look at the SATOD rates in London (5%) compared to Durham, Darlington and Tees (19.5%).
The socio-demographic characteristics of the respective regions go a long way to explaining this contrast in prevalence. Smoking in pregnancy is known to exhibit a strong social class gradient and a 2002 study by Penn & Owen found that “pregnant women were more likely to smoke if they were less well educated, living in rented accommodation, in unskilled manual or unemployed groups, and single or had a partner who smokes”. The 2013 ‘Smoking cessation in pregnancy: A call to action’ report also states that smoking rates vary greatly by social group, with pregnant women from unskilled occupation groups five times more likely to smoke than professionals. It is likely that factors such as parents behaviours, social environment and economic insecurity all contribute to the increased prevalence of smoking in pregnancy amongst the economically and socially deprived.
Health and Economic Consequences
The health effects of smoking during pregnancy, to both mother and child, are well documented. The Centers for Disease Control and Prevention reports that mothers who smoke are more likely to experience preterm delivery; a leading cause of death, disability and disease among new-borns. Low birth weight and weaker lungs are also common problems seen in babies born to mothers who smoke while pregnant or are exposed to second-hand smoke after birth. Both issues significantly increase the risk of further health problems for the child. The mother is also at an increased risk of experiencing spontaneous abortion and a preterm premature rupture of membranes.
Extensive investigation into the economic consequences of smoking in pregnancy has also been conducted and it is clear that not only are there immediate costs to the smoker, but that a significant economic burden is also imposed upon society as a result. A 2010 study by Eapen et al. ‘estimating the costs to the NHS of smoking in pregnancy for pregnant women and infants’ found that the increased risk to the mother of experiencing a range of health conditions during pregnancy as a result of their behaviour was resulting in costs of between £8-64 million per year to the NHS, based on differing costing methodologies. Similarly, the costs to the NHS associated with conditions faced by the infant (0-12 months) were estimated to be between £12-23.5 million per year.
These costs were only estimated for the year following birth but longer-term costs are also imposed upon society as a result of smoking in pregnancy. A 2005 study by Petrou et al. identified a strong association between smoking during pregnancy and hospital inpatient service utilisation and costs through the first five years of the infant’s life. The health and economic consequences, coupled with the worryingly high prevalence rates, make this an issue worth tackling.
Financial Incentives: Arguments for and against
The primary argument against using financial incentives to dissuade women from smoking in pregnancy is that society should not have to pay women to give up a habit which is so clearly having a negative impact on the health of the individual and unborn child. Rather, the argument goes, avoiding these health consequences and protecting the health of their unborn child should be incentive enough to quit without requiring payment in addition. Others claim that financial incentive interventions may be abused. In the case of smoking cessation in pregnancy, it could be argued that, depending on the structure of the intervention, the individual could potentially quit smoking for the period necessary to claim the ‘reward’ before reverting to previous behaviour.
The main argument in favour of using financial incentives is that they really do appear to work. A 2009 Cochrane review of interventions for promoting smoking cessation during pregnancy found that the most effective intervention was the provision of incentives, helping approximately 24% of women to quit smoking during pregnancy. In addition to the use of incentives, multiple interventions for promoting smoking cessation during pregnancy have been tested and include cognitive behaviour and motivational interviewing, nicotine replacement therapy and care pathway adaptation. However, on a consistent basis, the cessation rates produced by these interventions are lower than when financial incentives are offered.
The arguments against are legitimate but, in my opinion, they fail on the basis that for a large number of people (and the SATOD figures seem to confirm this) the health consequences clearly are not enough of a deterrent. Ironically, the success of financial incentive schemes in increasing smoking cessation rates tends to irritate those in opposition to the strategy even further as the implication is that quitting is indeed a choice that the woman can make when sufficiently incentivised. However, the attitude of blaming the expectant mother does not benefit anyone. Rather, the emphasis should be placed on protecting the health of the mother and child in the short-term and, from an economic perspective, making cost savings in the medium to long-term. Regardless of the perceived drawbacks and potential for exploitation, if financial incentives can achieve this then they are worth considering. Smoking in pregnancy is a significant public health concern and cessation interventions should be tailored to target those at the highest risk of smoking. As a final point, it is worth noting that, whilst the results of trials have looked promising, additional work on the cost-effectiveness of such interventions will need to be conducted, particularly in a UK setting.