Learning from 25 years of preventative interventions in Scotland

8. Financial Incentives for Smoking Cessation in Pregnancy

Smoking cessation in pregnancy: financial incentives

In 2007 Scotland was the first part of the UK to establish a financial incentive scheme for smoking cessation in pregnancy. A programme of research found that adding financial incentives to existing cessation services is effective and cost-effective, providing the basis for a change in NICE guidance, ongoing delivery in two NHS Boards in Scotland and a national incentive scheme in England.

Introduction

Smoking cessation in pregnancy programmes involve providing shopping vouchers to mothers at key points in their attempt to quit, combined with support from smoking cessation services. Research initiated in Scotland and subsequently led by researchers based in Scotland has demonstrated that financial incentives are an example of highly effective and cost-effective secondary prevention.

Context

Smoking during pregnancy harms mothers and babies. It is a leading preventable cause of premature birth, miscarriage and sudden infant death syndrome.^[179] Low birth weight is associated with a range of developmental problems in childhood and adult health conditions including type II diabetes and coronary heart disease.^[180] Most women who smoke and become pregnant are highly motivated to quit and aware of the potential health harms to them and their baby but find it difficult to do so. As smoking rates have declined, tobacco use has become increasingly concentrated in the most deprived groups who face multiple barriers to cessation. Around the time that incentives were first introduced in Scotland, smoking rates at the first maternity booking appointment varied from 5.8% in the least deprived communities to 29.4% in the most deprived.^[181] While smoking prevalence has declined overall since then, these inequalities remain – in the latest data (2023) rates were 2.4% compared with 20.4%.^[182]

Behavioural support (counselling) for smoking cessation is effective in pregnancy and there is some evidence on the effectiveness of nicotine replacement therapy (NRT). These are offered in combination by smoking cessation services in Scotland but reach and success rates can be low. Adding modest financial incentives to stop smoking support was first trialled in the USA in the late 1990s with promising evidence that it increased uptake of support and resulted in more women quitting.^[183] This prevents harms during pregnancy and after birth, and if the mother remains smokefree, avoids longer term morbidity and premature mortality due to smoking.

Response

NHS Tayside was the first part of the UK to launch a financial incentive scheme ‘Give it up for Baby’^[184] (GIUFB) as part of their stop smoking service for pregnant women. This was motivated by low uptake of cessation services by pregnant women in that NHS Board area at the time. A local consultant pharmacist in public health had reviewed evidence from the USA on incentives and considered this a worthwhile avenue for exploration. He worked with others to develop a programme targeted particularly at pregnant women living in deprived communities that was based on social marketing techniques.^[185] This approach involved engaging with a range of stakeholders including community development groups, the NHS and local authority. It led to a programme called ‘Give it Up for Baby’ (GIUFB).

Intervention

GIUFB was promoted in a wide range of settings including ante-natal clinics, general practices and in community settings (beyond the NHS) as well via local newspapers. All pregnant women who smoked were invited to register at a local pharmacy. Women who joined needed to set a quit date to stop smoking following a brief intervention (advice on the risk of smoking and the benefits of quitting, particularly with support) and then attended weekly sessions (for up to 12 weeks) with a member of the local pharmacy team trained in smoking cessation. Pharmacy staff provided behavioural support and NRT, in line with NHS Tayside’s pharmacy based smoking cessation services. At each visit post quit date, women were asked to take a carbon monoxide (CO) breath test which provides evidence of smoking status. If their CO reading was below the cut off for active smoking, the pharmacist sent the results to an administrative officer in NHS Tayside, who provided a supermarket voucher that could be topped up to the value of £12.50 each week. The voucher was redeemable in two major supermarket chains and could be used to purchase goods excluding tobacco and alcohol. Women who were still smokefree at 12 weeks could continue to claim a monthly incentive up to 12 weeks after the birth if they provided further CO breath tests at their local pharmacy.

Following the establishment of the NHS Tayside programme, academics collaborated with the pharmacist who had set up the programme to explore the expansion of an incentive scheme to another health board area – NHS Greater Glasgow and Clyde (NHSGGC). This involved a programme of research starting with feasibility work, followed by two large randomised controlled trials.

The intervention for the trials was like GIUFB but adapted to be feasible for different configurations of smoking cessation services. This was important given NHS Tayside’s model was pharmacy led. Further evidence needed to be generated from other service models including in general practices, maternity units and via telephone. The same combination of behavioural support and NRT was offered with biochemical validation in pharmacies or other health care settings via a CO breath test with the addition of providing a urine sample sent to the research team at the end of pregnancy. The incentive amount and form of voucher was also modified based on feasibility work, to embed the administration of the voucher within the research team (via a procurement partner) rather than add this to the workload of health board staff.

Women involved in the trials were provided with Love to Shop vouchers (redeemable at a range of retailers) worth £50 for setting a quit date, £50 if they had stopped smoking at four weeks, £100 if still smokefree at 12 weeks and £200 at the end of pregnancy. At each point they needed to provide a CO breath test with a reading below the cut off for smoking to receive the vouchers, and at the end of pregnancy (34-38 weeks gestation), also provide a urine sample to test for cotinine, a nicotine metabolite.

Monitoring and Evaluation

The evaluation of GIUFB involved a mixed methods study^[186] with two main elements. The first was analysis of routine monitoring data from March 2007 to December 2009, with the second comprising a process evaluation. The monitoring data included the Scottish National Smoking Cessation Dataset; weekly and periodic carbon monoxide (CO) breath tests; smoking cessation quit attempts; and the number of vouchers paid. The process evaluation involved 20 service users identified from client databases as well as six local pharmacists responsible for supporting the scheme.

The subsequent research in Greater Glasgow and Clyde began with a feasibility study involving qualitative interviews with pregnant women and health professionals which was funded by the Glasgow Centre for Population Health (GCPH).^[187] A phase II (pilot) trial then followed which was funded by the Chief Scientist’s Office, GCPH and endowments from NHSGGC and the Yorkhill Children’s Charity.^[188] The subsequent multi-centre phase 3 (definitive) trial^[189] was conducted in NHS Lanarkshire and six other sites in England and Northern Ireland and funded by Cancer Research UK, the Chief Scientist’s Office, the public health agency in Northern Ireland and several small charities. Both the pilot and multi-centre trial included economic evaluations.

Key Findings

a) Improved outcomes

In the GIUFB evaluation covering the period 2007-2009⁷, quit rates (validated by CO breath test) for those registering were 54% at four weeks, 32% at 12 weeks and 17% at three months post-partum. A comparison group was not established which was a limitation, but unavoidable as GIUFB resulted from service development rather than a research programme. However, the Tayside evaluation had a national audit from 2006 to compare their results to. This found that only a small proportion (13%) of women identified as smoking at maternity booking in Scotland engaged with services and 3.9% quit by four weeks, compared with 20% and 7.8% in the three areas in Tayside where GIUFB was in place.^[190],7

The process evaluation for GIUFB used the findings from interviews with participants to develop a service user typology to provide insights into why some women benefitted more from the scheme than others. The most deprived women who engaged with the scheme valued the incentives but still found it difficult to quit due to very challenging life circumstances. Those who were successful, including among these more deprived groups described the incentives as supporting engagement with the service and continuing to use it. They also noted that other aspects of the scheme were equally important including supportive relationships established with the pharmacist delivering the programme as well as regular CO breath tests. This combination of the incentive with smoking cessation service support – rather than incentives alone, is something noted in local evaluations of similar subsequent schemes in England, for example.^[191]

For the pilot trial in Greater Glasgow and Clyde,⁹ 612 pregnant women who smoked were recruited and randomised to the offer of ‘routine care’ (NRT obtained via a local pharmacy and behavioural support delivered by telephone) or the ‘intervention’ which involved adding incentives (using the timing and amounts described) above to routine care. The primary outcome for the trial was cessation at the end of pregnancy, with results adjusted for age, smoking years, SIMD, and cigarette dependence (Fagerstrom) score, all factors that can influence cessation outcomes. More than twice as many women quit smoking by the end of pregnancy (RR 2.63) in the intervention compared to the control group (22.5% vs 8.6%). This study had limitations as it was conducted in a single site, albeit involving a large number of participants. A more definitive trial was needed covering several locations.

The multi-centre trial¹⁰ therefore followed, and had the same design, intervention and analysis approach as in the pilot trial but was conducted in seven different stop smoking service operating in a range of settings (primary care, pharmacy, maternity services) in Scotland, Wales and Northern Ireland. As in the pilot trial, more than twice as many women quit smoking by the end of pregnancy (RR 2.78) – 27% in the intervention group compared to 12% in the control group.

Taken together, these two trials provided strong evidence that adding incentives of up to £400 to the offer of stop smoking service support more than doubles quit rates – contributing to improved health and wellbeing outcomes for babies and mothers.

b) Cost savings

The economic evaluations embedded in each of the trials found that incentives were cost-effective. Both involved a cost-utility analysis using a life-time Markov model, which is an approach that compares the costs and effects of different interventions by measuring health outcomes in terms of quality and quantity.

For the pilot trial, the economic analysis^[192] found that the incremental cost effectiveness ratio (ICER – which highlights the difference in costs divided by the difference in outcomes) per quitter at the end of pregnancy was £1127. When analysed over a lifetime the ICER was £482 per Quality Adjusted Life Year (QALY). This is well below recommended thresholds for cost-effective healthcare interventions. In the multi-centre trial, the findings^[193] were similar although the ICER was higher in part due to the inclusion of neonatal costs in this larger trial. However, as in the pilot, the life-time analysis findings were that incentives were cost-saving and that financial incentives were highly cost-effective.

c) Addressing inequalities

Smoking in pregnancy is highly concentrated in more deprived communities. This is reflected in the baseline study characteristics from both the pilot and multi-centre trials. In the first trial, 65% of the control group and 67% of the intervention group lived in communities in SIMD 1 (among the 20% most deprived areas in Scotland) compared to just 2.6% and 3.6% respectively who lived in SIMD 5. In the second trial (which used the Index of Multiple Deprivation to cover the UK) 42.2% of women in the control group and 43% of those in the intervention group lived in IMD 1 (most deprived) and just 2.9% and 3.2% respectively in IMD 5 (least deprived). In both trials, the largest group after SIMD 1/IMD 1 were living in SIMD 2/IMD 2. The analysis in both trials controlled for SIMD/IMD. It found no significant differences, suggesting incentives for smoking cessation during pregnancy are effective even for women living in the least affluent communities.

Learning and Next Steps

GIUFB is still in place in NHS Tayside. NHS Greater Glasgow and Clyde also provide incentives as part of their smoking cessation service for pregnant women and were involved in a recent study^[194] that assessed the roll out after completion of the trial there. This found that financial incentives were successfully integrated into local smoking cessation services. It also found when comparing outcomes before and after the roll out, that incentives had increased routinely monitored quit rates among pregnant women using the services. Further roll out in Scotland to other health board areas has not occurred to date, but the wider applicability of this type of preventative intervention has been explored for other public health issues. This includes in a recent positive trial of incentives combined with behavioural support for weight loss among men living in more disadvantaged communities in Glasgow (as well as Bristol and Belfast).^[195]

The studies of incentive schemes for smoking cessation in pregnancy that began in Scotland influenced policy in England and informed an international evidence-base. These trials were included in Cochrane reviews^[196],[197] (international gold standard reviews for guiding health care and health policy) which found incentives to be the most effective of all interventions for smoking cessation in pregnancy. The studies also directly resulted in a change in NICE guidance in 2021 to recommend that providers of stop smoking support offer voucher incentives to support women to quit during pregnancy in addition to NRT and behavioural support.^[198],11

This change in NICE guidance, along with several areas in England initiating incentive schemes as well as further studies (that involved the members of the Scottish research team and others) to evaluate incentives schemes in Greater Manchester,^[199],[200] led to a national programme in England that was announced in November 2023.^[201] This is currently being rolled out^[202] and any organisation providing stop smoking support to pregnant women in England can join the scheme.