A £400 bribe to stop smoking during pregnancy. Whatever next?

Earlier on this week I was involved in a number of good-natured twitter exchanges about the efficacy of financial incentives for smoking cessation in pregnancy (*), or as the Daily Mail rather more sensationally put it, the payment of £400 bribes to help pregnant women stop smoking.

Most of these exchanges centred on the argument that if anyone needed any extra incentive to give up smoking while pregnant, then the woman concerned wasn’t fit to have a child in the first place.

Well quite. But the evidence suggests that pregnancy alone doesn’t appear to be enough motivation to quit in and of itself for a significant minority, with 12% of women in the UK smoking during pregnancy according to a different study undertaken in 2010(+). Leaving aside the health of the mother for the moment, the authors of this study reiterate prior research demonstrating that in the UK:

  • 5,000 miscarriages every year are due to smoking during pregnancy
  • 180 stillbirths are due to smoking due to smoking during pregnancy
  • 113 infant deaths are due to smoking during pregnancy
  • 1/3rd of excess stillbirths in deprived areas are due to smoking during pregnancy

That all adds up to an incredibly depressing amount of additional human suffering and misery, due to a dangerous habit taken up because of personal stupidity / peer pressure / the billions spent by cigarette manufacturers to persuade us to smoke (delete according to your own political biases).

So because the unborn child has no say over the choices their mother makes, I think that it’s a good idea – no – it’s an excellent idea – for research to be carried out into how to further reduce smoking during pregnancy, above and beyond what decades of public health education, taxation and the gradual de-normalisation of smoking has so far managed to achieve.

And that’s precisely what the lurid ‘bribe’ headlines miss – this was a well run, randomised controlled trial (the most rigorous way of determining whether a cause-effect relation exists between treatment and outcome and for assessing the cost effectiveness of a treatment) across a representative sample of 612 volunteers – with 306 of those receiving the incentive. It wasn’t a cash incentive (it was provided as shopping vouchers, presumably by a retailer eager to market their wares with the aim of securing longer-term business) and neither was it given to the participants up-front (so, whatever the payment is, it is definitely not a bribe). The vouchers were earned through the participants demonstrating (though a number of scientific, objective tests) that they had actually managed to stop smoking.

The result of this trial was that 69 (22.5%) of the smokers offered incentives managed to stop smoking, whereas only 26 (8.6%) of those not offered the incentive managed to do so. My own (admittedly crude) extrapolation of that data onto the miscarriage, stillbirth and infant death statistics suggests to me that an additional 13.9% of these could therefore be prevented if it was turned into a national programme – allowing a further 735 unique, precious human beings to experience what it is to live.

And I haven’t even taken account of the positive impact on the mother here too. Nor on the NHS and the taxpayer in general. The study notes that the additional costs of treatment (for mother and child) that the NHS has to fund every year due to smoking during pregnancy is between £20m – £88m, depending on how you count it.

Now, of course there are ethical considerations. The study points these out. We should never be in the business of rewarding bad behaviour that is solely the choice of the individual concerned. However, the behaviour being rewarded is demonstrably a good one – giving up smoking. And in addition to that, I genuinely don’t believe that the ‘choice’ to start smoking is solely down to our own personal agency. Societal conditions (remember peer pressure and the £billions spent by tobacco companies on ensuring cigarettes are available) also play a part in the decision to start.

But if you’re still wavering, consider these facts:

  • No harms were reported, and the incentives offered were acceptable to the participants and healthcare professionals.
  • The longer term cost of the programme per life year gained was £482. The NHS (in general) operates on the basis that a treatment costing £20,000 per life year gained is a cost-effective intervention.
  • Existing interventions aimed at encouraging pregnant women to stop smoking during pregnancy are not highly effective.

So if we believe in basing public policy on evidence based research (and I do), then for me the conclusions of this study and its call for further research to be undertaken must be acted upon, regardless of what the yellow press believes.

 

(*) The report mentioned is published by the British Medical Journal and is free to read. It’s just twelve pages long and well-written.

(+) Health and Social Care Information Centre, Infant feeding survey 2010. Encouragingly, the numbers of UK women smoking during pregnancy have dropped from 17% in 2005 to 12% in 2010, without “the bribe”.

 

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