To get pregnant smokers to quit, money talks

Cash has been shown to be an effective incentive for French pregnant women to quit smoking during gestation, according to a randomized trial.

Quit rates doubled in a group rewarded with money for confirmed abstinence, compared to a control group who received payments for showing up for clinic visits but not for quitting smoking real (16% vs. 7%; OR 2.45, 95% CI 1.34-4.49), reported Ivan Berlin, MD, PhD, of the Pitié-Salpêtrière-Sorbonne University in Paris, and his colleagues.

The group paying for abstinence could receive up to € 520 (~ $ 600); the maximum payout for control participants was € 120 (~ $ 140), the group explained in BMJ.

Other factors related to the strength of participants’ smoking habits were also reduced in the group paid to maintain abstinence. These included the time elapsed before resuming smoking and participants’ ratings of their urge to smoke.

Perhaps more importantly, the financial incentives appeared to benefit participants’ babies, with a lower risk of poor neonatal outcomes (2% in the intervention group vs. 9% in controls, P= 0.003).

A support BMJ An editorial by three Dutch and UK researchers applauded the study, saying it “adds to growing evidence that now is the time to start including incentives as part of standard practice to support smoking cessation during pregnancy.” .

How this might work in the United States is another question. Besides parents and infants, the main beneficiaries of improved maternal and newborn health are their health care payers, that is, private and public insurers. In theory, they could reduce or waive premiums for pregnant smokers. It is unclear whether this would serve as well as direct cash payments, which would represent an entirely new model for insurers.

Called FISCP, the trial randomized 460 pregnant smokers 1: 1 in each of the two arms. Participants reported smoking at least five regular cigarettes per day (or three that they rolled themselves) and were less than 18 weeks gestation. All received € 20 vouchers for each monthly clinic visit, with six scheduled. The intervention group received additional vouchers both for demonstrating abstinence at each visit (via self-report and expired carbon monoxide testing) and also for maintaining it over time. These additional vouchers were up to € 400 (~ $ 460) for participants whose abstinence was confirmed throughout the trial.

In a given clinic visit, abstinence at this stage ranged from 25% to 40% over the five follow-up visits with financial incentives, compared to about 12% to 21% among controls. The midpoint at which abstinence was lost was visit 5 in the intervention group, versus visit 4 for the controls.

A total of 451 live births were registered in the trial. Four in the intervention group and 18 in the control group had poor neonatal outcomes, defined as a composite of neonatal intensive care referral, birth defect, seizure, or perinatal death.

Additionally, a post-hoc analysis (i.e. not included in the original protocol) found that fewer babies in the intervention group had low birth weight, with an odds ratio for a weight ≥ 2,500 g of 1.95 (95% CI 0.99-3.85). On the other hand, the mean birth weight was only 50 g less in the control group, which did not approach statistical significance. Berlin and colleagues explained the gap by suggesting that “the effect of financial incentives on birth weight may not be linear.”

The editorial writers, led by Leonieke J. Breunis, MD, of the Rotterdam University Medical Center in the Netherlands, did not seem bothered by the low rate of total abstinence or the questionable difference in infant birth weights. They felt, however, that more research was needed to answer outstanding questions, such as’ what is the optimal incentive program (i.e. timing, frequency, value, duration and type of incentive)? Who should offer this program? How? ‘Or’ What ? Could personalized incentives be more effective than a one-size-fits-all approach? Would the involvement of an important person (such as a partner) in the intervention increase the effectiveness? “

But providing financial incentives shouldn’t wait for answers to these questions, the group suggested. On the contrary, “we argue that implementation should be continued alongside ongoing and future research,” wrote Breunis and his colleagues.

  • John Gever was editor-in-chief from 2014 to 2021; he is now a regular contributor.


The study was funded by the French government.

The study’s authors and columnists said they have no relevant relationship with any business entity.

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