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 percent) and improvements in birth outcomes often modest or absent. Current treatments usually entail relatively brief, low-cost interventions (e.g. pregnancy-specific quit lines). There is broad consensus that more effective interventions are sorely needed. We have developed a novel behavioral-economic intervention in which women earn financial incentives contingent on smoking abstinence. In a meta-analysis 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, we are proposing a randomized, controlled clinical trial comparing the efficacy and cost effectiveness throuh one-year postpartum of current best practices for smoking-cessation during pregnancy vs. best practices plus financial incentives among 230 pregnant, Medicaid recipients. We will also include a third condition of 115 pregnant non-smokers matched to the smokers on socio-demographic and health conditions 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. We hypothesize that best practices plus financial incentives will be more effective than best 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.

Public Health Relevance

We will examine whether adding financial incentives to current best practices for smoking cessation during pregnancy (i.e., counseling using a telephone quit-line) increases cessation rates and improves infant health. While more expensive upfront, this treatment approach may be economically justified by the later cost savings associated with more women quitting, having healthier babies, and needing less healthcare. It should also help to reduce the greater risk for health problems often seen among those who less well off economically.

National Institute of Health (NIH)
Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD)
Research Project (R01)
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Health Disparities and Equity Promotion Study Section (HDEP)
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King, Rosalind B
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University of Vermont & St Agric College
Schools of Medicine
United States
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Higgins, Stephen T; Reed, Derek D; Redner, Ryan et al. (2016) Simulating demand for cigarettes among pregnant women: A Low-Risk method for studying vulnerable populations. J Exp Anal Behav :
Bickel, Warren K; Moody, Lara; Higgins, Stephen T (2016) Some current dimensions of the behavioral economics of health-related behavior change. Prev Med 92:16-23
Higgins, Stephen T; Solomon, Laura J (2016) Some Recent Developments on Financial Incentives for Smoking Cessation Among Pregnant and Newly Postpartum Women. Curr Addict Rep 3:9-18
Chivers, Laura L; Hand, Dennis J; Priest, Jeff S et al. (2016) E-cigarette use among women of reproductive age: Impulsivity, cigarette smoking status, and other risk factors. Prev Med 92:126-134
Kurti, Allison N; Davis, Danielle R; Skelly, Joan M et al. (2016) Comparison of nicotine dependence indicators in predicting quitting among pregnant smokers. Exp Clin Psychopharmacol 24:12-7
Kurti, Allison N; Davis, Danielle R; Redner, Ryan et al. (2016) A Review of the Literature on Remote Monitoring Technology in Incentive-Based Interventions for Health-Related Behavior Change. Transl Issues Psychol Sci 2:128-152
Clark, Eric M; Jones, Chris A; Williams, Jake Ryland et al. (2016) Vaporous Marketing: Uncovering Pervasive Electronic Cigarette Advertisements on Twitter. PLoS One 11:e0157304
White, Thomas J; Redner, Ryan; Skelly, Joan M et al. (2015) Examination of a recommended algorithm for eliminating nonsystematic delay discounting response sets. Drug Alcohol Depend 154:300-3
Higgins, Stephen T (2015) Borrowing from tobacco control to curtail the overweight and obesity epidemic: Leveraging the U.S. Surgeon General's Report. Prev Med 80:47-9
Higgins, Stephen T (2015) Editorial: 2nd Special Issue on behavior change, health, and health disparities. Prev Med 80:1-4

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