This cigarette-package warning label is short, thoughtful, and completely backed by science.


Unfortunately, many Canadian women – statistically, 1 in 10 – ignore it and so much other health information, continuing to smoke when pregnant.

What can be done?

Corporate boards give CEOs bonuses when their companies are profitable. Governments (like Canada’s) award athletes with money when they win Olympic medals. Universities give scholarships for academic achievements. So, should we give financial incentives to pregnant women who stop smoking? A recently published British Medical Journal paper suggests that we should. And this controversial paper is the Reading of the Week.

On Smoking

Since the Surgeon General of the United States issued the Report on Smoking and Health in 1964, smoking rates in the U.S. – and across the west – have dropped sharply. Canada has seen the same general decline: from half the population in 1965 to about 15% today. (!)


This incredible public-policy success story can’t be pinned on a single event or government action: tax increases, public education campaigns, and regulations have all worked, and worked well. That said, the Surgeon General’s report is worth particular note, since it laid to waste the claim that smoking wasn’t harmful – a position advocated by the tobacco industry and (embarrassingly) a host of health-care professionals.

But if the war on tobacco has been a great success overall, it’s important to recognize its ongoing battles. In some segments of the population, particularly among the poor and the mentally ill, tobacco use remains high. As noted before, about 1 in 10 Canadian women smoke during their pregnancy. There is incredible variation, though, across the country. Consider Ontario. Here in Toronto, we are slightly better than the average (1 in 9); in contrast, in North-Eastern Ontario, the smoking rate is more than triple that (about 35%).

On the Reading

This week’s Reading is about targeting a population with a high smoking rate. “Financial incentives for smoking cessation in pregnancy: randomised controlled trial” by Tappin et al. was just published in the British Medical Journal.

Speaking to high rates of tobacco use in some populations: in Scotland, Tappin et al. note that 24% of pregnant women self-report that they smoke. (!)

Drawing on the literature on tobacco and pregnancy, Tappin et al. argue that of the 125,000 miscarriages in the United Kingdom every year, a full 25,000 are due to smoking pregnant women. Tobacco also claims young lives, killing approximately 113 infants. And the damage isn’t just in more deaths but more illness. The cost of smoking and pregnancy:

The total annual cost to the UK National Health Service of smoking during pregnancy is estimated to range between £8.1m and £64m [$15.2m and $120.3m] for treating the resulting problems in mothers, and between £12m and £23.5m in infants [$22.6m and $44.2m]…

Tappin et al. also make another good argument for targeting pregnant smokers. The vast majority of women in Scotland have at least one baby (some 70%). Thus by pushing smoking cessation with this group, they could potentially reach many in the general population.

So the researchers ask a simple question: can we pay women to stop smoking?

Here’s what they did:

· 609 pregnant smokers from Scotland were enrolled in this study.

· Some women were randomly assigned to the routine smoking cessation group – the control group.

· Others were offered bonuses of up to £400 (about $750) in shopping vouchers if they quit smoking – the incentives group.

· The bonuses were all shopping vouchers, and spread out over time depending on how a woman did: a £50 voucher for attending an initial meeting and setting a quit date; another £50 voucher if they were smoke free a month later; £100 pound voucher at 12 weeks; finally, at the end of their pregnancy, a £200 voucher for being tobacco free.

· Smoking cessation included nicotine replacement therapy (10 weeks) and weekly support calls.

· Non-smoking status was confirmed with saliva or urine samples.

Here’s what the study authors found:

· More women quit smoking in the incentives group (22.5%) than the control group (8.6%).

· 12 months after quit date, the women who participated in the incentive were doing better (15% incentives vs. 4% control).

· Babies in the intervention group weighed more (3140 g vs 3120 g).

They conclude:

This trial indicates that financial incentives can motivate pregnant smokers to quit. Significantly more smokers offered incentives stopped smoking (22.5%) than controls (8.6%). This study is the largest so far undertaken to test financial incentives to help pregnant women stop smoking.

Breaking these numbers down: the authors find a number needed to treat of about 7 – or, in other words, the intervention needs to be tried on 7 women to get a positive result, that is, smoking cessation. (!!)

This study raises a larger question: is paying for smoking cessation ethical?

Needless to say, the study is controversial. Some, including ethicists and taxpayer groups, have challenged the use of “bribery” (to use their term). You can draw your own conclusions but it should be noted that no woman was punished for continuing to smoke. Rather, study participants were offered an incentive to participate in a cessation program, and offered more incentives to stop smoking and to abstain from smoking.

Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.

Financial incentives.pdf