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How Financial Incentives Could Help Pregnant Women To Stop Smoking

A researcher who showed that financial incentives could push cocaine users to stay clean is trying out the same method on pregnant women who can't stop smoking.

Stephen Higgins, Ph.D., a psychiatry professor at the University of Vermont and director at the Vermont Center on Behavior and Health, was the first to experiment in the late 1980s with giving cocaine users a retail voucher every time their urine sample tested negative for cocaine. Now, in a study published online this month in the journal Preventive Medicine, Higgins demonstrates that vouchers in escalating amounts for pregnant smokers more than doubled smoking abstinence rates during pregnancy and were associated with better fetal growth.

"Obstetricians are just pulling their hair out over what to do with this problem" of maternal smoking, Higgins told The Huffington Post. "Almost everybody knows that you shouldn't be smoking while pregnant, yet these women kept smoking."

The children of women who smoke while pregnant face higher risks of premature birth, low birth weight, cleft palate, asthma and sudden infant death syndrome, just to name a few.

Higgins' study involved 118 pregnant smokers from Burlington, Vt. He divided them into three groups. The first received vouchers no matter what they did. The second group received vouchers in escalating amounts if they continued to refrain from smoking, which was verified with breath and urine tests. The third group were also financially rewarded for refraining from smoking, but they received the largest voucher amounts early on -- the theory being that quitting smoking earlier has the biggest payoff for the fetus and is also the most likely predictor for abstinence over the duration of the pregnancy.

The study showed that both of the groups who were given incentives to quit smoking were more than twice as successful at quitting as the control group who received vouchers no matter what.

Ultrasound tests conducted throughout the pregnancies also found that babies born to the group who received escalating incentives (starting at $6.25) grew more than babies born to the control group. However, babies born to the women who had received the largest voucher amount upfront ($296.25) showed no difference in growth rates from babies born to the control group.

In total, a study participant had the potential to earn $1,180 over the course of her pregnancy. On average, participants in both groups given incentives earned $450 each. By comparison, the Centers for Disease Control and Prevention estimates that neonatal health care costs linked to maternal smoking in the U.S. cost about $366 million per year, or $740 per pregnant smoker. The financial argument seems like it could be a compelling one for federal and state health care plans that often subsidize the health care costs of women most likely to continue smoking during pregnancy: young, unwed, socioeconomically disadvantaged and more likely to have only a high school education or less.

"One of the implications of my study is, why don't we think about using that money for this kind of incentive approach to keep the women from smoking and to keep the babies from in utero smoke exposure," said Higgins.

Some states are experimenting with it now. In 2013, Wisconsin smokers who wanted to quit during pregnancy may have been eligible for a state study that offered them cash to quit. This year Oregon launched a similar program. Both states cited a desire to cut down on the rates of premature and underweight births.

The participants in Higgins' study were all white women from a rural area, so more research needs to be done to test the effectiveness of anti-smoking incentives in other parts of the U.S. But based on his experiments with cocaine abstinence incentives, Higgins predicts that further studies would verify, not complicate, his findings.

"The early cocaine studies were done in Vermont with an exclusively Caucasian population, and then similar studies were done in Baltimore and Los Angeles, primarily with African-American populations," explained Higgins. "We got the same results."

More than half of female smokers (54 percent) quit smoking cigarettes when they find out they are pregnant, according to 2010 CDC data from 27 states. But that means the rest of them, almost 11 percent of all pregnant women, reported smoking cigarettes during the last three months of pregnancy.

According to Higgins, the most effective way to "lure" these pregnant smokers into abstinence is by offering larger financial incentives.

"How much matters a lot," he said. "When you do incentive programs, you've got to offer a meaningful amount or you don't get a response. And you usually get a better response with still larger amounts."

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