Incentivising Smokefree Pregnancy: Rewarding Women to Stop Smoking throughout pregnancy and beyond Andrea Crossfield Public Health Consultant Tobacco Strategic Lead – GMHSC Partnership

Every baby born smokefree in GM? Smoking single biggest modifiable risk factor for poor birth outcomes and infant death in GM with 13% of mums smoking at delivery  The GM Making Smoking History Strategy commits to reducing smoking at delivery to 6% by 2021 with an aspiration to work towards every baby to be born smokefree Wider targets include 13% smoking rate by 2021 (from 18.6%) GM-wide smokefree pregnancy pathway supported through universal implementation of babyClear; an evidenced based approach to systematise and embed change to reduce smoking in pregnancy + targeted support for vulnerable women at high risk of relapse to smoking via an evidenced- based incentive scheme programme This will positively impact child development outcomes and health inequalities. Making smokefree homes the norm and offering whole family support to quit will support smokefree childhoods

Percentage of mothers smoking at the time of delivery NHS England North (Greater Manchester) Not knowns removed Vertical Line indicates the national ambition of 6%

The case for financial incentives A review of four trials in the United States indicated that: financial incentives to encourage smoking cessation in pregnant women are more effective than any other cessation intervention A Cochrane review (2013) indicated that that the use of ‘incentives’ with pregnant women and their ‘significant other’ provide: a cost-effective measure to promote smoking cessation within the target group a substantial return on investment equating to up to £4 saved for every £1 spent on the intervention A Scottish RCT (2015) indicated that incentives for smoking cessation in pregnancy are highly cost effective and effective This evidence is referenced in the full report

Supporting a Smokefree Pregnancy Scheme North West - What does the data tell us (un-published) so far? Overall, 82% of women enrolled between 2010 to 2015 on to the SaSFPS achieved a CO validated four-week quit (N=1065).. The odds of achieving a four-week quit was increased by 55% when participants received support from a significant other as compared to those who had none (OR: 1.55 95% CI:1.13 to 2.14 P=0.007). The proportion of women who achieved a four-weeks quit through conventional NHS smoking cessation services never exceeded 48% between 2010 and 2015 and the average four-week quit within the same period was 45%. On the other hand, participants in the incentive scheme nearly doubled this figure with an 82% four-week quit. Each participating local area appointed a ‘Project Lead’ who managed the scheme locally. Project leads attended a 1-day training programme and were provided with all the materials necessary to deliver the scheme locally and to cascade the training to local colleagues. The scheme sat with in existing delivery systems, with cessation support being delivered to the women by a range of professionals such as specialist smoking cessation advisors or smoking cessation midwives depending on local arrangements. Data was collected locally, analysed 3-monthly and presented back to the localities at quarterly network meetings (facilitated by TFF) which were also used to share best practice and problem solve.

The GM Incentives Plus Scheme The overarching principles of the scheme are to: Improve the woman’s health Reduce the risk of harm to her unborn child The scheme is: Designed to support and incentivise pregnant women to set a quit date achieve a Carbon Monoxide (CO) validated 4-week quit sustain their quit attempt throughout pregnancy and for either 12 weeks post partum or up to 12 months post partum Up to 300 women will be to 12 weeks annually Plus up to 300 women will be supported to 12 months Women were seen weekly for the first 4-weeks Followed by a minimum of 4-weekly cessation support from a trained advisor – including CO screening throughout the pregnancy Women encouraged to recruit a ‘Significant Other Support’ to provide support throughout the pregnancy (50% of women recruited an SOS). The SOS was a non-smoker or in some cases quitting in partnership with her. Following delivery the approach was more flexible, support might be via telephone according to the woman’s need. Where possible the SOS was encouraged to attend each meeting with the cessation advisor – they were required to attend a minimum of 2 meeting – the first to sign the contract and participate in CO screening and the second prior to payment of their £40 – which also included CO screening.

Incentive Scheme Pathway

Participation Criteria Pregnant smokers living in a challenging environment are considered a high priority for recruitment to the scheme: Living with a smoker Living in an area of deprivation or high smoking prevalence Smoked throughout a previous pregnancy Teen pregnancy The absolute definition of ‘challenging environment’ is up to the professional judgement of local practitioners. Women who agree to participate are asked to sign a contract accepting an enhanced level of support and to CO screening at each visit.

Previous outcomes: Smokefree Homes Women who participated in the scheme were encouraged to make their homes smokefree Amongst those who responded to the Client Facing Evaluation the number of smokefree homes increased from 53% to 97% The majority of respondents indicated that having a smokefree home helped them stay stopped All women who were participating in the scheme during April 2013 were invited to complete an anonymous questionnaire, 79 of the 84 women involved in the scheme at that time responded. A response rate of 94%. Of those who participated 11 were pre-natal, 87 had given birth and one had experienced a miscarriage.

Broader Outcomes: Impact on others 57% of participants lived with one or more children whose health is likely to have benefited – particularly where the home became smokefree 45% self-reported that someone close to them quit as result of them giving up smoking

Outcomes: Impact of SOS 51% of the women who participated in the scheme recruited an SOS 70% of respondents to the Client Facing Evaluation were supported by an SOS 49% of whom indicated “my significant other was very important” in helping them stop and stay stopped Further post-report analysis of the data indicates that women were 55% more likely to quit smoking when supported by an SOS Anecdotal evidence provided by those delivering the scheme indicates that women were unable to recruit an SOS because they were unable to find someone within their community who was either a non-smoker or who was willing to quit alongside her.

Conclusions from previous experience Incentives work and generate real and cost effective benefits for women and their babies Targeted financial incentives combined with enhanced support are more effective than standard stop smoking support and need to be integrated into service commissioning priorities The focus on women in ‘challenging situations’ is supportive of public health priorities to address health inequalities and is a justified ongoing investment Women support CO screening  There is a significant increase in smokefree homes, providing extended protection for other family members and smokefree childhoods The presence of the SOS supports quitting and staying quit Maintaining quits post partum provides additional benefits eg breastfeeding

Pregnant women could be offered up to £300 in shopping vouchers if they quit smoking Mums-to-be in Greater Manchester are being offered shopping vouchers as a reward for quitting smoking during their pregnancies ”Mums who stay smoke free for at least 12 weeks after birth will receive up to £300 in Love2Shop vouchers, which can be spent on baby products or pampering.”

Public Interest

Delivering a smokefree generation Tackling inequalities requires system-wide and targeted interventions Implementing incentives at scale alongside babyClear in GM will maximise engagement and accelerate progress to 6% ROI to NHS is positive built on most conservative case – and evaluation will consider wider benefits eg NICU beds Delivering this commitment is key to delivering a smokefree generation

Thank You Questions? contact:a.crossfield@icloud.com