Engagement of women who continue to smoke during their pregnancy is challenging, especially in deprived areas, with 30% of pregnant women smoking at booking in most deprived areas in Scotland compared to 6.7% in least deprived . Give It Up For Baby aimed to encourage engagement and cessation through the offer of financial incentives in NHS Tayside health board area. Quantitative data for this evaluation was derived from routinely collected data used in the administration of the scheme. A formal control area was not established as GIUFB resulted from service development rather than a research programme. However, work to review the effectiveness of existing smoking cessation services for pregnant women across Scotland provides useful comparisons with the results of this study . Tappin et al. analysed data and reported uptake and successes in 2006 based on all pregnant smokers across Scotland living in areas with recognised specialist or good generic services (rather than rates for those already engaged with services). These data covered all existing services for pregnant women. Whilst these services had evolved with differing configurations, ranging from opt-in intensive home based support to opt-out clinic based services; none incorporated financial incentives or required weekly attendance at pharmacies for CO readings. These can be compared with the GIUFB data similarly based on all pregnant smokers reported at the booking visit for 2009 (Table 4). Tappin et al. found that only a small proportion of pregnant smokers (as reported at the booking visit) were supported to stop across Scotland, with only 13% of pregnant smokers having engaged and set a quit date in 2006, compared with 20.1% engaging and setting a quit date with GIUFB in 2009. Furthermore, only 3.9% quit smoking during pregnancy at 4 weeks in 2006 across Scotland, from an intention to treat viewpoint. In contrast, the GIUFB intervention supported 7.8% of pregnant smokers to quit at 4 weeks across the three intervention areas (range 5.5%, Area 1 to 12.3%, Area 2). The nearest comparative performances in Scotland were 5.0% for an opt-out clinic based service and for an opt-in home-based service . The GIUFB outcomes therefore indicate a substantial improvement on national figures in relation to engagement and cessation. Of note, however, are the differences between rates of engagement and quit success within the three intervention areas, with a higher proportion of pregnant smokers from the more affluent area (Area 2) engaging and quitting at 4 and 12 weeks than women from the substantially more disadvantaged locality (Area 1).
It is notable that results reported for GIUFB by community pharmacies were based on weekly CO breath testing. The results from GIUFB are therefore likely to be more reliable than self-reports of tobacco abstinence in other datasets. For example, in the review of services in Scotland, only half of quits were CO breath tested . In addition, this aspect of the scheme was valued by participants, as it gave immediate feedback and provided a focus for a behavioural support discussion. Although CO breath-testing has limitations as a tool for validation of smoking status, especially in terms of the persistence of CO on the breath, the method was simple to administer and had face validity for participants. Use of other methods such as salivary or blood testing of cotinine were felt to have significant drawbacks because of their invasive nature .
Focussing on GIUFB participants 2007–2009, rather than all pregnant smokers in Tayside, the GIUFB intervention was also able to demonstrate that 53.7% of women managed to continue their quit attempt for 4 weeks. This is higher than in the earlier review of Scottish services  which found that 29%-35% were successful at 4 weeks post-quit date, depending on service type. The 4 week success rate for GIUFB was highest in the more affluent intervention area at 59.7%, a substantial increase on the standard Scottish performance for four week quits (38%). This pattern is also repeated for 12 week quits where GIUFB achieved a 31.8% quit rate compared to a 15% 12 week quit rate reported by the NHS Smoking Cessation Service statistics . Smokers are 1.5 times as likely to set a quit date (relative risk (95% CI) of 1.58 (1.38-1.81)) and twice as likely to be quit 4 weeks later with GIUFB compared with other specialist smoking cessation services in Scotland where incentives are not part of the intervention strategy (relative risk (95% CI) of 2.03 (1.60-2.59)) .
Interestingly, while GIUFB utilised community pharmacies as the service delivery route, in general, community pharmacies across Scotland deliver a lower 4 week quit rate than other smoking cessation service settings . The evaluation of a similar smoking cessation incentive scheme (Quit4U) has suggested that the weekly CO breath test provided a place from which to engage the participant in a supportive discussion . A further paper evaluating this incentive scheme proposed that the smoking cessation incentive scheme might reverse the felt contractual relationship between service-provider and client with the client now the provider who is paid to quit .
Although the literature suggests it is likely that incentive schemes may encourage engagement, the effectiveness of incentive schemes in promoting compliance in complex behaviour change is still challenged . This paper presents some further evidence that using incentive schemes to promote smoking cessation in pregnant women through NHS service provision can also improve and maintain the patient outcomes that are delivered. For example, across the three years of implementation of GIUFB, 16.5% of women engaged with GIUFB have been found to be abstinent at three months post partum. Further challenges to the use of public money for incentive schemes have been made and little evidence exists to gauge the correct level of incentive to produce a worthwhile effect, although NICE have recommended small cash amounts for contingency management in substance misusers . Some emerging evidence suggests that the beneficial effect of the incentive may be sustained beyond the period of payment: the Quit4U intervention mentioned above provided incentives for 12 weeks and the evaluation showed 46% increase in cessation at 12 months compared to the Scottish benchmark .
A critical issue to emerge from the outcome evaluation was differences in the level of engagement and quit success achieved in the different intervention areas, with the service performing better in the more affluent area. This is particularly pertinent given similar patterns were also found by the process evaluation and the difficulties experienced in tackling health inequalities by targeting disadvantaged communities [23, 24]. Data from this study appear to suggest that women from more affluent communities derive greater benefit from the incentive scheme than those from more deprived communities. In addition, older women and women undertaking a second pregnancy were more likely to engage, with young smokers less likely to engage. The reason for this may be partially explained by service-level factors with, for example, more effective support in the more affluent area being provided by a peer support worker and midwives in the same area being better positioned to forge closer relationships with their clients due to fewer competing priorities and pressures on time. Nevertheless, 4 week quit rates of over 45% in the most deprived quintile represents a substantial achievement, as does engagement by 20.1% of the women still smoking at their booking visit.
The process evaluation conducted with a small sample of participants was used to develop a service user typology which provides additional insight into why some women benefited more from the scheme than others. This is the first time such a typology has been developed and whilst the sample size places constraints on the generalisabilty, these findings were particularly helpful in shedding light on why socio-economic factors appears to predict level of engagement with the scheme and differences in quit rate. Self-reported smoking behaviour from the process evaluation indicated that those least successful at quitting tended to be ‘breadline survivors’, often single mothers who as a consequence of their deprived circumstances and competing lifestyle pressures had less commitment to stopping and who attached a greater value to the material incentive than to the cessation support on offer. In contrast those who were more successful tended to conceptualise the incentive as part of a wider reward structure (e.g. ‘mothers to be’ and ‘enthusiastic amateurs’). In these groups the financial reward appeared to help to incentivise continuing, routine participation and engagement with the support on offer, rather than quitting per se. For these participants other aspects of the scheme were equally as important, for example, confirmation of their non-smoking status delivered by regular CO breath tests, and the supportive relationships established with their local community pharmacy. In addition, the process evaluation also found that younger smokers or ‘novice quitters’ who were still living in the family home and dependent on parents for support, attached a low value to the material incentives and were relatively unsuccessful at quitting. Findings suggest that these smokers express feelings of isolation and report being open to the idea of meeting with other pregnant mothers in a similar position as themselves. There was also evidence that for some successful quitters the material incentive had limited effect, especially for light smokers, or ‘opportunists’ who reported being able to give up without support and would have done so irrespective of participation in the scheme.
Variations in self-reported quit rates to emerge from the process evaluation interviews were also supported by attendance levels at registered pharmacies and CO breath test data. Taken together these findings provide some valuable insight into how incentives work with different sub-groups and suggest that there may be scope to develop these typologies to help identify and target those user groups more likely to benefit from approaches incorporating a financial incentive. Difficulties in linking the process and outcome data also highlights the importance of a mixed methods approach to data collection incorporating an integrated research design. Such an approach does not typically fall within the scope of service development programmes and requires additional resources and planning.