Financial Incentives for Smoking Cessation Among Disadvantaged Pregnant Women

描述（由申请人提供）：在美国，怀孕期间吸烟是导致不良妊娠结局的主要可预防原因，大多数怀孕吸烟者在怀孕期间继续吸烟，对婴儿产生严重的直接和长期不良健康后果。怀孕期间吸烟与经济劣势密切相关，是造成健康差距的重要因素。有有效的干预措施，但戒烟率很低（< 20%），出生结果的改善往往不大或根本没有。目前的治疗通常需要相对短暂、低成本的干预措施（例如，针对怀孕的戒烟线）。人们普遍认为，迫切需要更有效的干预措施。我们已经开发了一种新的行为经济干预，在这种干预中，妇女可以根据戒烟获得经济奖励。在一项针对怀孕期间吸烟治疗的荟萃分析中，通过经济激励获得的效应量比低强度方法或药物获得的效应量大几倍。干预措施似乎也改善了分娩结果，延长了母乳喂养时间。虽然前景很好，但至少在三个领域需要进一步研究。(1)关于分娩结果和母乳喂养的证据来自综合试验数据的研究，而不是单一的前瞻性试验；(2)干预是否产生其他产后健康改善尚未调查；(3)该方法的总体成本效益尚未得到检验。为了研究这些尚未解决的问题，我们建议进行一项随机对照临床试验，比较目前妊娠期戒烟与妊娠期戒烟的最佳做法在产后一年的疗效和成本效益。

DESCRIPTION (provided by applicant): 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.