UK Program Will Pay People to Quit Smoking During Pregnancy

    Pregnant people will be offered vouchers worth up to £400 (almost $500) to quit smoking in a pilot scheme in the North West of England. The program hopes to reduce harms and address widening health inequalities.

    Smoking is the leading cause of cancer, preventable illness and premature mortality in England, with almost 80,000 annual smoking-related deaths. Smoking during pregnancy is associated with a range of harms to parent and child.

    In 2019, the UK government set an objective for England to be ”smoke-free” by 2030, meaning a national smoking rate of 5 percent or below. It remains to be seen whether the country will meet that target, although smoking is declining—assisted by a national vaping landscape that has encouraged millions to switch. Severe disparities in smoking rates persist, by income, demographics and region.

    East Cheshire, where the local council is implementing the pilot scheme, has a smoking rate higher than the national average, and 10 percent of pregnant residents continue to smoke. The program, due to start in the fall, will be offered to up to 300 people depending on how far the money stretches. (Other members of pregnant participants’ households will also be offered up to £200 to quit smoking, and it’s unknown how many will qualify.)

    Asked whether participants who switch from smoking to vaping will still be rewarded, Dr. Tyrer confirmed that they will.

    Altogether, it’s set to cost around £116,000. That may sound a lot, but Dr. Matt Tyrer, director of public health at Cheshire East Council, told Filter that the resulting savings in health care costs could amount to £450,000. According to the UK government, “In addition to the human cost, smoking costs the economy £14.7 billion per year, £2.5 billion of which falls to the [National Health Service].”

    The Cheshire program is an example of contingency management—an evidence-based intervention that provides incentives, typically in the form of vouchers or gift cards, for people to quit or reduce their use of drugs. The model is better known for its use with state-banned drugs, such as methamphetamine.

    An East Cheshire Council spokesperson told Filter that they recognized the strong evidence behind such programs, and were convinced that they were both “effective” and “cost-effective.”

    And while some programs of this kind reward only abstinence, the Cheshire pilot will reflect the UK’s pro-vaping policies by accepting other forms of nicotine consumption. Asked whether participants who switch from smoking to vaping will still be rewarded, Dr. Tyrer confirmed that they will. He said that he recognized that vaping was much less harmful than smoking, and could be a valuable quitting aid. He’d still “rather people didn’t smoke or vape,” but characterized vaping as “the lesser of two evils.”

    National Health Service advice on vaping and pregnancy reads: “If you’re pregnant, licensed NRT products such as patches and gum are the recommended option to help you stop smoking. But if you find using an e-cigarette helpful for quitting and staying smokefree, it’s much safer for you and your baby than continuing to smoke.”

    “It isn’t really as simple as ‘choosing’ to smoke.”

    The East Cheshire scheme was supported by most members of the council, but some vociferously opposed it. One councilor, for example, stated that he was “fundamentally opposed to paying people to stop something that they voluntarily choose to do.”

    “The criticism is understandable if you do consider smoking as something that someone simply chooses to do, or not,” Dr. Tyrer said. “But it’s not as simple as that and we know that there are many things that make it more likely that someone will smoke—things like being raised by smokers, peer pressure, poor health and the advertising and glamorization of smoking in the media.”

    “It isn’t really as simple as ‘choosing’ to smoke,” he concluded.

    Other critics of the scheme claim that it could easily be abused. How can the council be sure that someone smokes in the first place, and then be sure that the person has actually quit?

    Dr. Tyrer said that rigorous measurements, in the form of carbon monoxide testing throughout the program, will be used to biologically confirm people’s smoking status. “The rewards themselves will also be provided as vouchers,” he added, “which cannot be spent on tobacco products.”

    For some, this program—both the nature of contingency management itself, and the focus here on disproportionately disadvantaged pregnant smokers—will raise further ethical questions.

    Dr. Marilou Gagnon is a professor in the UVic School of Nursing and a scientist with the Canadian Institute for Substance Use Research, who has researched the ethical tensions of incentivized health care. “We know that voucher-based programs are designed to target people who experience the greatest health and social inequities, and who are not in a position to decline a financial incentive because of their socio-economic situation,” she told Filter. She added that a key question we should be asking is whether the incentive scheme is “appropriate and ethical in the care of pregnant people.”

    Lindsey English Hull, a staff attorney for the New York-based organization National Advocates for Pregnant Women, meanwhile contrasted this approach with damaging alternatives. She told Filter that NAPW has documented a significant increase in punitive policies aimed at forcing pregnant people into drug treatment or drug cessation through the criminal or civil legal systems. She said these approaches were “harmful to both moms and babies,” and result in a decrease of engagement in prenatal care.

    Asked about the Cheshire pilot, she said: “Our organization would certainly support any policy that seeks to incentivize health care through awards and encouragement.”

     


     

    Photograph by Marsel Hasanllari via Pexels.com

    • Kiran is a tobacco harm reduction fellow for Filter. She is a London-based writer and journalist, who has has written for publications including the Guardian, the Telegraph and I Paper.

      Kiran’s fellowship is supported by an independently administered tobacco harm reduction scholarship from Knowledge-Action-Change—an organization that has separately provided restricted grants and donations to Filter.

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