An incentive-based prenatal smoking cessation program for low-income women appears to improve birth outcomes while at the same time reducing cost. Although smoking prevalence has decreased over the past decades, the reduction has not been as dramatic among low-income smokers. Due to the link between social disadvantage and prenatal smoking, there is a need for focused interventions adapted to the needs of these populations.
The research, published in Public Health Nursing, examined birth outcomes and projected cost savings at the individual and state level associated with participating in a prenatal smoking cessation intervention, known as the Baby & Me Tobacco Free (BMTF) program). The study used prospective data from 2,431 women enrolled in the program between January 1, 2014 and March 31, 2017. The authors linked individual data to the birth certificate registry at the Colorado Department of Public Health and Environment (CDPHE) to obtain the birth outcomes of BMTF enrollees. Two reference populations of low-income women who smoked in the 3 months prior to or during pregnancy were also obtained (one group form the birth certificate registry for the same time period [excluding BMTF participants] and one group from the Colorado Pregnancy Risk Assessment Monitoring System [PRAMS] from 2014-2015 [unable to exclude BMTF participants]).
Women were eligible to enroll in BMTF if they were currently pregnant, resided in a participating county (Colorado has 52 participating counties), and self-reported smoking at least 3 months prior to becoming pregnant. The program included four in-person prenatal counseling session led by public health nurses and health educators using motivational interviewing techniques. At each session, a carbon monoxide breath test was performed to validate smoking cessation status. Participants received a diaper voucher incentive at the third and fourth prenatal session if the carbon monoxide breath monitoring result was < 6 parts per million.
The authors used the birth certificates of participants to identify adverse reproductive outcomes for each study population. These included low birth weight (< 2500 g), preterm birth (PTB; birth at < 37 weeks’ gestation), admission to the neonatal intensive care unit, and maternal gestational hypertension.
A total of 2,231 participants (91.8%) were linked to a live birth in the birth certificate registry at CDPHE. The birth certificate reference population included 16,739 women and the PRAMS reference population consisted of 501 respondents (weighted response of 16,351 women). Compared to the birth certificate reference population, participants in BMTF were more likely to be < 20 years of age (P < .0001), non-Hispanic black (P = .03), have a high school education or greater (P=.004), be insured by Medicaid during pregnancy (p< .0001), unmarried (P = .0003), primiparous (P< .0001) or reside in a frontier county (P< .0001). Compared to the PRAMS reference population, BMTF enrollees were more likely to be non-Hispanic white or non-Hispanic black (P< .0001), unmarried (P < .0001), primiparous (P = .01) or reside in a frontier county (P< .0001).
Infants of mothers enrolled in the program had a lower risk of low birth weight (RR 0.86; 95% CI 0.75-0.97), preterm birth (RR 0.76; 95% CI 0.65-0.88) and neonatal intensive care unit admission (RR 0.76; 95% CI 0.66-0.88) than the birth certificate population. This led to a return of investment of $7.73 and an individual cost savings of $6,040. Compared to the PRAMS population, infants of BMTF mothers had a lower risk of PTB (RR 0.72; 95% CI 0.53-0.99) and neonatal intensive care unit admission (RR 0.45; 95% CI 0.32-0.62). These results led to a return of investment of $2.79 and an individual cost savings of $2,182.
The authors believe their findings indicate a reduction in preventable smoking-related adverse birth outcomes among women who participated in the BMTF program. Both health care systems and individual participants saw financial benefits. Future studies are recommended to better understand the sustainability and long-term integration of BMTF in communities and the replication of the program in a different setting. The authors suggest other assessments of the BMTF program should include a randomized controlled study to test the impacts of the most successful components of the program.