Are financial incentives cost-effective to support smoking cessation during pregnancy?

AIMS To investigate the cost-effectiveness of up to £400 worth of financial incentives for smoking cessation in pregnancy as an adjunct to routine health care. DESIGN Cost-effectiveness analysis based on a Phase II randomized controlled trial (RCT) and a cost-utility analysis using a life-time Markov model. SETTING The RCT was undertaken in Glasgow, Scotland. The economic analysis was undertaken from the UK National Health Service (NHS) perspective. PARTICIPANTS A total of 612 pregnant women randomized to receive usual cessation support plus or minus financial incentives of up to £400 vouchers (US $609), contingent upon smoking cessation. MEASUREMENTS Comparison of usual support and incentive interventions in terms of cotinine-validated quitters, quality-adjusted life years (QALYs) and direct costs to the NHS. FINDINGS The incremental cost per quitter at 34-38 weeks pregnant was £1127 ($1716).This is similar to the standard look-up value derived from Stapleton & West's published ICER tables, £1390 per quitter, by looking up the Cessation in Pregnancy Incentives Trial (CIPT) incremental cost (£157) and incremental 6-month quit outcome (0.14). The life-time model resulted in an incremental cost of £17 [95% confidence interval (CI) = -£93, £107] and a gain of 0.04 QALYs (95% CI = -0.058, 0.145), giving an ICER of £482/QALY ($734/QALY). Probabilistic sensitivity analysis indicates uncertainty in these results, particularly regarding relapse after birth. The expected value of perfect information was £30 million (at a willingness to pay of £30 000/QALY), so given current uncertainty, additional research is potentially worthwhile. CONCLUSION Financial incentives for smoking cessation in pregnancy are highly cost-effective, with an incremental cost per quality-adjusted life years of £482, which is well below recommended decision thresholds.