Phase 1: Acceptability
In total, 409 individuals responded to the online questionnaire. Figure 2 shows a total of 328 responses were included in the analyses to assess the Dutch population’s acceptability of financial incentives for smoking cessation in pregnant women. In total 81 responses were excluded from the analysis due to duplications (n=2), missing values on all items (n=36) or not answering all of the ten statements concerning smoking cessation support for pregnant women (n=43).
Table 1 shows the respondent’s characteristics. The majority of the respondents were female (n=266, 81.1%) and between 20-29 years (n=133, 40.5%). Most of the respondents had high education (n=213, 64.9%) and had never been pregnant (n=194, 59.1%). Furthermore, approximately half of the respondents or their partners were smoking (n=86, 26.2%) or had smoked in the past (n=80, 24.4%).
The sequent part of the questionnaire comprised ten statements concerning smoking cessation support for pregnant women. The results showed large disunity among the respondents. Respondents indicated that they consider financial incentives a controversial intervention and are both positive and negative towards various aspects of the implementation of the financial-incentive-intervention. The importance of smoking cessation for pregnant women was affirmed by the vast majority of the respondents (n=298, 90.9%). Furthermore, the majority of the respondents considered it feasible for pregnant women to quit smoking, both during and after the pregnancy (respectively n=268, 82.0%, and n=238, 72.8%). In total, 170 (51.8%) of the respondents indicated that they totally disagreed to disagreed with the statement for rewarding pregnant women with financial incentives if they quit smoking during their pregnancy. Additionally, half of the respondents (totally) disagreed with the possible implementation of the financial-incentive-intervention (n=178, 54.3%), and a quarter (n=80, 24.4%) of the respondents (totally) agreed with this statement.
The last five questions of the questionnaire concerned the design of the financial-incentive-intervention. The results showed that 55.1% of the respondents (n=179) thought it was inappropriate to give a financial incentive for smoking cessation, compared to 31.7% of the respondents (n=103) who did think it was an appropriate intervention and 13.2% (n=43) of the respondents who were not sure whether it was appropriate or inappropriate. Approximately one third (n=103, 31.4%) of the respondents thought it was feasible for the women to stop smoking using the financial-incentive-intervention, while one third (n=108, 33.0%) thought it was not feasible, and one third (n=117, 35.6%) did not know whether it was feasible. Furthermore, the respondents were asked who should help pregnant women stop smoking. The most chosen option was an addiction medicine physician (n=114, 37.9%), followed by a general practitioner (n=54, 17.9%), a midwife (n=45, 15.0%), a general practice-based nursing specialist (n=42, 14.0%), a gynaecologist (n=13, 4.3%), a combination of healthcare professionals and family or partner, (n=12, 4.0%) and the pregnant woman herself (n=9, 3.0%).
In case the financial-incentive-intervention would be implemented, most respondents felt the amount of money should be between €0-€100 (n=32, 31.1%), between €100-€200 (n=33, 32.0%) or between €200-300 (n=16, 15.3%). Furthermore, it was believed by a large group of respondents that the financial incentives could best be given in the form of vouchers (n=120, 38.6%). Around half of the respondents (n=158, 49.8%) believed it would then be best to give the complete reimbursement at the end of the pilot study, while 37.5% (n=119) believed the reimbursement should be incremental amounts during the pilot study and 12.6% (n=40) believed the reimbursement should be distributed equally during the pilot study.
Table 1. Sociodemographic characteristics of respondent’s participating in online questionnaire (Phase 1)(n=328).
RESPONDENTS CHARACTERISTICS
|
Total population
N=328, 100%
N (%)
|
Gender
Male
Female
|
62 (18.9)
266 (81.1)
|
Age (years)
< 20
20-29
30-39
40-49
50-59
≥ 60
|
22 (6.7)
133 (40.5)
52 (15.9)
66 (20.1)
36 (11.0)
19 (5.8)
|
Education1
Low
Medium
High
|
13 (4.0)
102 (31.1)
213 (64.9)
|
Pregnancy status
I/my partner is pregnant
I/my partner has been pregnant
I/my partner have never been pregnant
|
3 (0.9)
131 (39.9)
194 (59.1)
|
Smoking status
I smoke
My partner smokes
We both smoke
I have smoked
My partner smoked
We both smoked
No, I do not smoke
No, we both do not smoke
|
40 (12.2)
24 (7.3)
22 (6.7)
36 (11.0)
18 (5.5)
26 (7.9)
65 (19.8)
97 (29.6)
|
Stopped smoking during pregnancy
Stopped during pregnancy
Permanently stopped after pregnancy
Did not completely stop during pregnancy
Did not stop at all
|
N=87
34 (39.1)
12 (13.8)
23 (26.4)
18 (20.7)
|
1 Education is categorized the following, low education (i.e. primary education, lower vocational education, intermediate general secondary education or not completed primary school), medium education (i.e. higher general secondary education or intermediate vocational education) and high education (i.e. university of higher vocational education).
Phase 2: Composing a pilot study
Based on the composed study design, the pilot study lasted ten to fourteen weeks per participant. We aimed to schedule the visits of the pregnant women every three weeks. However, the majority (n=6, 85.7%) cancelled their appointment frequently, which resulted in a different visiting schedule than the proposed study design.
Phase 3: Execution Pilot study
In total, nine pregnant women were included in the pilot study at three different locations. Five women were recruited at the university hospital (UMCG), two women at the general hospital (MZH), and two women at the primary midwifery practice (VSP). Table 2 illustrates the number of conducted interviews, dropouts, and negative and positive cotinine urine tests during the pilot study. Two women dropped out before conducting the interview at the first appointment, and six women dropped out before the end of the pilot study. One woman completed all test points and tested negative at the end of the pilot study, despite having a positive test at test point 3.
Table 2. Numbers of included pregnant women, conducted interviews, dropouts, negative cotinine urine tests and positive cotinine urine tests during the pilot study.
|
INCLUSION
|
VISIT 1
|
VISIT 2
|
VISIT 3
|
VISIT 4
|
VISIT 5
|
TOTAL
|
|
|
Interview
|
Urine Test
|
Urine Test
|
Urine Test
|
Urine Test
|
|
Participating women (N)
|
9
|
7
|
6
|
3
|
2
|
1
|
NA1
|
Women dropped out (N)
|
0
|
2
|
1
|
3
|
1
|
1
|
8
|
Negative Urine Test (N)
|
NA
|
NA
|
2
|
1
|
0
|
1
|
4
|
Positive Urine Test (N)
|
NA
|
NA
|
4
|
2
|
2
|
0
|
8
|
1 Not applicable.
During the interviews at the start of the pilot study, it was found that all of the pregnant women were unemployed (n=7, 100.0%), all had attempted to stop smoking in the past (n=7, 100.0%), and most of them had health issues (n=6, 85.7%)(Table 3). The majority of the women started smoking at a young age, contributing to an average of 15 years of smoking, and the majority (n=5, 71.4%) also smoked inside their houses. Furthermore, the majority of women endured problems in their private situations, such as financial issues (n=5; 71.4%) or relational issues with partner or family (n=5; 71.4%). There were no distinctive differences between the case of the women who completed the pilot study and the women who dropped out.
When asked for the motivation to participate in the pilot study, the majority was motivated to participate due to the unborn child’s health. Some women also mentioned that the pilot study acted as extra motivation. All of the women had attempted smoking cessation, of which only two women (n=2, 28.5%) were once successful in the past, and all repeatedly affirmed that it was difficult for them to stop smoking. Women saw addiction (n=4, 57.1%), stress (n=6, 85.7%) and routine (n=5, 71.4%) as the main obstacles to successfully quit smoking. To illustrate this, someone quoted, “ (…) when I faced difficult times during my life, I started smoking again (…)”(Table 4). Other aspects that influenced their smoking cessation attempts were family or friends smoking in close proximity.
Table 3. Characteristics of women at the start of the pilot study who participated in semi structured interviews (n=7).
CHARACTERISTICS PREGNANT WOMEN
|
N (%)
|
Age (years)
20-25
26-30
31-35
36-40
|
3 (42.9)
1 (14.3)
2 (28.6)
1 (14.3)
|
Pregnancy
First
Second
Third
|
2 (28.6)
3 (42.9)
2 (28.6)
|
Gestation (weeks)
8+0 – 10+6
11+0 – 13+6
14+0 – 16+6
17+0 – 19+6
20+0 – 22+6
23+0 – 25+6
|
2 (28.6)
2 (28.6)
1 (14.3)
0 (0.0)
1 (14.3)
1 (14.3)
|
Employment
Yes
No
|
0 (0.0)
7 (100.0)
|
Years of smoking
< 5 years
5-10 years
10-15 years
> 15 years
|
0 (0.0)
1 (14.3)
4 (57.1)
2 (28.6)
|
Previous smoking cessation attempt
Yes
No
|
7 (100.0)
0 (0.0)
|
Private problems
|
|
Relational issues (with partner and/or family)
Financial issues
|
5 (71.4)
5 (71.4)
|
Health issues1
Yes
No
|
6 (85.7)
1 (14.3)
|
1 Health issues include Crohn’s disease, HELLP syndrome, preeclampsia, hereditary disorder, gestational diabetes, and peri-gestational haemorrhage.
Table 4. Code tree of the conducted interviews with the pregnant women (n=7) including the themes, categories, subcategories, codes, quotes and anonymised participant IDs.
CODE TREE - THEMES (CATEGORY)
|
SUBCATEGORY
|
CODE
|
QUOTE
|
PARTICIPANT ID1
|
Smoking
Positive influence on smoking cessation
|
Activity
Aid with smoking cessation
|
Distraction
Taking distance
Eating
Focus
Hobby’s
Household
Avoidance
Social
Sport
Approach
External support
Request for help
Internal support
Nicotine replacements
Self
|
“Usually I get up and then I know if I, when I get up and I have breakfast and do my things first, then um, I don’t have to smoke anymore”
“... I've also decided not to go to friends for a while, this week anyway, so that I won't be tempted either.”
“… well in the first week you just have to try to distract yourself that way ...”
“... when I have the ultrasound, that you can hear the heartbeat that I will become more aware of oh yes I really have something in my belly …”
“… hobby is photography, but uh, that's also paused at the moment. But I plan to do that again.”
“Cleaning up, tidying up.”
“Yes, especially with my boyfriend, when I, um, know that there is really nothing in the house. That there is nothing to look for ...”
“Yes indeed, and my best friend also has 2 children, so you spend a lot of time together”
“… pregnancy yoga first and I want to continue that later, …, you will fully relax yourself ...”
“... without there being, um, a pointing finger ...”
“… because you have to stop (…) not only my environment but eeh, also people in the hospital ...”
“And now I wonder, maybe it would be like this (…) if I had perhaps had, then it might have been that I would have stopped longer”
“... my friend gets angry if I smoke. But the rest of the environment is not so judgmental and angry.”
“... I would like to use nicotine patches. But then if I do urine test you still have that, it still has, uh, nicotine in it.”
“I'm really like eeh, yes I want it myself and I really support it so ehm, I can do that ...”
|
U08
U08
U11
M02
U05
U04
U11
M02
U05
S12
U05
U04
U04
U04
U05
|
Negative influence on smoking cessation
|
Counteractions
|
Barrier
Perseverance
To deny
Rushed
Temptation
|
“... after that there was no sympathy for the fact that I did smoke ... he reacted so angry that we got into a fight.”
“... not motivated enough to ...”
“And then you no longer assume things that can go wrong.”
“... I'm already doing really well and then I'm going to seven milligrams, well and then I'm done with it and I overestimated myself in that.”
“... then I was with friends again and then, yes, give me a cigarette too, yes then you start again.”
|
U04
U04
U08
U04
U11
|
|
Reasons to smoke
|
Reward
Relaxation
Smoking thoughts
Routine
Peace
Stress
Addiction
Boredom
Fancy
|
“... because I no longer smoke weed, I still smoke, because it is so good that I did stop smoking weed. That's my reward.”
“... now let's relax through ...”
“And then it was really every day that I still thought, I have to, I have to, I have to, I have to.”
“Yes, really dinner … I used to have, did I have in the morning that I thought now I'm going to have a cup of coffee and a cigarette ...”
“When I smoke a cigarette, I calm down too.”
“Then I ended up in a stressful situation again, so yes. Then you soon reach for a cigarette again.”
“... because I have smoked now and then in between, you still have the taste for a bit ...”
“... when you are home alone … I found it very difficult not to smoke because it was so quiet.”
“... every now and then you just feel like a cigarette.”
|
U04
U08
U04
U05
U05
U05
M02
U08
U05
|
Smoking behaviour
|
Location
Tobacco products
|
Inside
Outside
E-cigarette
Cigarette
Weed
|
“… usually in the kitchen with a window open, but not in the room.”
“Not even on the balcony, … just go outside.”
“... electric. I did that for a while.”
“I actually smoke cigarettes.”
“... before my pregnancy, um, I smoked weed too ….”
|
U08
U05
U04
U08
U04
|
Smoking cessation
|
Attempt to quit
Consequences
|
Fed up
Easy
Failed attempt
Hard
Period
Regret
Date of stopping
Successful attempt
Proud
Used to
Withdrawal symptoms
Symptomatic aid
|
“It is, yes, just a shame …”
“... it's okay (...) I actually stopped quite easily.”
“... I did smoke a few times again, when I faced difficult times during my life, I started smoking again”
“... it is very difficult for me to quit smoking.”
“... I quit on my own for three months.”
“Because then I have those side effects and now I also like well, I should have done this much sooner actually ...”
“... I have something like (...) I'm going to start quitting today ...”
“I pretty much stopped together with him, actually.”
“... I am kind of proud but it doesn't feel um, I am not very proud. Because I (...) now also like, well, I should have done this much earlier actually ...”
“... now that was really after three days that I really didn't have that anymore.”
“Uh, yeah the first few days it was just that I was um, really cranky.”
“Yes, I still got a prescription from the midwife, um, yes, the midwife gave me, um, something.”
|
S01
U04
U05
U08
U05
U04
U05
M02
U04
U04
U04
U04
|
Pregnancy
Pregnancy
|
|
Uncomplicated pregnancy
Preparations
Pregnancy ailments
|
“Yes, I am happy to have a new pregnancy. (…) But if I hear more and more things are going well, then, um, I am more relaxed myself.”
“... well at home I'm still busy with the nursery of course and buying clothes and things like that, so I'm preparing well, yes.”
“If something makes you nauseous all at once and then all at once, you've just eaten, well everything will come out again.”
|
U08
U05
U08
|
Social
Economic situation
|
|
Financial
Preliminary education
Employment
Unemployed
|
“... because I have a benefit, after about two or three weeks (...) my money is normal, so low that I cannot, um, spend twenty euros on it because I still have 50 euros for groceries ...”
“... lower vocational education, but I have been working since I was eighteen ...”
“I just got back to work ,so I'm going to work for the first time today.”
“... and now I stopped working again ...”
|
U04
U05
U08
U08
|
Person
|
|
Health
Deceased child
Personal
|
“Yes and eeh, then I got eeh, Crohn's disease …, so I have to gradually rebuild everything a bit.”
“... I also had a miscarriage before at 11 weeks ...”
“And, well, I found those telephone contacts, um, that I found it really difficult to be open to others”
|
U05
M02
U04
|
Research
Test
|
|
Negative test
Positive test
|
“... it is indeed negative ...”
“... we had expected it a bit, unfortunately, …, but there was no second line to be seen and that actually means that there is still cotinine in the urine”
|
U04
U08
|
Reason to stop smoking
|
|
Purpose
Child
|
“... I just know there is, a creature living inside me, a daughter, … that stands up, really number one for me, so that's what I'm doing it for.”
“... then you also realize it more, there is something in my belly . There's a creature in my belly.”
|
U05
U05
|
Other
|
|
Interest
Aim
Feedback
|
“I think it is very important, after all I have been through ...”
“I was already looking at second-hand but now I'm like oh, maybe I can get a new one.”
“... that also feels good, I have also been in conversations that one is only talking and the other is just sitting around, so this is, I just like this.”
|
U08
U04
U05
|
1 ID = Identity Documentation, generated by the first letter of the hospital recruiting the pregnant women and the number representing the month in which they were born.
Phase 4: Evaluation of Pilot study
All healthcare professionals (midwives, medical nurses, n=5) were enthusiastic about the financial-incentive-intervention pilot study, both prior to as after conducting the study. Some professionals were hesitant at first, as they thought the incentives were unfair to the non-smoking pregnant women. Despite this, they all acknowledged the importance of pregnant women to stop smoking and were pleased to convey this novel approach for smoking cessation in pregnant women. Aside from the positive feedback assembled during these contacts, a few suggestions were offered for possible future implication. The healthcare professionals in the hospitals commented that they think it would be more successful to include more pregnant women from midwifery practices instead of hospitals’ inclusion. They argued that many pregnant women in the hospital are more complex due to their medical situation as well as their social situation, possibly negatively influencing the pilot study. Additionally, the midwives stated that they have a large number of smoking pregnant women in their practice. The low inclusion number was, according to them, caused by a short period of inclusion and colleagues forgetting to mention the pilot study and not due to pregnant women not willing to participate in the pilot study. Additionally, all healthcare professionals mentioned that the pilot study’s execution was not troublesome, and they had no further suggestions about the practicality of execution in retrospect.
Furthermore, pregnant women were also asked about their experiences with the pilot study, about financial incentives for smoking cessation for pregnant women in general and suggestions for future implications. Overall, the pregnant women assented that they were well informed about the study before they started. The appointments were experienced as pleasant, although some mentioned being ashamed about their smoking habits and found it hard to talk about it with healthcare professionals. All pregnant women thought of the financial-incentive-intervention as a helpful approach for pregnant women to stop smoking. Women also shared the perceptions of their partners about the financial incentives for smoking cessation and most of them (n=5) were positive about the intervention, since they acknowledged the importance of stopping smoking for their unborn child and wanted their partner to be able to abstain smoking during the pregnancy. It must be acknowledged that not all partners felt the same way about this and believed that the women should be able to stop without any help, as mentioned either by themselves when present or reported by the pregnant women about their partners. Along with the study, the researchers noticed that some pregnant women (n=4; 57.1%) desired additional support in the form of professional help. Therefore, they were provided with information about possible options such as support by telephone or therapy by another healthcare professional.
Moreover, the qualitative data from the conducted interviews with the nine pregnant women found that the main factors essential for the successfulness of smoking cessation were the absence of stress, stable home situation and support from the environment, as shown in Table 4.
Lastly, the prosperity and practicality of the pilot study were assessed. At the end of the pilot study, one out of nine pregnant women was able to abstain from smoking utilizing the financial-incentive-intervention. In total, 11 vouchers (7x €25,-; 2x €50,-; 1x €100; 1x €150,-) were given during the pilot study to different pregnant women, representing the financial-incentive-intervention practicality in clinical practice.