Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2025 Mar 3;8(3):e250214.
doi: 10.1001/jamanetworkopen.2025.0214.

Financial Rewards for Smoking Cessation During Pregnancy and Birth Weight: A Meta-Analysis

David Tappin  1 , Jiyoung Lee  2 , Alex McConnachie  2 , Loren Kock  3 , Stephen T Higgins  4 , Sarah H Heil  5 , Ivan Berlin  6 , Steven J Ondersma  7 , Frank Kee  8 , Ira Bernstein  9 , Linda Bauld  10
Affiliations
Meta-Analysis

Financial Rewards for Smoking Cessation During Pregnancy and Birth Weight: A Meta-Analysis

David Tappin et al. JAMA Netw Open. .

Abstract

Importance: Offering pregnant women financial rewards to stop smoking is associated with a more than 2-fold increase in smoking cessation and is cost-effective; however, it is possible that the association is the result of gaming of the outcome measure (eg, not smoking for 24 hours before outcome measurement using a carbon monoxide breath test). Birth weight is an outcome measure that is independent of the rewards process.

Objective: To examine birth weight change associated with offering financial rewards for smoking cessation to pregnant women, and to estimate the average expected birth weight change for neonates born to those who quit smoking because of the rewards.

Data sources: Medline, American Psychological Association PsycInfo, Embase, Cochrane (the Cochrane Central Register of Controlled Trials, the Cochrane Tobacco Addiction Group Specialized Register, and the Cochrane Database of Systematic Reviews), and PubMed were searched from their inception until December 5, 2023, for published reports of trials of incentives for abstinence from substance use among pregnant women.

Study selection: Only trials using an experimental design allowing treatment effects to be attributed to the reward intervention were included. For this review update, potentially relevant studies retrieved were screened by a reviewer.

Data extraction and synthesis: Data were pooled using both fixed-effects and random-effects models. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed.

Main outcomes and measures: The primary outcomes were mean (SD) birth weight, birth weight for gestational age z score, and numbers of newborns with low birth weight (<2.5 kg) and who were small for gestational age (<10th percentile).

Results: Fixed-effects intention-to-treat analysis including 8 trials (2351 participants)-2 trials from the UK (1475 participants), 1 trial from France (407 participants), and 5 trials from the US (469 participants)-estimated a statistically significant mean 46.30 g (95% CI, 0.05 to 92.60 g) birth weight increase associated with adding financial rewards for smoking cessation. Complier average causal effects analysis (2239 participants) estimated a mean 206.00 g (95% CI, -69.12 to 481.14 g) increase for neonates born to smokers who quit because of rewards, but the increase was not statistically significant. There was no association with low birth weight or birth weight adjusted for gestational age, although fewer neonates were born small for gestational age, particularly if cessation was associated with rewards (complier average causal effects risk difference -17.70%; 95% CI, -34.90% to -0.42%).

Conclusions and relevance: In this meta-analysis, neonates were significantly heavier when pregnant women were offered the addition of financial rewards contingent on smoking cessation, supporting the effectiveness and, therefore, cost-effectiveness of financial rewards in this health care setting.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Dr Heil reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study and grants from the NIH and Health Resources and Services Administration outside the submitted work. Dr Ondersma reported receiving grants from the NIH, National Institute on Drug Abuse during the conduct of the study. Dr Bauld reported receiving grants from University of Edinburgh during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Intention-to-Treat Estimates of the Association of Financial Rewards for Smoking Cessation With Birth Weight
Forest plot shows the intention-to-treat estimates of the association of the offer of financial rewards for smoking cessation during pregnancy with birth weight (kilograms). The pooled effect was calculated using a fixed-effect model. The size of data markers is proportional to the weight in the meta-analysis.
Figure 2.
Figure 2.. Complier Average Causal Effect (CACE) Estimates of Smoking Cessation During Pregnancy on Birth Weight
Forest plot shows the CACE estimates of the association of smoking cessation during pregnancy with birth weight (kilograms). The pooled effect was calculated using a fixed-effect model. The size of data markers is proportional to the weight in the meta-analysis.
Figure 3.
Figure 3.. Intention-to-Treat Estimates of the Association of Financial Rewards for Smoking Cessation With Small for Gestational Age
Forest plot shows the intention-to-treat estimates of the association of the offer of financial rewards for smoking cessation during pregnancy with the risk of being born small for gestational age (<10th percentile), expressed as risk differences. The pooled effect was calculated using a fixed-effect model. The size of data markers is proportional to the weight in the meta-analysis.
Figure 4.
Figure 4.. Complier Average Causal Effect (CACE) Estimates of Smoking Cessation During Pregnancy on Small for Gestational Age
Forest plot shows the CACE estimates of the association of smoking cessation during pregnancy with the risk of being born small for gestational age (<10th percentile), expressed as risk differences. The pooled effect was calculated using a fixed-effect model. The size of data markers is proportional to the weight in the meta-analysis.
See this image and copyright information in PMC

Comment in

  • doi: 10.1001/jamanetworkopen.2025.0247

References

    1. Selvaratnam RJ, Sovio U, Cook E, Gaccioli F, Charnock-Jones DS, Smith GCS. Objective measures of smoking and caffeine intake and the risk of adverse pregnancy outcomes. Int J Epidemiol. 2023;52(6):1756-1765. doi:10.1093/ije/dyad123 - DOI - PMC - PubMed
    1. Lawder R, Whyte B, Wood R, Fischbacher C, Tappin DM. Impact of maternal smoking on early childhood health: a retrospective cohort linked dataset analysis of 697 003 children born in Scotland 1997-2009. BMJ Open. 2019;9(3):e023213. doi:10.1136/bmjopen-2018-023213 - DOI - PMC - PubMed
    1. US Department of Health and Human Services . A Report of the Surgeon General. Highlights: overview of finding regarding reproductive health. 2010. Accessed December 8, 2024. https://stacks.cdc.gov/pdfjs/web/viewer.html?file=https://stacks.cdc.gov...
    1. Vaz LR, Jones MJ, Szatkowski L, Tata LJ, Petrou S, Coleman T. Estimating the health-care costs of children born to pregnant smokers in England: cohort study using primary and secondary health-care data. Addiction. 2018;113(7):1305-1316. doi:10.1111/add.14183 - DOI - PMC - PubMed
    1. Oster G, Delea TE, Colditz GA. Maternal smoking during pregnancy and expenditures on neonatal health care. Am J Prev Med. 1988;4(4):216-219. doi:10.1016/S0749-3797(18)31176-0 - DOI - PubMed