Online advertisements prompting pregnant smokers to take up stop-smoking support reached women earlier in pregnancy than interventions delivered via clinical settings can typically achieve, and at a lower cost, in a new, NIHR-funded study from the Universities of Cambridge, East Anglia and Nottingham.

This study, published in the Journal of Medical Internet Research (JMIR), is the first to investigate online uptake of cessation support among pregnant smokers. The researchers concluded that commercial online advertising to pregnant smokers was effective in engaging large numbers of women, is likely to be cost-effective and can probably be made more so.

Reducing smoking prevalence in pregnancy is a key public health priority in the UK, where it is a leading preventable cause of adverse prenatal outcomes including miscarriage, stillbirth and prematurity. It is also linked with a wide range of infant health problems. Around 11% of UK women smoke throughout pregnancy and rates rise considerably with increasing social deprivation, exacerbating health inequalities.

But most pregnant smokers want to quit. Effective ‘distance’ interventions, such as text-message support, may be particularly helpful for this group because of their low cost, convenience, anonymity and wide reach potential, with mobile phone ownership high across the socio-economic spectrum.

This study explored the likely real-world uptake of a smoking cessation intervention called MiQuit, should it become routinely available to pregnant smokers, and looked at what the best implementation strategies might be to maximise its reach and uptake. MiQuit is a low-cost, NHS-supported, tailored text-messaging intervention designed specifically for pregnant smokers. MiQuit is fully-automated and user-initiated, so women can start using it without the need for any health professional involvement, minimising implementation costs. There is early evidence of its effectiveness for helping pregnant smokers to quit and a definitive trial is now underway.

We have shown that a significant minority of pregnant smokers are willing to initiate an automated text messaging intervention when offered this online; given the high reach of the internet this could translate into substantial numbers of pregnant smokers supported to quit.”

– Dr Joanne Emery, Research Associate, Department of Public Health and Primary Care, University of Cambridge

For this study, links to a website providing MiQuit initiation information were advertised online on a cost-per-click basis on two websites (Google Search, Facebook, with £1000 budget each). Ads were also placed free of charge within smoking-in-pregnancy webpages on two non-commercial websites (National Childbirth Trust, NHS Choices). Would-be users were invited to text a short-code to MiQuit to get started.  The study authors recorded the numbers of times adverts were shown and clicked on, the number of MiQuit initiations, the characteristics of those initiating MiQuit, and whether support was discontinued prematurely. For the commercial adverts, the cost per initiation was calculated and, using quit rates obtained from an earlier study, the cost per additional quitter was estimated.

The results showed that:

• An overall uptake (initiation) rate of 3.4% was seen among individuals who clicked on any of the four adverts. As it is probable that not all advert clickers were pregnant smokers, the true uptake rate among this group is likely to be higher.
• Commercial adverts on Google and Facebook cost, on average, £24.73 per MiQuit initiation and an estimated £736 per confirmed quitter. This compares favourably with other interventions deemed highly cost-effective for pregnant smokers, such as offering financial incentives (£1,127 per quitter) or identifying pregnant smokers using exhaled carbon monoxide and referring all to specialist NHS cessation support unless they object (£952 per quitter). Free-of-charge adverts on health websites yielded relatively few initiations in this study, though these had fairly low visibility.
• User engagement and interaction with MiQuit appeared high. Over half of online initiators texted a quit date to the system and approximately two-thirds continued with MiQuit until the end of the 12-week programme.
• While the Facebook advert generated initiations throughout pregnancy, around 50% of those who initiated MiQuit via Google were within their first five weeks’ gestation. Adverts attached to online search engines may therefore be a useful way to reach women when they are first pregnant and looking for support or information about smoking during pregnancy. Currently, the earliest cessation interventions tend to target pregnant smokers at their antenatal booking appointment, at around 8-12 weeks’ gestation.

The study also indicated that uptake rates might be increased substantially by making it easier for women to initiate support after clicking on an advert to the MiQuit website. The need to text a short-code is one potential target, as is clearly labelling the website as an NHS service. Whilst further work is needed to determine MiQuit’s effect on quit rates in an online setting, online advertising appears to be a valuable means of promoting health interventions to hard-to-reach groups.

More information

Read the study ‘Uptake of Tailored, Text Message, Smoking Cessation Support in Pregnancy When Advertised on the Internet (MiQuit): Obervational Study‘ J Emery,  Journal of Medical Internet Research (JMIR)

Learn more about the Behavioural Science Group at the Primary Care Unit

Media queries: Lucy Lloyd

Image credit: Lucy Lloyd

Notes

This research was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme (RP-PG-0109-10020), awarded to Professor Tim Coleman, University of Nottingham. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Joanne Emery also received salary funding from the National Institute for Health Research (NIHR) School for Primary Care Research (SPCR). Felix Naughton received salary funding from a fellowship from the Society for the Study of Addiction (SSA).