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Am J Prev Med
. Author manuscript; available in PMC: 2020 Jun 1.
Published in final edited form as: Am J Prev Med. 2019 Apr 17;56(6):852–859.
doi: 10.1016/j.amepre.2019.02.008
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SMOKE-FREE MOMS: FINANCIAL REWARDS FOR SMOKING CESSATION BY LOW-INCOME RURAL
PREGNANT WOMEN

Ardis L Olson


ARDIS L OLSON, MD

1Department of Pediatrics, Dartmouth Geisel School of Medicine, Hanover, New
Hampshire
2Department of Community and Family Medicine, Dartmouth Geisel School of
Medicine, Hanover, New Hampshire
Find articles by Ardis L Olson
1,2, Maureen B Boardman


MAUREEN B BOARDMAN, ARNP

2Department of Community and Family Medicine, Dartmouth Geisel School of
Medicine, Hanover, New Hampshire
Find articles by Maureen B Boardman
2, Deborah J Johnson


DEBORAH J JOHNSON, MHA

2Department of Community and Family Medicine, Dartmouth Geisel School of
Medicine, Hanover, New Hampshire
Find articles by Deborah J Johnson
2
 * Author information
 * Article notes
 * Copyright and License information

1Department of Pediatrics, Dartmouth Geisel School of Medicine, Hanover, New
Hampshire
2Department of Community and Family Medicine, Dartmouth Geisel School of
Medicine, Hanover, New Hampshire
*

Address correspondence to: Ardis L. Olson, MD, Dartmouth Geisel School of
Medicine, Dartmouth Hitchcock Medical Center, Dept. of Pediatrics, HB 7450, 1
Medical Center Drive, Lebanon NH 03756. ardis.l.olson@dartmouth.edu.

Issue date 2019 Jun.

PMC Copyright notice
PMCID: PMC6527358  NIHMSID: NIHMS1527317  PMID: 31003804
The publisher's version of this article is available at Am J Prev Med


ABSTRACT


INTRODUCTION:

Maternal smoking places the child at risk during pregnancy and postpartum Most
women who quit smoking do so early when they first learn of pregnancy. Few
low-income women quit once they enter prenatal care. The purpose of this study
is to test in a clinical prenatal care setting the effectiveness of the
Smoke-Free Moms intervention that provides pregnant women a series of financial
incentives for smoking cessation.


STUDY DESIGN:

A prospective nonrandomized controlled trial that collected control population
data of smoking cessation rates at each clincal visit during pregnancy and
postpartm with usual smoking counseling in 2013–2014. In 2015–2016 the same data
was collected during the implementation of the Smoke-Free Moms intervention of
financial incentives. Data analysis occurred in 2017.


SETTING/PARTICIPANTS:

Women who were smoking at the first prenatal visit at four federally qualified
health centers in rural New Hampshire.


INTERVENTION:

All women received 5A’s smoking counseling from clinic staff. At each clinic
visit, with point-of-care confirmed negative urinary cotinine, intervention
women received gift cards.


MAIN OUTCOME MEASURES:

Cotinine confirmed smoking cessation without relapse: (1) during pregnancy and
(2) smoking cessation in both pregnancy and postpartum.


RESULTS:

Of 175 eligible pregnant women enrolled, 134 women were followed to the
postpartum visit (Intervention n=66, Control n=68). The quit rates during
pregnancy did not differ between groups (Intervention 36.4%, Control 29.4%,
p=0.46). However, significantly more intervention mothers quit and continued as
nonsmokers postpartum (Intervention 31.8%, Control 16.2%, p=0.04). In a logistic
regression model including baseline sociodemographic, depressed mood, stress,
and readiness to quit items, confidence in being able to quit predicted both
cessation outcomes. The financial incentive intervention was an independent
predictor of cessation in pregnancy through postpartum.


CONCLUSIONS:

Financial incentives with existing smoking cessation counseling by staff in
low-income clinical prenatal programs led to cessation that continued during the
postpartum period. Further study in larger populations is indicated.


INTRODUCTION

Maternal smoking is the leading preventable cause of adverse pregnancy outcomes
in the U.S.1 Smoking increases the risk of pregnancy complications including
pre-eclampsia, placental abnormalities, and premature rupture of membranes.2
Smoking in pregnancy places the infant at greater risk because of prematurity
and low birth weight, birth defects, and higher rates of sudden infant death.3
Ongoing exposure of the infant to secondhand smoke results in significant
respiratory morbidity.4 Women’s smoking rates overall, and in pregnancy, have
slowly declined and rural and lower-income women continue to have higher rates
of smoking and lower quit rates in pregnancy.5–7 In addition national birth
certificate data from 2014 shows 10.1% women smoked just prior to pregnancy and
8.4% reporting smoking in pregnancy. Of these smokers in pregnancy about one in
five women had quit between the first and third trimester.6

Pregnancy can serve as a catalyst for mothers to change health behaviors to
benefit their child.8 Mothers alter diet, alcohol, and tobacco use in response
to being pregnant. Most women who quit tobacco do so early in pregnancy.9,10
Spontaneous rates of quitting upon first learning they are pregnant, before
receiving prenatal care, averaged 28% in low-income populations.11 After
presenting for prenatal care, cessation rates with smoking cessation
interventions are very low.10 In a review of 72 intervention studies, smoking
cessation by late pregnancy of women presenting as smokers occurred in only
3%–6%12 despite a variety of prenatal counseling approaches. The only approach
that had better results was the use of financial incentives (24% cessation).12

Two different successful approaches have been used in the U.S. to financially
incentivize pregnant women to quit. The first, contingency management, is based
on success with this approach with alcohol and illicit drug users.13 Smokers
were randomized to receive closely spaced reinforcement with increasing
financial rewards for biochemically confirmed cessation. Intervals progress from
daily to weekly after 12 weeks and then biweekly until delivery.14 A second
approach randomly provided women at Women, Infant, and Child supplemental
nutrition programs with monthly vouchers varying from $25 to $50 until the
2-month postpartum visit for biochemically confirmed cessation.15 Providing
financial incentives to a supporter of the mother as well did not change
results.15 These trials showing efficacy were conducted by outside research
staff. More recently single arm and randomized trials in the United Kingdom
using contingency16 or intermittent rewards17 with much larger incentives (up to
400–752 £), have had last trimester quit rates of 20%–22%. A large RCT in a U.S.
Medicaid population intervened from early pregnancy through the first year
postpartum. Financial incentives (up to $500), provided primarily for engagement
in smoking treatment visits and calls, had mixed results.18 Smoking cessation by
birth had not improved, but women who participated in more calls in either arm
had greater smoking cessation at 6 months postpartum. All three of these studies
referred patients from a clinical prenatal setting to well-established external
programs that provided prenatal smoking cessation treatment. These programs had
the resources for multiple home visits and phone calls that are not available in
many clinical settings. To the best of the authors’ knowledge, there are no
effectiveness studies where financial incentives were used as a complement to
the clinical practice’s usual onsite prenatal smoking cessation counseling.

The objective of this study is to explore the effectiveness of a smoking
cessation program with immediate financial incentives conducted in rural
prenatal clinics serving low-income women.


METHODS


STUDY POPULATION

Smoke-Free Moms, was a behavioral economics–based smoking cessation
intervention19 designed to complement cessation counseling and be provided by
clinical staff during routine prenatal and postpartum visits. It was an adjunct
to current smoking cessation counseling already provided by staff at prenatal
clinics. Smoke-Free Moms was directed at the population of pregnant smokers in
clinic settings serving low-income populations who had not spontaneously quit on
learning of their pregnancy and were still smoking at the time of their first
prenatal visit.

Smoke-Free Moms was evaluated in a nonrandomized controlled prospective study in
four rural New Hampshire federally qualified health centers. During the planning
stage staff indicated it would be problematic to randomize women living in small
communities where intervention women would be receiving financial incentives
while control subjects seen at the same time would not receive rewards. Thus,
first at each site in 2013 to 2014 at consecutive first prenatal visits, the
control population was recruited and followed through to the postpartum visit.
This was followed by the intervention phase in 2015–2016 with the same data
collected. From the volume of prenatal care patients and known smoking rates,
the goal was to recruit 100 women per study arm. Sample size calculations, based
on the literature12 with quit rate of 6% spontaneously vs 24% with incentives,
it was determined that 58 women per group would be needed in the final groups
(α=0.05, β=0.80). The women recruited were still smoking at their first prenatal
visit.

At each site usual care provided to all women included personalized smoking
cessation counseling at their entry visit utilizing the best practice 5 A’s
approach with referral to the state quit-line when desired. The 5A’s counseling
framework includes: Ask about tobacco use, Advise to quit, Assess willingness to
quit, Assist to quit, and Arrange follow-up and support. Pharmacologic treatment
for smoking cessation in pregnant women was not recommended by the U.S.
Preventive Services Task Force in 2009 or 201420 and nicotine replacement
therapy was not used for pregnant women at these sites. Staff followed up about
smoking status and encouraged women to quit at each visit. No other statewide or
local community smoking cessation initiatives for pregnant women were initiated
during data collection.

After completion of informed consent approved by the authors’ institutional
committee for the protection of human subjects, subjects completed baseline
surveys. If a woman stated she was not smoking, urinary cotinine testing was
immediately completed at any prenatal visit and the 6-to 8-week postpartum
visit. Urine cotinine was selected as the most accurate and practical
assessment.21 It was determined using a rapid urinary cotinine screening
test.22,23 Rooming staff were trained in interpretation using a color end point
that was similar to other point-of-care clinical tests such as rapid
streptococcal tests. This cotinine test detects urinary cotinine levels of ≥200
ng/mL reflecting smoking up to 2–3 days prior to the test.

Control subjects were paid $5 each visit for testing their urine but not
informed of the results. During the intervention phase, women were enrolled in
the Smoke-Free Moms program at their first visit and informed they would receive
a $25 gift card to Walmart® at each visit if not smoking and their cotinine test
was negative. In addition, at the postpartum visit at 6 to 8 weeks, they
received $50 gift card if not smoking and their cotinine test was negative.
Women who said they had quit but were cotinine positive were not confronted
about the discrepancy but encouraged to stay in the program and quit longer to
receive a gift card at a future visit.


MEASURES

At enrollment all women completed a baseline survey that assessed the
sociodemographic factors and self-reported smoking status. The motivational
factor of readiness to quit was assessed with three questions: (1) intent to
quit during pregnancy, (2) plan to quit in next 30 days, and (3) confidence in
being able to quit if decided to quit smoking in the next 30 days. Expected
social support from friends, family, and coworkers if she tried to quit,
assessment of depressed mood (how much of the time felt downhearted and blue in
the past month), and perceived stress were assessed. The four-item abbreviated
Perceived Stress Scale24 was scored for responses from 1 to 5 (never to very
often). Baseline survey items were from the Robert Wood Johnson Foundation’s
Smoke-Free Families multisite implementation and dissemination project.25,26
Smoking status was defined by a confirming negative rapid urinary cotinine test
among women who said they had quit.


STATISTICAL ANALYSIS

Data were tracked by subject identifier code only. Women were included in the
analysis if they were smoking at their enrollment visit and had more than one
follow-up prenatal visit before delivery. Initially clinic staff enrolled seven
women who had already quit since learning of pregnancy and they were excluded.
Nine women were seen only once after their enrollment visit. Cotinine logs were
misfiled into medical records and could not be accessed for 19 subjects. Because
of an interruption in the intervention protocol at one clinic during staff
changes, four subjects were excluded because no financial incentives were
provided. Three subjects dropped out. Thirteen women who transferred care and 14
with early miscarriage or termination of pregnancy were excluded. Details of
which arm of the study these events occurred is provided in Figure 1. The final
study population with data from first clinic visit through the postpartum visit
was 64% (68/106) of consented control and 71% (66/92) of consented intervention
subjects. Data were analyzed in 2017.

FIGURE 1.



Open in a new tab

CONSORT diagram.

The key outcomes assessed were: (1) quitting smoking without relapse during
pregnancy and (2) smoking cessation in pregnancy that continued to the
postpartum visit at 6–8 weeks. Baseline characteristics of each group for the
key outcomes were first compared using chi-square and Fisher’s exact test, and
Student’s t-test. The initial logistic regression analysis was conducted for
both outcomes utilizing all baseline characteristics, practice site, and
intervention status. Other than intervention status only variables in the
initial logistic regression with p-values <0.2 were retained in the final
multivariate adjusted logistic regression model.

For the above two key outcomes, an additional intention-to-treat analysis was
conducted to confirm the findings. For this post-hoc analysis, mothers were also
categorized as smokers with the following conditions: enrolled subjects with
missing data, those who had quit upon learning of pregnancy prior to the first
prenatal visit, those who withdrew, and those who had a miscarriage or
termination or transferred care. Data were analyzed using SPSS, version 24.


RESULTS

At their first prenatal visit intervention and control subjects did not differ
(Table 1). Maternal gestational age at this visit was similar (control 11.6
weeks [SD=6.6], intervention 12.6 weeks [SD=7], t-test, p=0.64). The baseline
survey completed by 129 women showed that sociodemographic and insurance status,
mood, and stress did not differ by intervention status. In both groups prior
cigarette use was similar with reduced smoking frequency in the past week.
Nearly all women reported planning to quit in the next month and nearly half
reported being very confident they could quit in the next month. The number of
prenatal visits did not differ between groups (Intervention 6.4 [SD=1.8],
Control 5.9 [SD=2.3] visits, t-test, p=0.20).


TABLE 1.

Baseline Sociodemographic and Smoking-related Variables by Treatment Group
(n=129)

Characteristics Control
N (%) Intervention
N (%) p-value Births: none vs births at >20 weeks gestation 29/64 (45.3) 33/65
(50.8) 0.48 Years of education (mean/SD) 11.6 ± 2.2 11.9 ± 2.2 0.38 Gestational
age (weeks) at first visit (mean/SD) 11.6 ± 6.3 12.6 ± 7.0 0.37 Caucasian race
vs other 62/64 (96.9) 62/65 (95.4) 0.56 Private insurance vs Medicaid and
uninsured 7/64 (10.9) 8/65 (12.3) 0.81 Married vs other 9/64 (14.1) 14/65 (21.5)
0.45 Depressed mood past montha 9/64 (14.1) 8/65 (12.3) 0.80 Perceived Stress
Scoreb (mean/SD) 9.62 ± 3.4 9.42 ± 2.7 0.71 Support to quit from othersd 51/64
(79.7) 50/65 (76.9) 0.83 Cigarettes/day before pregnant (mean/SD) 15.8 ± 7.5
17.2 ± 9.5 0.38 Cigarettes/day in past 7 days (mean/SD) 6.58 ± 5.8 7.68 ± 10.8
0.47 Readiness to quit  Seriously thinking of quitting smoking during this
Pregnancye 63/64 (98.4) 64/65 (98.5) 0.37  Plan to quit in the next 30 daysf
61/64 (95.3) 62/65 (95.3) 0.98  Confidence can quitc 29/63 (46) 28/65 (43.1)
0.67

Open in a new tab
a

How much of the time, during the past month, have you felt downhearted and blue?
(scoring: a lot, all the time, or a lot vs some or never).

b

Perceived Stress Scale (scoring: sum of four items range 4–20, scoring - high
scores less stress).

c

If you decided to quit smoking during the next month, how confident are you that
you could do it? (very vs somewhat, not very, or not at all).

d

If you tried to quit smoking, how much support or understanding do you think you
would get from family, friends, and coworkers? (scoring; a lot vs some, not
much, or none).

e

Are you seriously thinking about quitting smoking completely during this
pregnancy (yes vs no).

f

Are you planning to quit smoking completely within the next 30 days (yes vs no).

Women’s smoking cessation patterns are summarized in Table 2. The average
gestational age when women quit did not differ between the two groups (Control:
20.8 weeks [SD=9.8], Intervention: 18.9 weeks [SD=8.9], t-test, p=0.55). The
proportion of mothers who quit smoking in pregnancy until delivery did not
differ significantly (36.4% [24/66] Intervention vs 29.4% [20/68] Control,
p=0.46). However, women in the intervention group were more likely to quit
smoking and continue to not smoke to their postpartum visit (Intervention 32.3%
[21/66] vs Control 16.2% [11/68], p=0.04). Examination of the impact of the
intervention on smoking relapse rates in only the postpartum sample (n=44)
showed similar results (Intervention 12.5% [3/24] vs Control 45% [9/20],
p=0.016).


TABLE 2.

Smoking Cessation for Intervention Versus Control Pregnant Women (Control=68,
Intervention=66)

Smoking status Control
N (%) Intervention
N (%) p-value
Fisher’s exact test During pregnancy 0.46  Quit until delivery 20 (29.4) 24
(36.4)  Smokera 48 (70.6) 42 (63.6) Quit 0.04  During pregnancy until delivery 9
(13.2) 3 (4.5)  During both pregnancy and postpartum 11 (16.2) 21 (32.3)

Open in a new tab

Notes: Boldface indicates statistical significance (p<0.05). Percentages may not
add to 100% due to rounding.

a

Includes: Quit but relapsed in pregnancy (control=1, Intervention=3, Relapse
occurred after an average of 7.5 weeks), and Only quit at postpartum visit
(control=1, Intervention=1).

The intention-to-treat analyses of all eligible subjects confirmed these
findings. The proportion of women who quit during pregnancy did not differ
significantly by intervention status (Intervention 30.4% [24/79] vs Control
21.3% [20/94], p=0.22). Women in the intervention were significantly more likely
to quit in pregnancy through the postpartum visit (Intervention 26.9% [21/78] vs
Control 11.7% [11/94], p=0.02).

The multivariate logistic regression final model (Table 3) shows the predictors
for two outcomes: (1) quitting until delivery without relapse and (2) smoking
cessation during pregnancy that continued to the postpartum visit. For every
1-point increase in the 4-point confidence score women were 2.47 times more
likely to have quit smoking in pregnancy and 3.48 times more likely to have
smoking cessation in both pregnancy and postpartum. Medicaid/uninsured at entry
into care independently decreased the odds of quitting in pregnancy through
postpartum (AOR=0.27) but not quit rates in pregnancy. In addition to these
factors, the intervention group was an independent predictor (AOR=2.88) of
quitting smoking in pregnancy to postpartum.


TABLE 3.

Final Logistic Regression Model of the Predictors of Smoking Cessation Outcomes
(n=129)

Variable Quit in pregnancy without
relapses Quit in pregnancy and through the
postpartum visit

--------------------------------------------------------------------------------

AOR (95% CI) p-value AOR (95% CI) p-value Medicaid/uninsured ref: Private
insurance 0.54 (0.17, 1.69) 0.29 0.27 (0.08, 0.92) 0.037* Education (years) 1.14
(0.95, 1.38) 0.16 1.21 (0.96, 1.53) 0.10 Prior births >20 weeks 0.75 (0.48,
1.15) 0.19 0.84 (0.51, 1.39) 0.50 Confidence can quita 2.47 (1.27, 4.78) 0.01*
3.48 (1.58, 7.79) 0.002** Intervention ref: Control group 1.36 (0.62, 2.98) 0.44
2.88 (1.14, 7.3) 0.026*

Open in a new tab

Notes: Boldface indicates statistical significance (*p<0.05; **p<0.01).
Variables in unadjusted model >0.2 that were removed in adjusted model:
cigarettes pre-pregnancy, cigarettes in past 7 days at entry, thinking of
quitting, plan to quit in next 30 days, support to quit, marital status,
perceived stress, depressed mood in past month

a

AOR for each 1 point increase in confidence score from 1 to 4.

The program costs for cotinine testing and financial rewards were calculated for
the intervention group. Point-of-care urinary cotinine tests ($2/test) were
completed only if the mother said she had quit. The number of tests per mother
averaged 5 (range, 2–9) for a cost of $10 per mother who said she had quit. The
total cost of rewards was $3,700 (range, $50–$250) with an average of $148 per
mother who had cotinine confirmed smoking cessation at any point in pregnancy or
postpartum. These costs included mothers who quit but relapsed in pregnancy or
quit postpartum. The number of women provided the incentive program for each
woman who had smoking cessation that continued to the postpartum visit is 6.4
(number needed to treat). The total cost for an additional quit because of the
intervention was $1,050 (number needed to treat x [average of rewards + tests]).


DISCUSSION

This study implemented financial incentives in addition to best practice smoking
cessation counseling in low-income rural clinics. To the authors’ knowledge it
is the first study using financial incentives, in addition to smoking cessation
counseling, where the intervention occurred within the routine clinical prenatal
care process without outside resources providing the incentives and counseling.
This study found 5 A’s counseling and counseling with incentives had similar
quit rates in pregnancy but that the addition of financial incentives resulted
in more women whose smoking cessation persisted at 6–8 weeks postpartum. This
study’s intervention cessation rates are consistent with other incentive studies
with noncontingent vouchers14,15,17 where smoking cessation rates at delivery
varied from 23% to 37% compared with this study’s 36% rate. Studies with
postpartum follow-up at 2–3 months had cessation rates of 21%–33% compared with
the current finding of 32%. In this study’s population, counseling alone
resulted in better cessation rates (29%) than those found in earlier studies
(9%–12%).

Since earlier perinatal smoking studies, there have been changing public
policies and more public health messages about the risks of smoking. This may
have resulted in nearly all smoking women in this study’s setting entering
prenatal care intending to quit in the next 30 days compared with 64% in a
similar population two decades ago.26 The impact of the intervention was strong
after controlling for important baseline readiness to quit, social and
psychosocial factors, whose impact has not been explored in previous incentive
studies.14–18 It is important to note the key role of maternal confidence that
she can quit, but not variation in supports from others to quit, on all smoking
cessation outcomes. Unfortunately, the influence of age on the outcomes could
not be explored because maternal age was not collected. In other studies
intention to quit did not vary by age25 and the average age of women who both
quit and relapsed was about 2 years younger, but age did not influence
maintaining cessation postpartum.27,28

It was surprising to find in the regression model an independent strong impact
of the incentives on sustained smoking cessation but not on quitting prior to
delivery. The counseling provided to all patients may have a role. Psychosocial
counseling interventions have some impact on quitting.29 Specifically the
components of 5A’s have been shown to improve prenatal smoking cessation15,30,31
and endorsed as evidence-based best practices by the U.S. Preventive Services
Task Force32 and the American College of Obstetrics and Gynecology.33 These
efforts to widely implement 5A’s clinical counseling may be reflected in both
the current results and in 2014 birth certificate data showing a 20% quit rate
between the first and third trimester.34 Another possibility is that in this
population, where all intended to quit, the clinical staff implementing the 5
A’s reinforced strategies to not smoke at all visits for both groups and this
support was most effective in pregnancy for women with more confidence to quit.
After having cessation rewarded in pregnancy, expectations of a financial reward
may have then increased the motivation of intervention mothers to remain smoke
free when new stressors occurred after birth. Because this was a pragmatic study
where data collection was limited to not burden the clinical staff, the
specifics of counseling session content at visits or a postpartum survey to
explore these possible reasons is not available.


LIMITATIONS

These results were found in a rural white population. One of the sites cared for
Hispanic patients, but most of these women were not smoking at their first
prenatal visit. Although the quit rate in pregnancy favored the intervention
(36.4% versus 29.4%), a larger randomized study is needed to determine if these
differences were significant. In the future, this incentive approach could be
studied in settings with ethnic and racial diversity and determine its
applicability to urban settings. It may be helpful to vary incentives and
determine if a greater incentive earlier in pregnancy could increase quitting in
pregnancy. During immediate postpartum, relapse is common especially for women
who did not spontaneously quit early.35 Although relapse postpartum was reduced,
it was a limitation to not follow women further to see if it was sustained.
Previously both maternal engagement in more postpartum counseling visits18 and a
diaper incentive program for women who had quit have prevented relapse to 6
months postpartum.36 In the future, continuing postpartum incentives with
counseling at well-child visits may prolong postpartum cessation.

It is important to consider these findings in light of the difficult challenge
of prenatal and postpartum smoking. Despite extensive population-level primary
prevention and cessation interventions addressing smoking in pregnancy, 9% of
pregnant women smoke24,26 with higher rates in white low-income females. The
prevalence of smoking in pregnancy is also higher in rural than urban women and
did not decline from 2008 to 2016.6 Relapse in the postpartum period is not
declining despite publicity about secondhand smoke.27 More widespread use of
perinatal voucher incentives is possible in local hospital systems by
partnership with local businesses and foundations. Although other studies with
much larger incentives15–17 using external resources to deliver incentives and
counseling can produce greater smoking cessation rates, this study has shown
that with modest resources clinical practice sites can improve smoking cessation
in pregnancy and beyond delivery.


CONCLUSIONS

This study demonstrates that clinical staff can incorporate cotinine testing and
financial incentives into existing prenatal smoking cessation efforts and
increase smoking cessation that lasts past delivery. The authors found that the
program costs were reasonable. The average cost of incentives per woman who quit
was similar to the cost of one clinical visit in the region. Counseling
interventions may need to emphasize specific evidence-based approaches to
enhance low confidence and provide extra support to women who present with low
levels of confidence so that they can successfully quit smoking.


ACKNOWLEDGMENTS

Study data were managed using Research Electronic Data Capture (REDCap)
electronic data capture tools hosted at Dartmouth College.37 REDCap is a secure,
web-based application designed to support data capture for research studies,
providing (1) an intuitive interface for validated data entry, (2) audit trails
for tracking data manipulation and export procedures, (3) automated export
procedures for seamless data downloads to common statistical packages, and (4)
procedures for importing data from external sources.

This publication was supported by The Dartmouth Clinical and Translational
Science Institute, under award number UL1TR001086 from the National Center for
Advancing Translational Sciences of NIH. The content is solely the
responsibility of the authors and does not necessarily represent the official
views of NIH.


FOOTNOTES

No financial disclosures were reported by the authors of this paper.

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