(66) Mixed-Methods Contingency Management for Smoking in Perinatal Opioid Use Disorder

Background & Introduction: Tobacco use during pregnancy is associated with serious adverse maternal and fetal outcomes, including fetal growth restriction, placental abruption, low birth weight, and sudden infant death syndrome. Pregnant individuals with opioid use disorder (OUD) have disproportionately high tobacco use rates of 75-95%, compared to 7-12% of the general pregnant population. Contingency management (CM), an evidence-based intervention using positive reinforcement through financial incentives to encourage substance use reduction, has shown efficacy in promoting smoking cessation in pregnancy. CM is especially relevant during pregnancy due to the defined timeframe for health optimization, frequent healthcare provider engagement, and increased motivation to address substance use. Despite this relevance, no mixed-methods research has examined CM implementation in the perinatal OUD population.

Methods: This mixed-methods study aimed to quantitatively evaluate CM effectiveness in reducing tobacco use among pregnant individuals with OUD and qualitatively identify motivations, barriers, and facilitators to CM implementation.

Twenty-one pregnant participants (mean age 35.2 years, SD=4.3; 55% Black/African American, 40% White, 5% Other) were recruited from the Perinatal Resources for Opioid Use Disorder (PROUD) clinic.

Quantitative

Methods: Carbon monoxide (CO) monitoring assessed smoking behavior at randomized visits (≥10 ppm indicated recent tobacco use within 24 hours). Financial incentives up to $275 over six months were provided for CO readings < 10 ppm. Tobacco Use and Craving Questionnaires were administered at baseline and follow-up. Paired t-tests compared baseline and final CO levels and self-reported cigarette use per week.

Qualitative

Methods: Post-intervention semi-structured interviews explored experiences, challenges, motivations, and perspectives on CM effectiveness for long-term cessation. Interviews were transcribed and coded using NVivo software, with thematic analysis identifying key themes related to behavior change and intervention impact.

Results: Quantitative Outcomes:
Paired samples t-tests demonstrated significant reductions in both objective and self-reported tobacco use. CO levels decreased from baseline (M = 11.7 ppm, SD = 12.5) to final visit (M = 0 ppm, SD = 0), t(20) = 4.3, p .001. Self-reported cigarette use per week decreased from baseline (M = 67, SD = 38.1) to final visit (M = 41.4, SD = 38.1), t(20) = 2.8, p = .011.

Qualitative Themes:
Thematic analysis identified three key factors influencing smoking behavior and quit success with CM.
Successful Cessation Factors: Participants identified reinforced accountability through regular CO monitoring and financial incentives as key supports. Structured breath testing increased motivation, while incentives provided tangible reinforcement for abstinence.
Motivations for Quitting: Motivations included maternal identity such protecting fetal health and a desire to live longer for their children, financial incentives, and perceived health improvements such as increased energy and fewer respiratory symptoms.
Barriers to Quitting: Persistent challenges included smoking due to boredom, environmental triggers such as exposure to other smokers, and limited personal investment in cessation, describing ambivalence or rationalizing continued smoking due to stress or circumstances.

Implementation Factors:
Fishbone analysis identified six domains contributing to successful study completion: material resources (CO monitors, data platforms), personnel (staff training and adaptability), communication (clear expectations, accessible contact), environment (clinic workflow, transportation), personal factors (motivation and perceived health benefits), and community support (time constraints, family and social influences). These multilevel factors highlight the importance of comprehensive support systems for CM implementation in perinatal OUD populations.

Conclusion & Discussion: This mixed-methods study demonstrates that CM significantly reduced CO levels and self-reported cigarette use among pregnant individuals with OUD, addressing a critical gap in tobacco cessation for this high-risk population. Key motivators for cessation included financial incentives, maternal identity, and breath test accountability. Barriers such as environmental triggers, stress, and deeply ingrained smoking behaviors, highlight the complexity of nicotine dependence. Qualitative findings emphasize the importance of tailored, supportive interventions addressing multilevel implementation factors. Future research should include randomized controlled trials comparing CM to standard practice, and assess impacts on pregnancy health outcomes, including neonatal abstinence syndrome severity and sustained postpartum cessation.

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