Financial incentives motivate smokers to kick the butt, research shows

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Smokers who want to quit fall in two categories – there are those who will voluntarily kick the butt and there are those who need to be motivated. For the second group, there are various care programmes available wherein they are provided with counselling and free smoking cessation aids that will help them quit, but a new research has said that if this group is provided financial incentives, there is a higher probability that they will quit and remain smoke-free.

According to a research, four different financial incentive programs, each worth roughly $800 over six months helped a lot more smokers kick the habit than those who were provided with free access to behavioral counseling and nicotine replacement therapy.

Further, the research also found that the way in which equally-sized payouts are structured influences their effectiveness. The findings are the result of a year-long randomized trial among CVS Caremark (now CVS Health) employees that was conducted by researchers at the Perelman School of Medicine at the University of Pennsylvania and is published online first in the New England Journal of Medicine.

The study enrolled 2,538 participants from across the United States during an eight-month period in 2012. Participants were then assigned to one of five groups: individual reward (reward based on individual performance), collaborative reward (reward based on group performance), individual deposit (requiring an upfront deposit of $150 with subsequent matching funds), competitive deposit (competing for other participants’ deposits and matching funds) or usual care (including informational resources and free smoking cessation aids).

Of the participants assigned to the reward-based programs, 90 per cent accepted the assignment, compared to just 14 per cent of those assigned to the deposit-based programs. As a result, 16 per cent of those assigned to reward programs remained smoke-free for six months, compared with 10 per cent in the deposit programs, and 6 per cent in the usual care group. Contrary to the authors’ expectations, the group-oriented programs were not significantly more successful than the individual-oriented programs (14 vs. 12 per cent).

Among the 14 per cent of people who accepted deposits, 55 per cent of them were still smoke-free at six months. Although the authors caution that this is a select group, analyses that took such selection into account still found that for any given person who would accept deposits, such programs were by far the most effective.

“We found that the reward-based programs were more effective than deposits overall because more people accepted them in the first place,” said lead author Scott D. Halpern, MD, PhD, an assistant professor of Medicine, Epidemiology, and Medical Ethics and Health Policy, and deputy director of the Center for Health Incentives and Behavioral Economics (CHIBE). “However, among people who would have accepted any program we offered them, the deposit contracts were twice as effective as rewards, and five times more effective than free information and nicotine replacement therapy, likely because they leveraged people’s natural aversion to losing money. With such unprecedented rates of success, the trick now is to figure out how to get more people to sign up — to feel like they have skin in the game.”

CVS Health, which partnered on the trial, will be the first to try out this approach. Based on the study’s results, they will soon launch a campaign called “700 Good Reasons,” in which all employees who smoke will be able to deposit just $50, and if they test negative for tobacco 12 months later, they will get back their $50 plus $700 more.

“As we continue to see smoking as the number one cause of preventable death in the United States, it’s important for employers to consider different options to use benefit design to help their workers quit,” said senior author Kevin Volpp, MD, PhD, a professor of Medicine and Health Care Management in the School of Medicine and Wharton, director of CHIBE, and vice chair of Health Policy in the department of Medical Ethics and Health Policy. “When compared to the estimated $4,000 to 6,000 incremental annual cost associated with employing a smoker over a non-smoker, a $700 to 800 incentive paid only to those who quit seems well worth the cost.”

Additional research in this area will focus on how to make deposit contracts more appealing, and how to tailor different programs to best match the psychological and behavioral profiles of different smokers. “Just as people’s genes may determine their response to certain drugs, people’s mindsets and behavior patterns likely dictate which types of incentive programs will work best for them,” Halpern said.

Limitations of the study

The study had its own set of limitation. First, the low rate of acceptance of the deposit programs required protocol modifications to restrict the proportions of participants who would be randomly assigned to those groups. Implementing these limitations preserved balance in participant characteristics across groups and preserved power for all effectiveness analyses but limited the precision of analyses comparing the efficacy of reward and deposit groups.

Second, only 41 per cent of the participants had access to free pharmacologic and behavioral cessation aids through their employee benefits. However, smoking-cessation rates were not higher among those with access to such aids, a finding that suggests that the superiority of incentives would hold in populations with universal access.

Third, in all trial groups, nearly half the smokers who quit at the end of the intervention at 6 months did not document sustained abstinence through 12 months. This suggests similar durability of financial incentives to nicotine-replacement therapy and bupropion, for which relapse after completion of treatment has also occurred in roughly 50 per cent of the participants. Secondary analyses suggest that the true relapse rates in our trial may have been lower, given the reduction in submission of any samples at 12 months across groups

Strengths of the study

In addition to comparing financial incentives for smoking cessation in a large number of participants, the trial measured the specific contributions of acceptance and efficacy of the interventions to their overall effectiveness.

This trial also compared multiple incentive programs with design features based on behavioral economic theory, including repeated payments to reinforce target behaviors, bonus payments at the end of the intervention to offset smokers’ tendencies to discount the importance of future events, and the provision of ongoing feedback regarding participants’ accrued gains and losses contingent on their self-reported smoking status to maximize the effect of regret aversion.

Finally, this trial randomly selected participants for screening cotinine tests to prevent nonsmokers from enrolling. The robustness of our findings in analyses accounting for potential participation of nonsmokers provides strong evidence regarding the effectiveness of incentives.