Financial incentive programs significantly improve smoking cessation

1. All four financial incentive programs tested led to significantly higher rates of abstinence from smoking at 6 months compared to usual care.

2. At 12 months, only participants in the reward programs still had significantly higher rates of sustained abstinence compared to usual care.

Evidence Rating Level: 1 (Excellent)      

Study Rundown: Programs involving financial incentives have been shown to be effective in promoting changes in health behaviors. Different types of incentive programs exist. Some are termed deposit or commitment programs, where participants are asked to deposit a certain amount of money into the program and avoid losing it by improving their behaviors, while others reward participants for making positive changes. It has also been thought that incentives targeting groups may be more effective than those targeting individuals, as people are motivated by seeing their peers make similar efforts. The purpose of this trial was to compare different interventions (i.e., deposit vs. reward, individual vs. collaborative) aimed at smoking cessation. The findings demonstrate that participants were significantly more likely to accept entry into a reward program rather than a deposit program. All programs were associated with significantly higher abstinence rates at 6 months than usual care, though only the reward programs were shown to have significantly higher rates of abstinence at 12 months. Moreover, reward programs were also shown to have significantly higher abstinence rates at 6 months when compared with deposit programs.

This study had several limitations, including low acceptance rates, limited access to nicotine-replacement therapy, and high relapse rates, as many participants were not abstinent at the 12-month mark. Nevertheless, the authors demonstrated that programs involving financial incentives are an effective way of promoting smoking cessation in the short-term. In the future, studies should be conducted evaluating interventions of longer duration, as they may show higher rates of sustained smoking cessation.

Click to read the study, published today in NEJM

Click to read an accompanying editorial in NEJM

Relevant Reading: A randomized, controlled trial of financial incentives for smoking cessation

In-Depth [randomized controlled trial]: This randomized controlled trial enrolled 2538 CVS Caremark employees, and randomized them to 5 groups: 1) usual care (i.e., information about smoking cessation resources, behavioral-modification program, nicotine-replacement therapy), 2) individual reward group, 3) individual deposit group, 4) collaborative reward group, and 5) collaborative deposit group. The incentive programs lasted 6 months. The primary outcome measure was sustained abstinence from smoking for 6 months after the target quit date. This was verified by saliva samples with nicotine concentrations <10 ng/mL at 14 days, 30 days, and 6 months, or by urine anabasine analysis for individuals on nicotine-replacement therapy. Secondary outcomes included sustained abstinence rates at 12 months.

Approximately 80% of participants were white. Of the 2070 participants in intervention groups, 1060 accepted the assigned intervention (51.2%). Acceptance rates were significantly higher in the two reward programs compared to the two deposit programs (90.0% vs. 13.7%, respectively, p < 0.001), while there were no differences in acceptance rates between individual or group programs (50.6% vs. 51.9%, respectively, p = 0.55). At 6 months, all four programs resulted in significantly higher sustained abstinence rates when compared to usual care (p < 0.05 for all comparisons). Sustained abstinence rates were significantly higher with reward programs compared to deposit programs (15.7% vs. 10.2%, respectively, p < 0.001), while there were no differences between the individual and collaborative groups (p = 0.29). At 12 months, however, only the individual reward and collaborative reward groups had sustained abstinence rates higher than that of usual care (p < 0.01).

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