Efficacy of an incentive-based community smoking cessation program

Competitions for smoking cessation

BACKGROUND

Competitions might encourage people to undertake and/or reinforce behaviour change, including smoking cessation. Competitions involve individuals or groups having the opportunity to win a prize following successful cessation, either through direct competition or by entry into a lottery or raffle.

OBJECTIVES

To determine whether competitions lead to higher long-term smoking quit rates. We also aimed to examine the impact on the population, the costs, and the unintended consequences of smoking cessation competitions.

SEARCH METHODS

This review has merged two previous Cochrane reviews. Here we include studies testing competitions from the reviews 'Competitions and incentives for smoking cessation' and 'Quit & Win interventions for smoking cessation'. We updated the evidence by searching the Cochrane Tobacco Addiction Group Specialized Register in June 2018.

SELECTION CRITERIA

We considered randomized controlled trials (RCTs), allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures in which participants were assigned to interventions by the investigators. Participants were smokers, of any age and gender, in any setting. Eligible interventions were contests, competitions, lotteries, and raffles, to reward cessation and continuous abstinence in smoking cessation programmes.

DATA COLLECTION AND ANALYSIS

For this update, data from new studies were extracted independently by two review authors. The primary outcome measure was abstinence from smoking at least six months from the start of the intervention. We performed meta-analyses to pool study effects where suitable data were available and where the effect of the competition component could be separated from that of other intervention components, and report other findings narratively.

MAIN RESULTS

Twenty studies met our inclusion criteria. Five investigated performance-based reward, where groups of smokers competed against each other to win a prize (N = 915). The remaining 15 used performance-based eligibility, where cessation resulted in entry into a prize draw (N = 10,580). Five of these used Quit & Win contests (N = 4282), of which three were population-level interventions. Fourteen studies were RCTs, and the remainder quasi-randomized or controlled trials. Six had suitable abstinence data for a meta-analysis, which did not show evidence of effectiveness of performance-based eligibility interventions (risk ratio (RR) 1.16, 95% confidence interval (CI) 0.77 to 1.74, N = 3201, I2 = 57%). No trials that used performance-based rewards found a beneficial effect of the intervention on long-term quit rates.The three population-level Quit & Win studies found higher smoking cessation rates in the intervention group (4% to 16.9%) than the control group at long-term follow-up, but none were RCTs and all had important between-group differences in baseline characteristics. These studies suggested that fewer than one in 500 smokers would quit because of the contest.Reported unintended consequences in all sets of studies generally related to discrepancies between self-reported smoking status and biochemically-verified smoking status. More serious adverse events were not attributed to the competition intervention.Using the GRADE system we rated the overall quality of the evidence for smoking cessation as 'very low', because of the high and unclear risk of bias associated with the included studies, substantial clinical and methodological heterogeneity, and the limited population investigated.

AUTHORS' CONCLUSIONS

At present, it is impossible to draw any firm conclusions about the effectiveness, or a lack of it, of smoking cessation competitions. This is due to a lack of well-designed comparative studies. Smoking cessation competitions have not been shown to enhance long-term cessation rates. The limited evidence suggesting that population-based Quit & Win contests at local and regional level might deliver quit rates above baseline community rates has not been tested adequately using rigorous study designs. It is also unclear whether the value or frequency of possible cash reward schedules influence the success of competitions. Future studies should be designed to compensate for the substantial biases in the current evidence base.

Reviewing the needs of unemployed youth in smoking intervention programmes

In Australia, the impact of unemployment on adolescent smoking behaviour continues to present a major public health problem. Traditional prevention programmes in both primary and secondary schools appear to be achieving a delay in the onset of smoking. However, smoking rates of young people who are unemployed are unacceptably higher than those of in-school youth. This paper provides a review of the published literature, showing that there has been little effort to address smoking patterns or experiences of quitting for this target group. While the provision of employment opportunities or skill training for this group is important, these strategies will not eliminate the problem of smoking. Steps must be taken to encourage research into the development of tailored programmes for unemployed youth who smoke. These programmes must be carefully considered and evaluated and meet the needs of this diverse group of young people.

Quit and Win contests for smoking cessation

BACKGROUND

Quit and Win contests were developed in the 1980s by the Minnesota Heart Health Program, and have been widely used since then as a population-based smoking cessation intervention at local, national and international level. Since 1994 an international contest has been held every two years in as many as 80 countries (2002).

OBJECTIVES

To determine whether quit and win contests can deliver higher long-term quit rates than baseline community quit rates.To assess the impact of such programmes, we considered both the quit rates achieved by participants, and the population impact, which takes into account the proportion of the target population entering the contest.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE, EMBASE, CINAHL, PsycINFO and Google Scholar. Search terms included competition*, quit and win, quit to win, contest*, prize*. Most recent search date was November 2007.

SELECTION CRITERIA

We considered randomized controlled trials, allocating individuals or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures.

DATA COLLECTION AND ANALYSIS

Data were extracted by one author and checked by the second. We contacted study authors for additional data where necessary. The main outcome measure was abstinence from smoking for at least six months from the start of the intervention. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. We decided against performing a meta-analysis, because of the heterogeneity of the included studies, and the small number of scientifically valid studies.

MAIN RESULTS

Five studies met our inclusion criteria. Three demonstrated significantly higher quit rates (8% to 20%) for the quit and win group than for the control group at the 12-month assessment. However, the population impact measure, where available, suggests that the effect of contests on community prevalence of smoking is small, with fewer than one in 500 smokers quitting because of the contest. Levels of deception, where they could be quantified, were high. Although surveys suggest that international quit and win contests may be effective, especially in developing countries, the lack of controlled studies precludes any firm conclusions from this review.

AUTHORS' CONCLUSIONS

Quit and win contests at local and regional level appear to deliver quit rates above baseline community rates, although the population impact of the contests seems to be relatively low. Contests may be subject to levels of deception which could compromise the validity of the intervention. International contests may prove to be an effective mechanism, particularly in developing countries, but a lack of well-designed comparative studies precludes any firm conclusions.

Quit and Win contests for smoking cessation

BACKGROUND

Quit and Win contests were developed in the 1980s by the Minnesota Heart Health Program, and have been widely used since then as a population-based smoking cessation intervention at local, national and international level. Since 1994 an international contest has been held every two years in as many as 80 countries (2002).

OBJECTIVES

To determine whether quit and win contests can deliver higher long-term quit rates than baseline community quit rates. To assess the impact of such programmes, we considered both the quit rates achieved by participants, and the population impact, which takes into account the proportion of the target population entering the contest.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group specialized register, with additional searches of MEDLINE (January 1966 to September 2004), EMBASE (180 to 2004/8), CINAHL (1982 to 2004/8) and PsycINFO (1872 to 2004/6). Search terms included competition*, quit and win, quit to win, contest*, prize*.

SELECTION CRITERIA

We considered randomized controlled trials, allocating individuals or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures.

DATA COLLECTION AND ANALYSIS

Data were extracted by one author and checked by the second. We contacted study authors for additional data where necessary. The main outcome measure was abstinence from smoking for at least six months from the start of the intervention. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. We decided against performing a meta-analysis, because of the heterogeneity of the included studies, and the small number of scientifically valid studies.

MAIN RESULTS

Four studies met our inclusion criteria. Three demonstrated significantly higher quit rates (8% to 20%) for the quit and win group than for the control group at the 12-month assessment. However, the population impact measure, where available, suggests that the effect of contests on community prevalence of smoking is small, with fewer than one in 500 smokers quitting because of the contest. Levels of deception, where they could be quantified, were high. Although surveys suggest that international quit and win contests may be effective, especially in developing countries, the lack of controlled studies precludes any firm conclusions from this review.

AUTHORS' CONCLUSIONS

Quit and win contests at local and regional level appear to deliver quit rates above baseline community rates, although the population impact of the contests seems to be relatively low. Contests may be subject to levels of deception which could compromise the validity of the intervention. International contests may prove to be an effective mechanism, particularly in developing countries, but a lack of well-designed comparative studies precludes any firm conclusions.

The use and impact of incentives in population-based smoking cessation programs: a review

PURPOSE

This review discusses current published literature on population-based smoking cessation interventions that involve incentives and examines whether such interventions are effective in reducing the prevalence of smoking.

SEARCH METHOD

Studies published between 1975 and Spring 1997 were identified through a computerized search of four electronic databases (MEDLINE, HEALTH, CINAHL, and PSYCINFO) and reference lists of key articles using the following key words: (smoking cessation OR quit smoking) AND (contest OR competition OR incentive OR lottery OR quit and win). This search yielded 79 articles. To be included, studies had to be published in English and had to have presented either quit rates or participation rates for an incentive-based program that used population-based recruitment. Of the 79 articles, 17 met these criteria.

FINDINGS

Population-based interventions generally attract 1 to 2% of the target population, but these participation rates can potentially be increased through the use of innovative recruitment techniques. No specific type of recruitment strategy was shown to be consistently more effective than others. There is no evidence that particular types of incentives are able to influence participation or quit rates, but the size of an incentive does appear to be important, with larger incentives viewed as more effectively motivating smokers to quit and stay smoke free than smaller ones. Estimates of the cost per quitter have ranged from less than $20 to over $400. There are some indications that the costs of such programs compare favorably with smoking cessation classes or clinic-based approaches.

CONCLUSION

Incentive-based smoking cessation programs that target an entire community have the advantage of reaching a large and diverse group of smokers. They may, however, attract only smokers who are already motivated to quit. Realistically, incentive-based programs aimed at the general population can expect 1% of all their smokers to quit smoking. Quit rates among participants may initially be high (i.e., mean quit rate of 34% at 1-month follow-up) but decrease over time (i.e., mean rate of 23% at 1 year). The results of this review suggest a continued need to establish standard and valid criteria for the evaluation of smoking cessation interventions. Methodological differences among existing studies make them difficult to compare and interpret.