A worksite smoking intervention: a 2 year assessment of groups, incentives and self-help

Incentives for smoking cessation

BACKGROUND

Financial incentives (money, vouchers, or self-deposits) can be used to positively reinforce smoking cessation. They may be used as one-off rewards, or in various schedules to reward steps towards sustained smoking abstinence (known as contingency management). They have been used in workplaces, clinics, hospitals, and community settings, and to target particular populations. This is a review update. The previous version was published in 2019.

OBJECTIVES

Primary To assess the long-term effects of incentives and contingency management programmes for smoking cessation in mixed and pregnant populations. Secondary To assess the long-term effects of incentives and contingency management programmes for smoking cessation in mixed populations, considering whether incentives were offered at the final follow-up point. To assess the difference in outcomes for pregnant populations, considering whether rewards were contingent on abstinence or guaranteed.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, PsycINFO, and two trials registers on 2 November 2023, and the Cochrane Tobacco Addiction Group Specialised Register on March 2023, together with reference checking, citation searching, and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered only randomised controlled trials (RCTs), allocating individuals, workplaces, groups within workplaces, or communities to smoking cessation incentive schemes or control conditions. We included studies in a mixed-population setting (e.g. community-, work-, clinic- or institution-based), studies with specific populations (e.g. those with diagnosed mental health conditions), and studies in pregnant people who smoke.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. The primary outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up (at least six months from the start of the intervention). In the trials of pregnant people, we used abstinence from smoking measured at the longest follow-up, and at least to the end of the pregnancy. Where available, we pooled outcome data using a Mantel-Haenszel random-effects model, with results reported as risk ratios (RRs) and 95% confidence intervals (CIs), using adjusted estimates for cluster-randomised trials. We analysed studies carried out in mixed populations separately from those carried out in pregnant populations.

MAIN RESULTS

Forty-eight mixed-population studies met our inclusion criteria, recruiting more than 21,924 participants; 15 of these are new to this version of the review. Studies were set in varying locations, including community settings, clinics or health centres, workplaces, and outpatient drug clinics. We judged eight studies to be at low risk of bias, and 16 to be at high risk of bias, with the remaining 24 studies at unclear risk. Thirty-three of the trials were run in the USA, two in Thailand, one in the Philippines, one in Hong Kong, and one in South Africa. The rest were European. Incentives offered included cash payments, self-deposits, or vouchers for goods and groceries, offered directly or collected and redeemable online. The pooled RR for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.52 (95% CI 1.33 to 1.74; I2 = 23%; 39 studies, 18,303 participants; high-certainty evidence). Results were not sensitive to the exclusion of seven studies that offered an incentive for cessation at long-term follow-up (result excluding those studies: RR 1.46, 95% CI 1.23 to 1.73; I2 = 26%; 32 studies, 15,082 participants), suggesting the impact of incentives continues for at least some time after incentives cease (at least six months). For this update, we included an adjusted analysis incorporating three cluster-RCTs. The pooled odds ratio was 1.57 (95% CI 1.37 to 1.79; I2 = 30%; 43 studies, 23,960 participants; high-certainty evidence). Although not always clearly reported, the total financial amount of incentives varied considerably between trials, from zero (self-deposits), to a range of between 45 US dollars (USD) and USD 1185. There was no clear difference in effect between trials offering low or high total value of incentives, nor those encouraging redeemable self-deposits. We ran an updated exploratory meta-regression and found no significant association between the outcome and the total value of the financial incentive (P = 0.963). Any such indirect comparison is particularly crude in this context, due to differences in the cultural significance of financial amounts (e.g. USD 50 might have different significance in different contexts). We included 14 studies of 4314 pregnant people (11 conducted in the USA, one in France, and two in the UK). We judged four studies to be at low risk of bias, two at high risk of bias, and eight at unclear risk. When pooled, the 13 trials with usable data delivered a risk ratio at longest follow-up (up to 48 weeks postpartum) of 2.13 (95% CI 1.58 to 2.86; I2 = 31%; 13 studies, 3942 participants; high-certainty evidence), in favour of incentives.

AUTHORS' CONCLUSIONS

Overall, our conclusion from this latest review update remains that there is high-certainty evidence that incentives improve smoking cessation rates at long-term follow-up in mixed population studies. The evidence demonstrates that the effectiveness of incentives is sustained even when the last follow-up occurs after the withdrawal of incentives. There is also now high-certainty evidence that incentive schemes conducted amongst pregnant people who smoke improve smoking cessation rates, both at the end of pregnancy and postpartum. This represents a change from the previous update in which we rated this evidence as moderate certainty. Current and future research might more precisely explore differences between trials offering low or high cash incentives and self-incentives (deposits), within a variety of smoking populations, focusing on low- and middle-income countries where the burden of tobacco use remains high.

How To Support Smoking Cessation In Primary Care And The Community: A Systematic Review Of Interventions For The Prevention Of Cardiovascular Diseases

Introduction

Smoking is a major risk factor for cardiovascular diseases (CVDs) and for many types of cancers. Despite recent policies, 1.1 billion people are active smokers and tobacco is the leading cause of mortality and illness throughout the world. The aim of this work was to identify smoking cessation interventions which could be implemented in primary care and/or at a community level.

Methods

A systematic review of CVDs prevention guidelines was realized using the ADAPTE Process. These were identified on G-I-N and TRIP databases. Additionally, a purposive search for national guidelines was successfully undertaken. Guidelines focusing on non-pharmacological lifestyle interventions, published or updated after 2011, were included. Exclusion criteria were specific populations, management of acute disease and exclusive focus on pharmacological or surgical interventions. After appraisal with the AGREE II tool, high-quality guidelines were included for analysis. High-grade recommendations and the supporting bibliographic references were extracted. References had to be checked in detail where sufficient information was not available in the guidelines.

Results

Nine hundred and ten guidelines were identified, 47 evaluated with AGREE II and 26 included. Guidelines recommended that patients quit smoking and that health care professionals provided advice to smokers but failed to propose precise implementation strategies for such recommendations. Only two guidelines provided specific recommendations. In the guideline bibliographic references, brief advice (BA) and multiple session strategies were identified as effective interventions. These interventions used Prochaska theory, motivational interviewing or cognitive-behavioral therapies. Self-help documentation alone was less effective than face-to-face counseling. Community-based or workplace public interventions alone did not seem effective.

Discussion

Behavioral change strategies were effective in helping patients to give up smoking. BA alone was less effective than multiple session strategies although it required fewer resources. Evidence for community-based interventions effectiveness was weak, mainly due to the lack of robust studies.

Incentives for smoking cessation

BACKGROUND

Financial incentives, monetary or vouchers, are widely used in an attempt to precipitate, reinforce and sustain behaviour change, including smoking cessation. They have been used in workplaces, in clinics and hospitals, and within community programmes.

OBJECTIVES

To determine the long-term effect of incentives and contingency management programmes for smoking cessation.

SEARCH METHODS

For this update, we searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The most recent searches were conducted in July 2018.

SELECTION CRITERIA

We considered only randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to smoking cessation incentive schemes or control conditions. We included studies in a mixed-population setting (e.g. community, work-, clinic- or institution-based), and also studies in pregnant smokers.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. The primary outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up (at least six months from the start of the intervention). In the trials of pregnant women we used abstinence measured at the longest follow-up, and at least to the end of the pregnancy. Where available, we pooled outcome data using a Mantel-Haenzel random-effects model, with results reported as risk ratios (RRs) and 95% confidence intervals (CIs), using adjusted estimates for cluster-randomised trials. We analysed studies carried out in mixed populations separately from those carried out in pregnant populations.

MAIN RESULTS

Thirty-three mixed-population studies met our inclusion criteria, covering more than 21,600 participants; 16 of these are new to this version of the review. Studies were set in varying locations, including community settings, clinics or health centres, workplaces, and outpatient drug clinics. We judged eight studies to be at low risk of bias, and 10 to be at high risk of bias, with the rest at unclear risk. Twenty-four of the trials were run in the USA, two in Thailand and one in the Phillipines. The rest were European. Incentives offered included cash payments or vouchers for goods and groceries, offered directly or collected and redeemable online. The pooled RR for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.49 (95% CI 1.28 to 1.73; 31 RCTs, adjusted N = 20,097; I2 = 33%). Results were not sensitive to the exclusion of six studies where an incentive for cessation was offered at long-term follow up (result excluding those studies: RR 1.40, 95% CI 1.16 to 1.69; 25 RCTs; adjusted N = 17,058; I2 = 36%), suggesting the impact of incentives continues for at least some time after incentives cease.Although not always clearly reported, the total financial amount of incentives varied considerably between trials, from zero (self-deposits), to a range of between USD 45 and USD 1185. There was no clear direction of effect between trials offering low or high total value of incentives, nor those encouraging redeemable self-deposits.We included 10 studies of 2571 pregnant women. We judged two studies to be at low risk of bias, one at high risk of bias, and seven at unclear risk. When pooled, the nine trials with usable data (eight conducted in the USA and one in the UK), delivered an RR at longest follow-up (up to 24 weeks post-partum) of 2.38 (95% CI 1.54 to 3.69; N = 2273; I2 = 41%), in favour of incentives.

AUTHORS' CONCLUSIONS

Overall there is high-certainty evidence that incentives improve smoking cessation rates at long-term follow-up in mixed population studies. The effectiveness of incentives appears to be sustained even when the last follow-up occurs after the withdrawal of incentives. There is also moderate-certainty evidence, limited by some concerns about risks of bias, that incentive schemes conducted among pregnant smokers improve smoking cessation rates, both at the end of pregnancy and post-partum. Current and future research might explore more precisely differences between trials offering low or high cash incentives and self-incentives (deposits), within a variety of smoking populations.

Effectiveness and cost-effectiveness of incentives as a tool for prevention of non-communicable diseases: A systematic review

The rising epidemic of non-communicable diseases (NCDs) poses substantial health and economic challenges to both individuals and society. Application of incentive-based strategies based on traditional and behavioural economic theory has emerged as a potential strategy to address rising rates of NCDs. Yet, whether or not incentives truly represent a promising strategy for addressing NCDs has not been systematically addressed nor is it clear whether certain behavioural economic strategies outperform others or simply offering a cash-based incentive for meeting a goal. In this systematic review we aim to determine whether there is an evidence base for any of these strategies. Forty-eight published randomized controlled trials (70 contrasts) evaluating the effectiveness of incentive-based strategies for improvements in NCD risk-factors were reviewed. Our primary conclusion is that there is a lack of compelling evidence that incentives of any form represent a compelling NCD reduction strategy. More evidence for long-term effectiveness and cost-effectiveness is needed to justify third party funding of any incentive based strategy.

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.

Strategies to improve the implementation of workplace-based policies or practices targeting tobacco, alcohol, diet, physical activity and obesity

BACKGROUND

Given the substantial period of time adults spend in their workplaces each day, these provide an opportune setting for interventions addressing modifiable behavioural risk factors for chronic disease. Previous reviews of trials of workplace-based interventions suggest they can be effective in modifying a range of risk factors including diet, physical activity, obesity, risky alcohol use and tobacco use. However, such interventions are often poorly implemented in workplaces, limiting their impact on employee health. Identifying strategies that are effective in improving the implementation of workplace-based interventions has the potential to improve their effects on health outcomes.

OBJECTIVES

To assess the effects of strategies for improving the implementation of workplace-based policies or practices targeting diet, physical activity, obesity, tobacco use and alcohol use.Secondary objectives were to assess the impact of such strategies on employee health behaviours, including dietary intake, physical activity, weight status, and alcohol and tobacco use; evaluate their cost-effectiveness; and identify any unintended adverse effects of implementation strategies on workplaces or workplace staff.

SEARCH METHODS

We searched the following electronic databases on 31 August 2017: CENTRAL; MEDLINE; MEDLINE In Process; the Campbell Library; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); and Scopus. We also handsearched all publications between August 2012 and September 2017 in two speciality journals: Implementation Science and Journal of Translational Behavioral Medicine. We conducted searches up to September 2017 in Dissertations and Theses, the WHO International Clinical Trials Registry Platform, and the US National Institutes of Health Registry. We screened the reference lists of included trials and contacted authors to identify other potentially relevant trials. We also consulted experts in the field to identify other relevant research.

SELECTION CRITERIA

Implementation strategies were defined as strategies specifically employed to improve the implementation of health interventions into routine practice within specific settings. We included any trial with a parallel control group (randomised or non-randomised) and conducted at any scale that compared strategies to support implementation of workplace policies or practices targeting diet, physical activity, obesity, risky alcohol use or tobacco use versus no intervention (i.e. wait-list, usual practice or minimal support control) or another implementation strategy. Implementation strategies could include those identified by the Effective Practice and Organisation of Care (EPOC) taxonomy such as quality improvement initiatives and education and training, as well as other strategies. Implementation interventions could target policies or practices directly instituted in the workplace environment, as well as workplace-instituted efforts encouraging the use of external health promotion services (e.g. gym membership subsidies).

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently performed citation screening, data extraction and 'Risk of bias' assessment, resolving disagreements via consensus or a third reviewer. We narratively synthesised findings for all included trials by first describing trial characteristics, participants, interventions and outcomes. We then described the effect size of the outcome measure for policy or practice implementation. We performed meta-analysis of implementation outcomes for trials of comparable design and outcome.

MAIN RESULTS

We included six trials, four of which took place in the USA. Four trials employed randomised controlled trial (RCT) designs. Trials were conducted in workplaces from the manufacturing, industrial and services-based sectors. The sample sizes of workplaces ranged from 12 to 114. Workplace policies and practices targeted included: healthy catering policies; point-of-purchase nutrition labelling; environmental supports for healthy eating and physical activity; tobacco control policies; weight management programmes; and adherence to guidelines for staff health promotion. All implementation interventions utilised multiple implementation strategies, the most common of which were educational meetings, tailored interventions and local consensus processes. Four trials compared an implementation strategy intervention with a no intervention control, one trial compared different implementation interventions, and one three-arm trial compared two implementation strategies with each other and a control. Four trials reported a single implementation outcome, whilst the other two reported multiple outcomes. Investigators assessed outcomes using surveys, audits and environmental observations. We judged most trials to be at high risk of performance and detection bias and at unclear risk of reporting and attrition bias.Of the five trials comparing implementation strategies with a no intervention control, pooled analysis was possible for three RCTs reporting continuous score-based measures of implementation outcomes. The meta-analysis found no difference in standardised effects (standardised mean difference (SMD) -0.01, 95% CI -0.32 to 0.30; 164 participants; 3 studies; low certainty evidence), suggesting no benefit of implementation support in improving policy or practice implementation, relative to control. Findings for other continuous or dichotomous implementation outcomes reported across these five trials were mixed. For the two non-randomised trials examining comparative effectiveness, both reported improvements in implementation, favouring the more intensive implementation group (very low certainty evidence). Three trials examined the impact of implementation strategies on employee health behaviours, reporting mixed effects for diet and weight status (very low certainty evidence) and no effect for physical activity (very low certainty evidence) or tobacco use (low certainty evidence). One trial reported an increase in absolute workplace costs for health promotion in the implementation group (low certainty evidence). None of the included trials assessed adverse consequences. Limitations of the review included the small number of trials identified and the lack of consistent terminology applied in the implementation science field, which may have resulted in us overlooking potentially relevant trials in the search.

AUTHORS' CONCLUSIONS

Available evidence regarding the effectiveness of implementation strategies for improving implementation of health-promoting policies and practices in the workplace setting is sparse and inconsistent. Low certainty evidence suggests that such strategies may make little or no difference on measures of implementation fidelity or different employee health behaviour outcomes. It is also unclear if such strategies are cost-effective or have potential unintended adverse consequences. The limited number of trials identified suggests implementation research in the workplace setting is in its infancy, warranting further research to guide evidence translation in this setting.

Cigarette dependence and depressive symptoms as predictors of smoking status at five-year follow-up after a workplace smoking cessation program

Workplace smoking cessation interventions increase quit rates compared to no treatment or minimal interventions. However, most studies report data up to one year. This study aims to evaluate long-term effects of a worksite smoking cessation intervention based on cognitive behavioral cessation groups combined with first-line medications, and determine to what extent cigarette dependence (FTCD) and depressive symptoms may influence results at five-year follow-up. Participants were invited to answer a short survey five years after starting the program. A total of 90.4% (n=227) of those who had attended at least one treatment session and were alive, completed the survey. At the five-year follow-up, 29.5% participants reported continuous abstinence. Low scores in the FTCD and low depressive symptoms at baseline predicted continuous abstinence. Three out of four continuous abstainers at twelve months remained abstinent at the five-year follow-up. The study shows that workplace smoking cessation interventions have long-term effects and supports the traditional one-year follow-up period to assess smoking cessation.

Group behaviour therapy programmes for smoking cessation

BACKGROUND

Group therapy offers individuals the opportunity to learn behavioural techniques for smoking cessation, and to provide each other with mutual support.

OBJECTIVES

To determine the effect of group-delivered behavioural interventions in achieving long-term smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register, using the terms 'behavior therapy', 'cognitive therapy', 'psychotherapy' or 'group therapy', in May 2016.

SELECTION CRITERIA

Randomized trials that compared group therapy with self-help, individual counselling, another intervention or no intervention (including usual care or a waiting-list control). We also considered trials that compared more than one group programme. We included those trials with a minimum of two group meetings, and follow-up of smoking status at least six months after the start of the programme. We excluded trials in which group therapy was provided to both active therapy and placebo arms of trials of pharmacotherapies, unless they had a factorial design.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data in duplicate on the participants, the interventions provided to the groups and the controls, including programme length, intensity and main components, the outcome measures, method of randomization, and completeness of follow-up. The main outcome measure was abstinence from smoking after at least six months follow-up in participants smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically-validated rates where available. We analysed participants lost to follow-up as continuing smokers. We expressed effects as a risk ratio for cessation. Where possible, we performed meta-analysis using a fixed-effect (Mantel-Haenszel) model. We assessed the quality of evidence within each study and comparison, using the Cochrane 'Risk of bias' tool and GRADE criteria.

MAIN RESULTS

Sixty-six trials met our inclusion criteria for one or more of the comparisons in the review. Thirteen trials compared a group programme with a self-help programme; there was an increase in cessation with the use of a group programme (N = 4395, risk ratio (RR) 1.88, 95% confidence interval (CI) 1.52 to 2.33, I2 = 0%). We judged the GRADE quality of evidence to be moderate, downgraded due to there being few studies at low risk of bias. Fourteen trials compared a group programme with brief support from a health care provider. There was a small increase in cessation (N = 7286, RR 1.22, 95% CI 1.03 to 1.43, I2 = 59%). We judged the GRADE quality of evidence to be low, downgraded due to inconsistency in addition to risk of bias. There was also low quality evidence of benefit of a group programme compared to no-intervention controls, (9 trials, N = 1098, RR 2.60, 95% CI 1.80 to 3.76 I2 = 55%). We did not detect evidence that group therapy was more effective than a similar intensity of individual counselling (6 trials, N = 980, RR 0.99, 95% CI 0.76 to 1.28, I2 = 9%). Programmes which included components for increasing cognitive and behavioural skills were not shown to be more effective than same-length or shorter programmes without these components.

AUTHORS' CONCLUSIONS

Group therapy is better for helping people stop smoking than self-help, and other less intensive interventions. There is not enough evidence to evaluate whether groups are more effective, or cost-effective, than intensive individual counselling. There is not enough evidence to support the use of particular psychological components in a programme beyond the support and skills training normally included.

Work Site Health Promotion Research: To what Extent can we Generalize the Results and what is Needed to Translate Research to Practice?

Information on external validity of work site health promotion research is essential to translate research findings to practice. The authors provide a literature review of work site health behavior interventions. Using the RE-AIM framework, they summarize characteristics and results of these studies to document reporting of intervention reach, adoption, implementation, and maintenance. The authors reviewed a total of 24 publications from 11 leading health behavior journals. They found that participation rates among eligible employees were reported in 87.5% of studies; only 25% of studies reported on intervention adoption. Data on characteristics of participants versus nonparticipants were reported in fewer than 10% of studies. Implementation data were reported in 12.5% of the studies. Only 8% of studies reported any type of maintenance data. Stronger emphasis is needed on representativeness of employees, work site settings studied, and longer term results. Examples of how this can be done are provided.

Incentives for smoking cessation

BACKGROUND

Material or financial incentives are widely used in an attempt to precipitate or reinforce behaviour change, including smoking cessation. They operate in workplaces, in clinics and hospitals, and to a lesser extent within community programmes. In this third update of our review we now include trials conducted in pregnant women, to reflect the increasing activity and resources now targeting this high-risk group of smokers.

OBJECTIVES

To determine whether incentives and contingency management programmes lead to higher long-term quit rates.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, with additional searches of MEDLINE, EMBASE, CINAHL and PsycINFO. The most recent searches were in December 2014, although we also include two trials published in 2015.

SELECTION CRITERIA

We considered randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures. We include studies in a mixed-population setting (e.g. community-, work-, institution-based), and also, for this update, trials in pregnant smokers.

DATA COLLECTION AND ANALYSIS

One author (KC) extracted data and a second (JH-B) checked them. We contacted study authors for additional data where necessary. The main outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up, and at least six months from the start of the intervention. In the trials of pregnant smokers abstinence was measured at the longest follow-up, and at least to the end of the pregnancy.

MAIN RESULTS

Twenty-one mixed-population studies met our inclusion criteria, covering more than 8400 participants. Ten studies were set in clinics or health centres, one in Thai villages served by community health workers, two in academic institutions, and the rest in worksites. All but six of the trials were run in the USA. The incentives included lottery tickets or prize draws, cash payments, vouchers for goods and groceries, and in six trials the recovery of money deposited by those taking part. The odds ratio (OR) for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.42 (95% confidence interval (CI) 1.19 to 1.69; 17 trials, [20 comparisons], 7715 participants). Only three studies demonstrated significantly higher quit rates for the incentives group than for the control group at or beyond the six-month assessment: One five-arm USA trial compared rewards- and deposit-based interventions at individual and group level, with incentives available up to USD 800 per quitter, and demonstrated a quit rate in the rewards groups of 8.1% at 12 months, compared with 4.7% in the deposits groups. A direct comparison between the rewards-based and the deposit-based groups found a benefit for the rewards arms, with an OR at 12 months of 1.76 (95% CI 1.22 to 2.53; 2070 participants). Although more people in this trial accepted the rewards programmes than the deposit programmes, the proportion of quitters in each group favoured the deposit-refund programme. Another USA study rewarded both participation and quitting up to USD 750, and achieved sustained quit rates of 9.4% in the incentives group compared with 3.6% for the controls. A deposit-refund trial in Thailand also achieved significantly higher quit rates in the intervention group (44.2%) compared with the control group (18.8%), but uptake was relatively low, at 10.5%. In the remaining trials, there was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that contingent rewards enhanced success rates over fixed payment schedules. We rated the overall quality of the older studies as low, but with later trials (post-2000) more likely to meet current standards of methodology and reporting.Eight of nine trials with usable data in pregnant smokers (seven conducted in the USA and one in the UK) delivered an adjusted OR at longest follow-up (up to 24 weeks post-partum) of 3.60 (95% CI 2.39 to 5.43; 1295 participants, moderate-quality studies) in favour of incentives. Three of the trials demonstrated a clear benefit for contingent rewards; one delivered monthly vouchers to confirmed quitters and to their designated 'significant other supporter', achieving a quit rate in the intervention group of 21.4% at two months post-partum, compared with 5.9% among the controls. Another trial offered a scaled programme of rewards for the percentage of smoking reduction achieved over the course of the 12-week intervention, and achieved an intervention quit rate of 31% at six weeks post-partum, compared with no quitters in the control group. The largest (UK-based) trial provided intervention quitters with up to GBP 400-worth of vouchers, and achieved a quit rate of 15.4% at longest follow-up, compared to the control quit rate of 4%. Four trials confirmed that payments made to reward a successful quit attempt (i.e. contingent), compared to fixed payments for attending the antenatal appointment (non-contingent), resulted in higher quit rates. Front-loading of rewards to counteract early withdrawal symptoms made little difference to quit rates.

AUTHORS' CONCLUSIONS

Incentives appear to boost cessation rates while they are in place. The two trials recruiting from work sites that achieved sustained success rates beyond the reward schedule concentrated their resources into substantial cash payments for abstinence. Such an approach may only be feasible where independently-funded smoking cessation programmes are already available, and within a relatively affluent and educated population. Deposit-refund trials can suffer from relatively low rates of uptake, but those who do sign up and contribute their own money may achieve higher quit rates than reward-only participants. Incentive schemes conducted among pregnant smokers improved the cessation rates, both at the end-of-pregnancy and post-partum assessments. Current and future research might continue to explore the scale, loading and longevity of possible cash or voucher reward schedules, within a variety of smoking populations.

The effectiveness of financial incentives for health behaviour change: systematic review and meta-analysis

BACKGROUND

Financial incentive interventions have been suggested as one method of promoting healthy behaviour change.

OBJECTIVES

To conduct a systematic review of the effectiveness of financial incentive interventions for encouraging healthy behaviour change; to explore whether effects vary according to the type of behaviour incentivised, post-intervention follow-up time, or incentive value.

DATA SOURCES

Searches were of relevant electronic databases, research registers, www.google.com, and the reference lists of previous reviews; and requests for information sent to relevant mailing lists.

ELIGIBILITY CRITERIA

Controlled evaluations of the effectiveness of financial incentive interventions, compared to no intervention or usual care, to encourage healthy behaviour change, in non-clinical adult populations, living in high-income countries, were included.

STUDY APPRAISAL AND SYNTHESIS

The Cochrane Risk of Bias tool was used to assess all included studies. Meta-analysis was used to explore the effect of financial incentive interventions within groups of similar behaviours and overall. Meta-regression was used to determine if effect varied according to post-intervention follow up time, or incentive value.

RESULTS

Seventeen papers reporting on 16 studies on smoking cessation (n = 10), attendance for vaccination or screening (n = 5), and physical activity (n = 1) were included. In meta-analyses, the average effect of incentive interventions was greater than control for short-term (≤ six months) smoking cessation (relative risk (95% confidence intervals): 2.48 (1.77 to 3.46); long-term (>six months) smoking cessation (1.50 (1.05 to 2.14)); attendance for vaccination or screening (1.92 (1.46 to 2.53)); and for all behaviours combined (1.62 (1.38 to 1.91)). There was not convincing evidence that effects were different between different groups of behaviours. Meta-regression found some, limited, evidence that effect sizes decreased as post-intervention follow-up period and incentive value increased. However, the latter effect may be confounded by the former.

CONCLUSIONS

The available evidence suggests that financial incentive interventions are more effective than usual care or no intervention for encouraging healthy behaviour change.

TRIAL REGISTRATION

PROSPERO CRD42012002393.

Workplace interventions for smoking cessation

BACKGROUND

The workplace has potential as a setting through which large groups of people can be reached to encourage smoking cessation.

OBJECTIVES

1. To categorize workplace interventions for smoking cessation tested in controlled studies and to determine the extent to which they help workers to stop smoking.2. To collect and evaluate data on costs and cost effectiveness associated with workplace interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register (July 2013), MEDLINE (1966 - July 2013), EMBASE (1985 - June 2013), and PsycINFO (to June 2013), amongst others. We searched abstracts from international conferences on tobacco and the bibliographies of identified studies and reviews for additional references.

SELECTION CRITERIA

We selected interventions conducted in the workplace to promote smoking cessation. We included only randomized and quasi-randomized controlled trials allocating individuals, workplaces, or companies to intervention or control conditions.

DATA COLLECTION AND ANALYSIS

One author extracted information relating to the characteristics and content of all kinds of interventions, participants, outcomes and methods of the studies, and a second author checked them. For this update we have conducted meta-analyses of the main interventions, using the generic inverse variance method to generate odds ratios and 95% confidence intervals.

MAIN RESULTS

We include 57 studies (61 comparisons) in this updated review. We found 31 studies of workplace interventions aimed at individual workers, covering group therapy, individual counselling, self-help materials, nicotine replacement therapy, and social support, and 30 studies testing interventions applied to the workplace as a whole, i.e. environmental cues, incentives, and comprehensive programmes. The trials were generally of moderate to high quality, with results that were consistent with those found in other settings. Group therapy programmes (odds ratio (OR) for cessation 1.71, 95% confidence interval (CI) 1.05 to 2.80; eight trials, 1309 participants), individual counselling (OR 1.96, 95% CI 1.51 to 2.54; eight trials, 3516 participants), pharmacotherapies (OR 1.98, 95% CI 1.26 to 3.11; five trials, 1092 participants), and multiple intervention programmes aimed mainly or solely at smoking cessation (OR 1.55, 95% CI 1.13 to 2.13; six trials, 5018 participants) all increased cessation rates in comparison to no treatment or minimal intervention controls. Self-help materials were less effective (OR 1.16, 95% CI 0.74 to 1.82; six trials, 1906 participants), and two relapse prevention programmes (484 participants) did not help to sustain long-term abstinence. Incentives did not appear to improve the odds of quitting, apart from one study which found a sustained positive benefit. There was a lack of evidence that comprehensive programmes targeting multiple risk factors reduced the prevalence of smoking.

AUTHORS' CONCLUSIONS

1. We found strong evidence that some interventions directed towards individual smokers increase the likelihood of quitting smoking. These include individual and group counselling, pharmacological treatment to overcome nicotine addiction, and multiple interventions targeting smoking cessation as the primary or only outcome. All these interventions show similar effects whether offered in the workplace or elsewhere. Self-help interventions and social support are less effective. Although people taking up these interventions are more likely to stop, the absolute numbers who quit are low.2. We failed to detect an effect of comprehensive programmes targeting multiple risk factors in reducing the prevalence of smoking, although this finding was not based on meta-analysed data. 3. There was limited evidence that participation in programmes can be increased by competitions and incentives organized by the employer, although one trial demonstrated a sustained effect of financial rewards for attending a smoking cessation course and for long-term quitting. Further research is needed to establish which components of this trial contributed to the improvement in success rates.4. Further research would be valuable in low-income and developing countries, where high rates of smoking prevail and smoke-free legislation is not widely accepted or enforced.

An innovative team-based stop smoking competition among Māori and Pacific Island smokers: rationale and method for the study and its evaluation

BACKGROUND

Māori and Pacific Island people have significantly higher smoking rates compared to the rest of the New Zealand population. The main aim of this paper is to describe how knowledge of Indigenous people's practices and principles can be combined with proven effective smoking cessation support into a cessation intervention appropriate for Indigenous people.

METHODS/DESIGN

A literature review was conducted to identify what cultural principles and practices could be used to increase salience, and what competition elements could have an impact on efficacy of smoking cessation. The identified elements were incorporated into the design of a cessation intervention.

DISCUSSION

Cultural practices incorporated into the intervention include having a holistic family or group-centred focus, inter-group competitiveness, fundraising and ritual pledging. Competition elements included are social support, pharmacotherapy use, cash prize incentives and the use of a dedicated website and iPad application. A pre-test post-test will be combined with process evaluation to evaluate if the competition results in triggering mass-quitting, utilisation of pharmacotherapy and in increasing sustained smoking cessation and to get a comprehensive understanding of the way in which they contribute to the effect. The present study is the first to describe how knowledge about cultural practices and principles can be combined with proven cessation support into a smoking cessation contest. The findings from this study are promising and further more rigorous testing is warranted.

The effect of a booster intervention to promote hearing protection behavior in operating engineers

BACKGROUND

Booster interventions may be useful in promoting workers' hearing protection device (HPD) use. Previous research on the effectiveness and the optimal timeframe for boosters is limited and inconsistent.

METHODS

In this randomized controlled trial, 403 workers were assigned to receive an individually tailored booster, a control booster, or no booster. The booster intervention groups were further divided by timeframe. Frequency of HPD use was measured 12 months post-intervention.

RESULTS

The booster intervention groups significantly accounted for the variance in HPD use in Year 2. Workers in middle-term booster (67-94 days) group reported a significantly greater increase in HPD use in Year 2 than those in other timeframes, when potential covariates were controlled for.

CONCLUSIONS

Booster intervention letters mailed between 67 and 94 days post-initial intervention may promote HPD use among participants. Future research should explore additional factors associated with optimal booster design, including more innovative mobile and internet-based approaches.

Competitions and incentives for smoking cessation

BACKGROUND

Background Material or financial incentives may be used in an attempt to reinforce behaviour change, including smoking cessation. They have been widely used in workplace smoking cessation programmes, and to a lesser extent within community programmes. Public health initiatives in the UK are currently planning to deploy incentive schemes to change unhealthy behaviours. Quit and Win contests are the subject of a companion review.

OBJECTIVES

To determine whether competitions and incentives lead to higher long-term quit rates. We also set out to examine the relationship between incentives and participation rates.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE, EMBASE, CINAHL and PsycINFO. Search terms included incentive*, competition*, contest*, reward*, prize*, contingent payment*, deposit contract*. The most recent searches were in November 2010.

SELECTION CRITERIA

We considered randomized controlled trials, allocating individuals, workplaces, groups within workplaces, 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 (KC) and checked by the second (RP). We contacted study authors for additional data where necessary. The main outcome measure was abstinence from smoking 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. Where possible we performed meta-analysis using a generic inverse variance model, grouped by timed endpoints, but not pooled across the subgroups.

MAIN RESULTS

Nineteen studies met our inclusion criteria, covering >4500 participants. Only one study, the largest in our review and covering 878 smokers, demonstrated significantly higher quit rates for the incentives group than for the control group beyond the six-month assessment. This trial referred its participants to local smoking cessation services, and offered substantial cash payments (up to US$750) for prolonged abstinence. In the remaining trials, there was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that contingent rewards enhanced success rates over fixed payment schedules. There is some evidence that recruitment rates can be improved by rewarding participation, which may be expected to deliver higher absolute numbers of successful quitters. Cost effectiveness analysis was not appropriate to this review, since the efficacy of most of the interventions was not demonstrated.

AUTHORS' CONCLUSIONS

With the exception of one recent trial, incentives and competitions have not been shown to enhance long-term cessation rates. Early success tended to dissipate when the rewards were no longer offered. Rewarding participation and compliance in contests and cessation programmes may have potential to deliver higher absolute numbers of quitters. The one trial that achieved sustained success rates beyond the reward schedule concentrated its resources into substantial cash payments for abstinence rather than into running its own smoking cessation programme. Such an approach may only be feasible where independently-funded smoking cessation programmes are already available. Future research might explore the scale and longevity of possible cash reward schedules, within a variety of smoking populations.

Smoking Cessation Intervention Using Stepwise Exercise Incentives for Male Workers in the Workplace

The authors developed a stepwise exercise-incentive-based smoking cessation program as one of the workplace health promotion program. The aim of this study is to evaluate the program offered in an electronics company in Korea. A total of 109 electronics company employees were recruited. Participants were surveyed for smoking history, nicotine dependence, and job stress. They received smoking cessation education and were provided with a stepwise fitness center ticket. Of 109 participants, 58 (53.2%) successfully ceased smoking for 3 months. Significant differences between success and fail groups were apparent in cigarettes smoked per day ( P = .002) and nicotine dependence score ( P = .049). However, there was no significant difference in job stress between success and fail groups. Based on multiple logistic regression analysis, there were no identifiable factors associated with smoking cessation. In conclusion, a stepwise exercise-incentive-based smoking cessation program was highly effective when applied in a workplace setting.

Does workplace social capital buffer the effects of job stress? A cross-sectional, multilevel analysis of cigarette smoking among U.S. manufacturing workers

OBJECTIVE

To investigate whether workplace social capital buffers the association between job stress and smoking status.

METHODS

As part of the Harvard Cancer Prevention Project's Healthy Directions--Small Business Study, interviewer-administered questionnaires were completed by 1740 workers and 288 managers in 26 manufacturing firms (84% and 85% response). Social capital was assessed by multiple items measured at the individual level among workers and contextual level among managers. Job stress was operationalized by the demand-control model. Multilevel logistic regression was used to estimate associations between job stressors and smoking and test for effect modification by social capital measures.

RESULTS

Workplace social capital (both summary measures) buffered associations between high job demands and smoking. One compositional item--worker trust in managers--buffered associations between job strain and smoking.

CONCLUSION

Workplace social capital may modify the effects of psychosocial working conditions on health behaviors.

Worksite-based incentives and competitions to reduce tobacco use. A systematic review

The Guide to Community Preventive Service (Community Guide) methods for systematic reviews were used to evaluate the evidence of effectiveness of worksite-based incentives and competitions to reduce tobacco use among workers. These interventions offer a reward to individuals or to teams of individuals on the basis of participation or success in a specified smoking behavior change (such as abstaining from tobacco use for a period of time). The review team identified a total of 26 published studies, 14 of which met study design and quality of execution criteria for inclusion in the final assessment. Only one study, which did not qualify for review, evaluated the use of incentives when implemented alone. All of the 14 qualifying studies evaluated incentives and competitions when implemented in combination with a variety of additional interventions, such as client education, smoking cessation groups, and telephone cessation support. Of the qualifying studies, 13 evaluated differences in tobacco-use cessation among intervention participants, with a median follow-up period of 12 months. The median change in self-reported tobacco-use cessation was an increase of 4.4 percentage points (a median relative percentage improvement of 67%). The present evidence is insufficient to determine the effectiveness of incentives or competitions, when implemented alone, to reduce tobacco use. However, the qualifying studies provide strong evidence, according to Community Guide rules, that worksite-based incentives and competitions in combination with additional interventions are effective in increasing the number of workers who quit using tobacco. In addition, these multicomponent interventions have the potential to generate positive economic returns over investment when the averted costs of tobacco-associated illnesses are considered. A concurrent systematic review identified four studies with economic evidence. Two of these studies provided evidence of net cost savings to employers when program costs are adjusted for averted healthcare expenses and productivity losses, based on referenced secondary estimates.

Television-supported self-help for problem drinkers: a randomized pragmatic trial

OBJECTIVES

To test the effectiveness of a television-supported self-help intervention for problem drinking.

METHODS

Dutch television viewers (N=181) drinking in excess of the guidelines for low-risk alcohol use were randomly assigned either to the Drinking Less TV self-help course (consisting of five televised sessions supplemented by a self-help manual and a self-help website) or to a waitlisted control group. To ensure trial integrity, intervention delivery was mimicked beforehand by sending intervention participants weekly DVDs in advance of the actual telecasts in 2006. Pre-post assessments were carried out on both groups, as well as a 3-month follow-up assessment on the intervention group to study effect maintenance. The primary outcome measure was low-risk drinking.

RESULTS

The intervention group was more successful than the waitlist group in achieving low-risk drinking at post-intervention (OR=9.4); the effects were maintained in the intervention group at 3-month follow-up.

CONCLUSIONS

The low-threshold television-based course Drinking Less appears effective in reducing problem drinking.

Workplace interventions for smoking cessation

BACKGROUND

The workplace has potential as a setting through which large groups of people can be reached to encourage smoking cessation.

OBJECTIVES

To categorize workplace interventions for smoking cessation tested in controlled studies and to determine the extent to which they help workers to stop smoking or to reduce tobacco consumption.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register in April 2008, MEDLINE (1966 - April 2008), EMBASE (1985 - Feb 2008) and PsycINFO (to March 2008). We searched abstracts from international conferences on tobacco and the bibliographies of identified studies and reviews for additional references.

SELECTION CRITERIA

We selected interventions conducted in the workplace to promote smoking cessation. We included only randomized and quasi-randomized controlled trials allocating individuals, workplaces or companies to intervention or control conditions.

DATA COLLECTION AND ANALYSIS

Information relating to the characteristics and content of all kinds of interventions, participants, outcomes and methods of the study was abstracted by one author and checked by another. Because of heterogeneity in the design and content of the included studies, we did not attempt formal meta-analysis, and evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

We include 51 studies covering 53 interventions in this updated review. We found 37 studies of workplace interventions aimed at individual workers, covering group therapy, individual counselling, self-help materials, nicotine replacement therapy and social support. The results were consistent with those found in other settings. Group programmes, individual counselling and nicotine replacement therapy increased cessation rates in comparison to no treatment or minimal intervention controls. Self-help materials were less effective. We also found 16 studies testing interventions applied to the workplace as a whole. There was a lack of evidence that comprehensive programmes reduced the prevalence of smoking. Incentive schemes increased attempts to stop smoking, though there was less evidence that they increased the rate of actual quitting.

AUTHORS' CONCLUSIONS

1. We found strong evidence that interventions directed towards individual smokers increase the likelihood of quitting smoking. These include individual and group counselling and pharmacological treatment to overcome nicotine addiction. All these interventions show similar effects whether offered in the workplace or elsewhere. Self-help interventions and social support are less effective. Although people taking up these interventions are more likely to stop, the absolute numbers who quit are low.2. There was limited evidence that participation in programmes can be increased by competitions and incentives organized by the employer.3. We failed to detect an effect of comprehensive programmes in reducing the prevalence of smoking.

Competitions and incentives for smoking cessation

BACKGROUND

Material or financial incentives may be used in an attempt to reinforce behaviour change, including smoking cessation. They have been widely used in workplace smoking cessation programmes, and to a lesser extent within community programmes. Quit and Win contests are the subject of a companion review.

OBJECTIVES

To determine whether competitions and incentives lead to higher long-term quit rates. We also set out to examine the relationship between incentives and participation rates.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE, EMBASE, CINAHL and PsycINFO. Search terms included incentive*, competition*, contest*, reward*, prize*, contingent payment*, deposit contract*. The most recent searches were in December 2007.

SELECTION CRITERIA

We considered randomized controlled trials, allocating individuals, workplaces, groups within workplaces, 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 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. Where possible we performed meta-analysis using a generic inverse variance model, grouped by timed endpoints, but not pooled across the subgroups.

MAIN RESULTS

Seventeen studies met our inclusion criteria. None of the studies demonstrated significantly higher quit rates for the incentives group than for the control group beyond the six-month assessment. There was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that different types of incentives were more or less effective. There is some evidence that although cessation rates have not been shown to differ significantly, recruitment rates can be improved by rewarding participation, which may be expected to deliver higher absolute numbers of successful quitters. Cost effectiveness analysis is not appropriate to this review, since the efficacy of the intervention has not been demonstrated.

AUTHORS' CONCLUSIONS

Incentives and competitions have not been shown to enhance long-term cessation rates, with early success tending to dissipate when the rewards are no longer offered. Rewarding participation and compliance in contests and cessation programmes may have more potential to deliver higher absolute numbers of quitters.

An intensive group therapy programme for smoking cessation using nicotine patch and internet mailing supports in a university setting

AIMS

Despite the growing literature on workplace tobacco control policies, very few studies have evaluated the role of smoking cessation programme as one of these policies in a university setting. We aimed to investigate the efficacy of intensive cessation programme delivered in a group format using nicotine patch therapy and internet mailing supports for our university employees.

METHODS

From January 2003, we conducted the group therapy programme for smoking cession seven times in Okayama University, Japan. This programme consisted of nicotine patch therapy and on-line supporting system. Smoking status was regularly assessed by direct interviews.

RESULTS

A total of 102 employees were enrolled in this programme, of whom 101 initiated their smoking cessation. One hundred participants (99%) received nicotine patch therapy, and its toxicities were generally mild. Of the 94 employees who could be follow-up for a year after the cessation, 50 (53%) sustained abstinence for a year. Multivariate analysis revealed that writing and sending e-mail messages within the first 1 week were significant factors affecting long-term cessation. The type of position also affected the cessation rate.

CONCLUSION

This study suggests that our programme in a university setting seems to be effective mainly because of peer-supports among the participants through regular face-to-face meetings and their own mailing supports.

Preventive care in Appalachia: use of the theory of planned behavior to identify barriers to participation in cholesterol screenings among West Virginians

CONTEXT

West Virginians are at increased risk for heart disease. Given that the process of atherosclerosis begins in childhood, the Coronary Artery Risk Detection in Appalachian Communities Project was developed to reduce this risk by implementing a cholesterol screening program in the schools. However, participation rates have been less than desired.

PURPOSE

This study examined the barriers to participation in preventive health screenings, specifically cholesterol screenings, in adults and children of West Virginia using the theory of planned behavior to guide conceptualization.

METHODS

A total of 14 community leaders, 36 parents, and 92 fifth-grade children from 6 West Virginia counties with predominately rural populations participated in individual and focus group interviews. Qualitative analysis was used to examine interview transcripts.

FINDINGS

Adult and child attitudes about preventive care were the largest barrier to cholesterol screenings. Adult attitudinal barriers included concerns with outcomes of testing, lack of knowledge about cholesterol and heart disease, concerns about needles, and traditional Appalachian cultural beliefs (resistance to change, denial, and fatalism). Children cited concerns about needles, outcomes of testing, privacy, and lack of concern about health and cholesterol. Adults also acknowledged environmental barriers to screenings. Finally, children reported a lack of social pressure to participate in prevention activities.

CONCLUSIONS

Attitudinal, social normative, and environmental barriers to health screenings may be characteristic of impoverished rural Appalachians. Interventions are being designed to target these belief barriers to improve participation in cholesterol screenings for fifth graders.

Contingency management for treatment of substance use disorders: a meta-analysis

AIMS

To examine the effectiveness of contingency management (CM) techniques in treating substance use disorders (i.e. illicit drugs, alcohol, tobacco).

DESIGN

Meta-analysis was used to determine the average effect size and potential moderators in 47 comparisons of the effectiveness of CM from studies based on a treatment-control group design and published between 1970 and 2002.

FINDINGS

The mean effect size (ES) of CM was positive, with a magnitude of d = 0.42 using a fixed effects model. The magnitude of the ES declined over time, following treatment. CM was more effective in treating opiate use (d = 0.65) and cocaine use (d = 0.66), compared with tobacco (d = 0.31) or multiple drugs (d = 0.42). Larger effect sizes were associated with higher researcher involvement, earlier studies and shorter treatment duration.

CONCLUSIONS

Study findings suggest that CM is among the more effective approaches to promoting abstinence during the treatment of substance use disorders. CM improves the ability of clients to remain abstinent, thereby allowing them to take fuller advantage of other clinical treatment components.

Competitions and incentives for smoking cessation

BACKGROUND

Material or financial incentives may be used in an attempt to reinforce behaviour change, including smoking cessation. They have been widely used in workplace smoking cessation programmes, and to a lesser extent within community programmes. Quit and Win contests are the subject of a companion review.

OBJECTIVES

To determine whether competitions and incentives lead to higher long-term quit rates. We also set out to examine the relationship between incentives and participation rates.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE (January 1966 to September 2004), EMBASE (1980 to 2004/8), CINAHL (1982 to 2004/8) and PsycINFO (1872 to 2004/6). Search terms included incentive*, competition*, contest*, reward*, prize*, contingent payment*, deposit contract*.

SELECTION CRITERIA

We considered randomized controlled trials, allocating individuals, workplaces, groups within workplaces, 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. Where possible we performed meta-analysis using a generic inverse variance model, grouped by timed endpoints, but not pooled across the subgroups.

MAIN RESULTS

Fifteen studies met our inclusion criteria. None of the studies demonstrated significantly higher quit rates for the incentives group than for the control group beyond the six-month assessment. There was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that different types of incentives were more or less effective. There is some evidence that although cessation rates have not been shown to differ significantly, recruitment rates can be improved by rewarding participation, which may be expected to deliver higher absolute numbers of successful quitters. Cost effectiveness analysis is not appropriate to this review, since the efficacy of the intervention has not been demonstrated.

AUTHORS' CONCLUSIONS

Incentives and competitions do not appear to enhance long-term cessation rates, with early success tending to dissipate when the rewards are no longer offered. Rewarding participation and compliance in contests and cessation programmes may have more potential to deliver higher absolute numbers of quitters.

Workplace interventions for smoking cessation

BACKGROUND

The workplace has potential as a setting through which large groups of people can be reached to encourage smoking cessation.

OBJECTIVES

To categorize workplace interventions for smoking cessation tested in controlled studies and to determine the extent to which they help workers to stop smoking or to reduce tobacco consumption.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register in October 2004, MEDLINE (1966 - October 2004), EMBASE (1985 - October 2004) and PsycINFO (to October 2004). We searched abstracts from international conferences on tobacco and we checked the bibliographies of identified studies and reviews for additional references.

SELECTION CRITERIA

We categorized interventions into two groups: a) Interventions aimed at the individual to promote smoking cessation and b) interventions aimed at the workplace as a whole. We applied different inclusion criteria for the different types of study. For interventions aimed at helping individuals to stop smoking, we included only randomized controlled trials allocating individuals, workplaces or companies to intervention or control conditions. For studies of smoking restrictions and bans in the workplace, we also included controlled trials with baseline and post-intervention outcomes and interrupted times series studies.

DATA COLLECTION AND ANALYSIS

Information relating to the characteristics and content of all kinds of interventions, participants, outcomes and methods of the study was abstracted by one author and checked by two others. Because of heterogeneity in the design and content of the included studies, we did not attempt formal meta-analysis, and evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

Workplace interventions aimed at helping individuals to stop smoking included ten studies of group therapy, seven studies of individual counselling, nine studies of self-help materials and five studies of nicotine replacement therapy. The results were consistent with those found in other settings. Group programmes, individual counselling and nicotine replacement therapy increased cessation rates in comparison to no treatment or minimal intervention controls. Self-help materials were less effective.Workplace interventions aimed at the workforce as a whole included 14 studies of tobacco bans, two studies of social support, four studies of environmental support, five studies of incentives, and eight studies of comprehensive (multi-component) programmes. Tobacco bans decreased cigarette consumption during the working day but their effect on total consumption was less certain. We failed to detect an increase in quit rates from adding social and environmental support to these programmes. There was a lack of evidence that comprehensive programmes reduced the prevalence of smoking. Competitions and incentives increased attempts to stop smoking, though there was less evidence that they increased the rate of actual quitting.

AUTHORS' CONCLUSIONS

We found: 1. Strong evidence that interventions directed towards individual smokers increase the likelihood of quitting smoking. These include advice from a health professional, individual and group counselling and pharmacological treatment to overcome nicotine addiction. Self-help interventions are less effective. All these interventions are effective whether offered in the workplace or elsewhere. Although people taking up these interventions are more likely to stop, the absolute numbers who quit are low. 2. Limited evidence that participation in programmes can be increased by competitions and incentives organized by the employer. 3. Consistent evidence that workplace tobacco policies and bans can decrease cigarette consumption during the working day by smokers and exposure of non-smoking employees to environmental tobacco smoke at work, but conflicting evidence about whether they decrease prevalence of smoking or overall consumption of tobacco by smokers. 4. A lack of evidence that comprehensive approaches reduce the prevalence of smoking, despite the strong theoretical rationale for their use. 5. A lack of evidence about the cost-effectiveness of workplace programmes.

Group behaviour therapy programmes for smoking cessation

BACKGROUND

Group therapy offers individuals the opportunity to learn behavioural techniques for smoking cessation, and to provide each other with mutual support.

OBJECTIVES

We aimed to determine the effects of smoking cessation programmes delivered in a group format compared to self-help materials, or to no intervention; to compare the effectiveness of group therapy and individual counselling; and to determine the effect of adding group therapy to advice from a health professional or to nicotine replacement. We also aimed to determine whether specific components increased the effectiveness of group therapy. We aimed to determine the rate at which offers of group therapy are taken up.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Trials Register, with additional searches of MEDLINE and PsycINFO, including the terms behavior therapy, cognitive therapy, psychotherapy or group therapy, in January 2005.

SELECTION CRITERIA

We considered randomized trials that compared group therapy with self help, individual counselling, another intervention or no intervention (including usual care or a waiting list control). We also considered trials that compared more than one group programme. We included those trials with a minimum of two group meetings, and follow up of smoking status at least six months after the start of the programme. We excluded trials in which group therapy was provided to both active therapy and placebo arms of trials of pharmacotherapies, unless they had a factorial design.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the participants, the interventions provided to the groups and the controls, including programme length, intensity and main components, the outcome measures, method of randomization, and completeness of follow up. The main outcome measure was abstinence from smoking after at least six months follow up in patients smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Subjects lost to follow up were analyzed as continuing smokers. Where possible, we performed meta-analysis using a fixed-effects (Mantel-Haenszel) model.

MAIN RESULTS

A total of 55 trials met inclusion criteria for one or more of the comparisons in the review. Sixteen studies compared a group programme with a self-help programme. There was an increase in cessation with the use of a group programme (N = 4395, odds ratio (OR) 2.04, 95% confidence interval (CI) 1.60 to 2.60). Group programmes were more effective than no intervention controls (seven trials, N = 815, OR 2.17, 95% CI 1.37 to 3.45). There was no evidence that group therapy was more effective than a similar intensity of individual counselling. There was limited evidence that the addition of group therapy to other forms of treatment, such as advice from a health professional or nicotine replacement, produced extra benefit. There was variation in the extent to which those offered group therapy accepted the treatment. There was limited evidence that programmes which included components for increasing cognitive and behavioural skills and avoiding relapse were more effective than same length or shorter programmes without these components. This analysis was sensitive to the way in which one study with multiple conditions was included. We did not find an effect of manipulating the social interactions between participants in a group programme on outcome.

AUTHORS' CONCLUSIONS

Group therapy is better for helping people stop smoking than self help, and other less intensive interventions. There is not enough evidence to evaluate whether groups are more effective, or cost-effective, than intensive individual counselling. There is not enough evidence to support the use of particular psychological components in a programme beyond the support and skills training normally included.

The effectiveness of workplace smoking cessation programmes: a meta-analysis of recent studies

OBJECTIVE

Using meta-analytic procedures, we compare the effectiveness of recent controlled trials of worksite smoking cessation during the 1990s with a previous meta-analysis of programmes conducted in the 1980s.

DATA SOURCES

ABI/Inform, BRS, CHID, Dissertation Abstracts International, ERIC, Medline, Occupational Health and Safety Database, PsycInfo, Smoking and Health Database, SSCI, and Sociological Abstracts.

STUDY SELECTION

Controlled smoking cessation interventions at the workplace with at least six months follow up published from 1989 to 2001 and reporting quit rates (QRs).

DATA EXTRACTION

Two reviewers independently scanned titles/abstracts of relevant reports, and we reached consensus regarding inclusion/exclusion of the full text reports by negotiation. A third reviewer resolved disagreements. Two reviewers extracted data according to a coding manual. Consensus was again reached through negotiation and the use of a third reviewer.

DATA SYNTHESIS

19 journal articles were found reporting studies conforming to the study's inclusion criteria. Interventions included self help manuals, physician advice, health education, cessation groups, incentives, and competitions. A total of 4960 control subjects were compared with 4618 intervention subjects. The adjusted random effects odds ratio was 2.03 (95% confidence interval 1.42 to 2.90) at six months follow up, 1.56 (95% CI 1.17 to 2.07) at 12 months, and 1.33 (95% CI 0.95 to 1.87) at more than 12 months follow up. Funnel plots were consistent with strong publication bias at the first two follow ups but not the third. In Fisher et al's 1990 study, the corresponding ORs were 1.18, 1.66, and 1.18.

CONCLUSIONS

Smoking cessation interventions at the worksite showed initial effectiveness, but the effect seemed to decrease over time and was not present beyond 12 months. Compared to the Fisher (1990) analysis, the effectiveness was higher for the six month follow up. Disappointingly, we found methodological inadequacies and insufficient reporting of key variables that were similar to those found in the earlier meta-analysis. This prevented us from determining much about the most effective components of interventions. It is advisable for researchers conducting studies in the future to report data on attrition and retention rates of participants who quit, because these variables can affect QRs.

Effects of booster interventions on factory workers' use of hearing protection

BACKGROUND

The provision of reinforcements or boosters to interventions is seen as a logical approach to enhancing or maintaining desired behavior. Empirical studies, however, have not confirmed the effectiveness of boosters nor assessed the optimum number of boosters or the timing for their delivery.

OBJECTIVES

This randomized controlled trial contrasted the effect of four booster conditions (a). 30 days; (b). 90 days; (c). 30 and at 90 days; and (d). no boosters of the intervention to increase the use of hearing protection devices (HPDs).

METHODS

A total of 1325 factory workers completed a computerized questionnaire and were randomly assigned to one of three computer-based (tailored, nontailored predictor-based, or control) multimedia interventions designed to increase the use of hearing protection devices. After the intervention, colorful boosters specific to the type of training received were mailed to workers' homes. Posttest measures of use were administered at the time of their next annual audiogram 6 to 18 months after the intervention. RESULTS Repeated measures of analysis of variance (ANOVA) showed a significant main effect for the booster (after 30 days) in the group that received tailored training (F[3442] = 2.722; p =.04). However, in the assessment of the interaction between time (pretest and posttest) and boosters (four groups), the ANOVA did not find significant differences in hearing protection device use for any of the training groups. To assess for significant differences between groups, post hoc comparisons were conducted at the pretest and posttest for the total sample and for the subsample of workers who reported using hearing protection devices less than 100% of the time needed. Sheffé contrasts by intervention group, gender, ethnicity, and hearing ability found no significant changes in the mean use of hearing protection devices for the booster groups.

CONCLUSIONS

Although the provision of boosters represented a considerable commitment of resources, their use was not effective in this study. However, it would be premature to eliminate boosters of interventions. Further study is needed to explore the effects of different booster types for increasing the use of hearing protection devices, and to assess carefully the effects of boosters on other health behaviors in studies with controlled designs.

Group behaviour therapy programmes for smoking cessation

BACKGROUND

Group therapy offers individuals the opportunity to learn behavioural techniques for smoking cessation, and to provide each other with mutual support.

OBJECTIVES

We aimed to determine the effects of smoking cessation programmes delivered in a group format compared to self-help materials, or to no intervention; to compare the effectiveness of group therapy and individual counselling; and to determine the effect of adding group therapy to advice from a health professional or nicotine replacement. We also aimed to determine whether specific components increased the effectiveness of group therapy. We aimed to determine the rate at which offers of group therapy are taken up.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register, with additional searches of PsycInfo and MEDLINE, including the terms behavior therapy, cognitive therapy, psychotherapy or group therapy, in December 2001.

SELECTION CRITERIA

We considered randomised trials that compared group therapy with self-help, individual counselling, another intervention or no intervention (including usual care or a waiting list control). We also considered trials that compared more than one group programmes. We included those trials with a minimum of two group meetings, and follow-up of smoking status at least six months after the start of the programme. We excluded trials in which group therapy was provided to both active therapy and placebo arms of trials of pharmacotherapies, unless they had a factorial design.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the people recruited, the interventions provided to the groups and the controls, including programme length, intensity and main components, the outcome measures, method of randomisation, and completeness of follow-up. The main outcome measure was abstinence from smoking after at least six months follow-up in patients smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Subjects lost to follow-up were counted as smokers. Where possible, we performed meta-analysis using a fixed effects (Peto) model.

MAIN RESULTS

A total of fifty two trials met inclusion criteria for one or more of the comparisons in the review. Sixteen studies compared a group programme with a self-help programme. There was an increase in cessation with the use of a group programme (N=4,395, odds ratio 1.97, 95% confidence interval 1.57 to 2.48). Group programmes were more effective than no intervention controls (six trials, N=775, odds ratio 2.19, 95% confidence interval 1.42 to 3.37). There was no evidence that group therapy was more effective than a similar intensity of individual counselling. There was limited evidence that the addition of group therapy to other forms of treatment, such as advice from a health professional or nicotine replacement produced extra benefit. There was variation in the extent to which those offered group therapy accepted the treatment. There was limited evidence that programmes which included components for increasing cognitive and behavioural skills and avoiding relapse were more effective than same length or shorter programmes without these components. This analysis was sensitive to the way in which one study with multiple conditions was included. There was no evidence that manipulating the social interactions between participants in a group programme had an effect on outcome.

REVIEWER'S CONCLUSIONS

Groups are better than self-help, and other less intensive interventions. There is not enough evidence on their effectiveness, or cost-effectiveness, compared to intensive individual counselling. The inclusion of skills training to help smokers avoid relapse appears to be useful although the evidence is limited. There is not enough evidence to support the use of particular components in a programme beyond the support and skills training normally included.

Gender and smoking behavior in a worksite smoking cessation program

Gender-specific patterns in smoking behavior among 844 men and women who participated in a worksite smoking cessation program were explored. Although gender did not predict outcome, men and women did differ on a number of smoking behaviors and smoking history variables. Male participants smoked cigarettes with a higher nicotine content and smoked a greater number of cigarettes per day. Females reported having made more previous attempts to quit, less confidence about quitting, greater effort to quit, greater worry about smoking-related illness, and that they would be less likely to quit on their own if this program were not offered. Females did tend to report receiving higher levels of general social support, as well as partner support for quitting smoking; however, greater support did not lead to higher quit rates. At the 2-year assessment, 14.3% of female participants (n = 532) reported abstinence, while 13.5% of male participants (n = 312) reported abstinence, when missing data were recoded as smoking.

Social support in a worksite smoking intervention. A test of theoretical models

To better understand how social support operates in smoking cessation, three models of support were tested: main effect, stress-buffering, and indirect. Employees from 61 worksites received (a) self-help manuals (SH); (b) self-help manuals and incentives (I); or (c) self-help manuals, incentives, and social support groups (G). At 24 months, results suggest that the main effect model of social support was operating in this study. That is, social support had a direct influence on smoking cessation. The group intervention significantly enhanced positive partner support across all time points, and partner support facilitated quitting smoking. Higher levels of appraisal support also significantly predicted successful quitting. The beneficial effects of social support were sustained throughout the process of quitting and long-term maintenance.

Tobacco, drug, and HIV preventive media interventions

Media-based health promotion interventions can reach large segments of the population and lower barriers to participation in programs. By collaborating with media specialists, we can develop interventions that might be broader, more publicized, and ultimately more likely to change behaviors and attitudes within the community. The present paper describes a series of media interventions involving smoking cessation, drug abuse prevention, stress reduction, weight control, and HIV/AIDS prevention. The process by which I became involved in these interventions is discussed, and the implications of developing these types of large-scale behavioral interventions are discussed.