The effect of financial incentives on top of behavioral support on quit rates in tobacco smoking employees: study protocol of a cluster-randomized trial

How Financial Incentives Increase Smoking Cessation: A Two-Level Path Analysis

Introduction

Financial incentives effectively increase smoking cessation rates, but it is unclear via which psychological mechanisms incentives influence quit behavior. The current study examines how receiving financial incentives for smoking cessation leads to quitting smoking and investigates several mediators and moderators of that relationship.

Aims and Methods

The study sample consisted of 604 tobacco-smoking employees from 61 companies in the Netherlands who completed a baseline and follow-up questionnaire. The current study is a secondary analysis from a cluster randomized trial where employees received smoking cessation group counseling at the workplace. Participants in the intervention group additionally received financial incentives of €350 in total for 12-month continuous smoking abstinence. We used a two-level path analysis to test a model that assesses the effects of financial incentives through smoking cessation program evaluation, medication use, nicotine replacement use, attitudes, self-efficacy, and social influences on quit success. We additionally tested whether an individual’s reward responsiveness moderated the influence of incentives on quit success.

Results

The effect of financial incentives on quit success was mediated by a higher self-efficacy. Financial incentives were also associated with a higher use of cessation medication. A more positive program evaluation was related to higher self-efficacy, more social influence to quit, and more positive attitudes about quitting. The results did not differ significantly by individual reward responsiveness.

Conclusions

The results of the current study suggest that financial incentives may be used to increase medication use and self-efficacy for quitting smoking, which offers an indirect way to increase successful smoking cessation.

Implications

(1) This is the first study investigating via which psychological pathways financial incentives for quitting smoking can lead to long-term quit success. (2) The results showed a path between financial incentives and a higher likelihood of medication use. Incentives may encourage smokers to use medication in order to increase their chance of quitting smoking and receive the reward. (3) There was a path from financial incentives to quit success via a higher self-efficacy. (4) The effects of financial incentives did not depend on individual reward responsiveness.

Cost-effectiveness and cost-utility analysis of a work-place smoking cessation intervention with and without financial incentives

AIMS

To perform an economic evaluation of a work-place smoking cessation group training programme with incentives compared with a training programme without incentives.

DESIGN

A trial-based cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) from a societal perspective and an employer's perspective.

SETTING

Sixty-one companies in the Netherlands.

PARTICIPANTS

A total of 604 tobacco-smoking employees.

INTERVENTION AND COMPARATOR

A 7-week work-place smoking cessation group training programme. The intervention group earned gift vouchers of €350 for 12 months' continuous abstinence. The comparator group received no incentives.

MEASUREMENTS

Online questionnaires were administered to assess quality of life (EQ-5D-5 L) and resource use during the 14-month follow-up period (2-month training period plus 12-month abstinence period). For the CEA the primary outcome measure was carbon monoxide (CO)-validated continuous abstinence; for the CUA the primary outcome was quality-adjusted life years (QALY). Bootstrapping and sensitivity analyses were performed to account for uncertainty. Incremental cost-effectiveness ratio (ICER) tables were used to determine cost-effectiveness from a life-time perspective.

FINDINGS

Of the participants in the intervention group, 41.1% had quit smoking compared with 26.4% in the control group. From a societal perspective with a 14-month follow-up period, the ICER per quitter for an intervention with financial incentives compared with no incentives was €11 546. From an employer's perspective, the ICER was €5686. There was no significant difference in QALYs between the intervention and control group within the 14-month follow-up period. The intervention was dominated by the comparator in the primary analysis at a threshold of €20 000 per QALY. In the sensitivity analysis, these results were uncertain. A life-time perspective showed an ICER of €1249 (95% confidence interval = €850-2387) per QALY.

CONCLUSIONS

Financial incentives may be cost-effective in increasing quitting smoking, particularly from a life-time perspective.

The Association of Peer Smoking Behavior and Social Support with Quit Success in Employees Who Participated in a Smoking Cessation Intervention at the Workplace

The current study investigated whether quit success among employees who participated in a smoking cessation intervention at the workplace was associated with social support from, and the smoking behavior of, people in their environment. Tobacco-smoking employees (n = 604) from 61 companies participated in a workplace group smoking cessation program. Participants completed questionnaires assessing social support from, and the smoking behavior of, people in their social environment. They were also tested for biochemically validated continuous abstinence directly after finishing the training and after 12 months. The data were analyzed using mixed-effects logistic regression analyses. Social support from colleagues was positively associated with 12-month quit success (odds ratio (OR) = 1.85, 95% confidence interval (CI) = 1.14-3.00, p = 0.013). Support from a partner was positively associated with short-term quit success (OR = 2.01, 95% CI = 1.23-3.30, p = 0.006). Having a higher proportion of smokers in the social environment was negatively associated with long-term abstinence (OR = 0.81, 95% CI = 0.71-0.92, p = 0.002). Compared to having a non-smoking partner, long-term quit success was negatively associated with having no partner (OR = 0.48, 95% CI = 0.26-0.88, p < 0.019), with having a partner who smokes (OR = 0.40, 95% CI = 0.24-0.66, p < 0.001), and with having a partner who used to smoke (OR = 0.47, 95% CI = 0.26-0.86, p = 0.014). In conclusion, people in a smoker's social environment, particularly colleagues, were strongly associated with quit success. The workplace may, therefore, be a favorable setting for smoking cessation interventions.

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.

'Secretly, it's a competition': a qualitative study investigating what helped employees quit smoking during a workplace smoking cessation group training programme with incentives

OBJECTIVES

Smoking cessation programmes in combination with financial incentives have shown to increase quit rates in smokers, but it is not clear which elements of this intervention help smokers to succeed in their quit attempt. The aim of this study was to explore the view of successful and unsuccessful quitters about which factors had affected their ability to quit smoking.

DESIGN

Semistructured qualitative interviews were conducted and analysed using the Framework method.

SETTING

Interviews were conducted in 2017 with employees from nine different Dutch companies.

PARTICIPANTS

24 successful and unsuccessful quitters from the intervention group of a cluster randomised controlled trial (RCT) who participated in a workplace smoking cessation group training programme in which smoking abstinence was rewarded with financial incentives.

RESULTS

Themes that emerged were the workplace setting, quitting with colleagues, motivation, family support, strategies and the financial incentives. The interviewees reported that the smoking cessation programme was appreciated in general, was convenient, lowered the threshold to sign up, stimulated peer support and competition and provided strategies to resist smoking. Personal motivation and a mind set to never smoke again were regarded as important factors for quit success. The financial incentives were not considered as a main motivator to quit smoking, which contradicts the results from the RCT. The financial incentives were considered as more attractive to smokers with a low income.

CONCLUSIONS

According to participants, contributors to quitting smoking were the workplace cessation programme, personal motivation and peer support, but not the incentives. More research is needed on the contradiction between the perceived effects of financial incentives on quit success and the actual difference in quit rates.

TRIAL REGISTRATION NUMBER

NTR5657.

Effect of a workplace-based group training programme combined with financial incentives on smoking cessation: a cluster-randomised controlled trial

BACKGROUND

Financial incentives are potentially useful tools to aid smoking cessation, but robust evidence to support their efficacy, particularly in combination with other interventions (eg, group counselling), has not been reported. We aimed to investigate whether financial incentives combined with a smoking cessation group training programme (compared with a training programme with no incentives) organised at the workplace would increase 12-month abstinence rates in tobacco-smoking employees with different education and income levels.

METHODS

This cluster-randomised controlled trial was done in the Netherlands with companies that offer a smoking cessation group training programme to all of their smoking employees. Eligible participants were tobacco-smoking employees and spouses of employees who were at least 18 years of age. Participants in the control group received a weekly 90-min session of smoking cessation group training for 7 weeks at the workplace; in addition to the group training, participants in the intervention group received vouchers for being abstinent (€50 at the end of the training programme, €50 3 months after completion of the programme, €50 after 6 months, and €200 after 12 months). Companies were randomly assigned by an independent research assistant to the intervention group or the control group with a digital randomisation programme, using a biased urn method. The primary outcome was carbon monoxide-validated continuous abstinence at 12 months. All randomised participants were included in the modified intention-to-treat analyses, with the exception of unavoidable loss (participants who had died or moved to an untraceable address (according to the Russell Standard), and in the sensitivity analyses, except the complete case analysis, which included only participants for whom all variables included in the model were not missing. This study is registered with the Dutch Trial Register, number NTR5657.

FINDINGS

Between March 1, 2016, and March 1, 2017, 61 companies with 604 participating smokers were enrolled. 31 companies (319 smokers) were randomly assigned to the intervention group and 30 companies (285 smokers) to the control group. 12 months after finishing the smoking cessation programme, the proportion of individuals abstaining from smoking in the intervention group was significantly higher than that in the control group (131 [41%] of 319 vs 75 [26%] of 284; adjusted odds ratio 1·93, 95% CI 1·31-2·85, p=0·0009; adjusted for education level, income level, and Fagerström score).

INTERPRETATION

Financial incentives in addition to a smoking cessation group training programme can significantly increase long-term smoking abstinence. The results of the current study could motivate employers to facilitate a workplace smoking cessation programme with financial incentives to help employees to quit smoking.

FUNDING

Dutch Cancer Society.

Characterizing Employees’ Preferences for Incentives for Healthy Behaviors: Examples to Improve Interest in Wellness Programs

Background. Many employers now incentivize employees to engage in wellness programs, yet few studies have examined differences in preferences for incentivizing participation in healthy behaviors and wellness programs. Method. We surveyed 2,436 employees of a large university about their preferences for incentivizing participation in different types of healthy behaviors and then used multivariable logistic regression to estimate associations between employees’ socioeconomic and demographic characteristics and their preferences for incentives for engaging in healthy behaviors. Results. Compared with nonunion members, union members had higher odds of wanting an incentive for eating healthily (adjusted odds ratio [AOR] = 1.60, 95% [CI; 1.21, 2.12]), managing weight (AOR = 1.53, 95% CI [1.14, 2.06]), avoiding drinking too much alcohol (AOR = 1.41, 95% CI [1.11, 1.78]), quitting tobacco (AOR = 1.37, 95% CI [1.06, 1.77]), managing stress (AOR = 1.37, 95% CI [1.08, 1.75]), and managing back pain (AOR = 1.64, 95% CI [1.28, 2.10]). Compared with staff, faculty employees reported higher odds for wanting an incentive for reducing alcohol intake (AOR = 1.34, 95% CI [1.00, 1.78]) and quitting tobacco (AOR = 1.43, 95% CI [1.04, 1.96]). Women had lower odds than men (AOR = 0.80, 95% CI [0.64, 0.99]) of wanting an incentive for managing back pain. Conclusions. Preferences for incentives to engage in different types of healthy behaviors differed by employees’ socioeconomic and demographic characteristics. Organizations may consider using survey data on employee preferences for incentives to more effectively engage higher risk populations in wellness programs.