Study: Incentives Help Smokers Quit - Effectiveness Varies By Program Design
 

Financial incentives can encourage people to adopt healthy behavior or drop harmful habits, but researchers continue to search for the most effective ways to offer these inducements. A recent University of Pennsylvania-led study of incentives for smoking cessation illustrates the complexity of the matter.

The study found that incentive programs were more effective than standard treatment in helping smokers to quit, but the degree of effectiveness varied based on how inducements of equal value were structured.

The research, published in the New England Journal of Medicine in May, examined a sample of more than 2,500 CVS Caremark -- now CVS Health -- employees and their friends and relatives, who were randomly assigned to one of four incentive programs or to a standard smoking-cessation regimen.

Two of the incentive programs were aimed at individuals and two were targeted at groups of six people. One individual program and one group program involved the opportunity to earn $800 in rewards for giving up smoking. The other individual and group programs required participants to make $150 deposits and offered them the chance to receive a refund and another $650 in potential reward payments if successful.

Standard stop-smoking care included educational materials and, for some participants, free access to nicotine-replacement therapy and a behavior-modification program.

All four incentive programs were more effective than standard care at helping participants sustain smoking abstinence through six months after the targeted quit date.

Scott Halpern MD, PhD

The pure rewards programs were more effective overall in achieving smoking abstinence because more people accepted that approach, according to CHIBE Deputy Director and lead author Scott Halpern, MD, PhD.  "However, we found that among people who would have accepted any program to which they were assigned, deposit programs were twice as effective as rewards and five times more effective than providing free access to nicotine replacement therapy or other aids to stop smoking," Halpern said.

Ninety percent of those appointed to the rewards programs accepted their assignments, while only 13.7 percent of participants accepted assignments to the deposit programs, according to the study, which involved several Penn researchers, including CHIBE Director Kevin Volpp, MD, PhD, Carnegie Mellon University Prof. George Loewenstein, and CVS Health Chief Medical Officer Troyen Brennan, MD.

Total costs spent per successful participant were lower in the deposit-based programs than in the pure-rewards plans.

"The trick is to modify deposit programs so that they become more effective in the future," Halpern said. People will do more to avoid losing $150 than to gain $150, he said. Now researchers need to find ways to nudge people into signing up for deposit incentive programs, he said.

The researchers suggested that future employee smoking-cessation programs be designed to require deposits smaller than the $150 used in the trial. The findings shaped a new CVS Health employee smoking-cessation program called "700 Good Reasons" that, as of June 1, 2015, requires participants to make a $50 up-front deposit. If these employees stop smoking for a year, they will earn $700 plus reimbursement of the $50.

These programs are important because smoking remains the leading cause of preventable illness and death in the United States more than a half century after the U.S. Surgeon General's initial report on its harmful effects, with 18 percent of Americans smoking regularly. Furthermore, the best available estimates suggest that employing a smoker costs several thousand dollars more each year than employing a non-smoker, the researchers wrote.
  

To the researchers surprise, no significant differences were found in the effectiveness of the group-focused and individual incentive programs, Halpern said. People tend to be motivated by social comparisons - a dynamic that might have been thwarted by the fact that group members didn't know each other before the study, he said.

Halpern and CHIBE founding Director Kevin Volpp, MD, PhD, are co-leading another trial to compare a straight rewards program with a virtual deposit program. "That's one of the most exciting future directions," Halpern said. He's also interested in developing interventions for people who are the hardest to change - those who heavily discount the future, or worry the least about what happens to themselves in the long term.

- Dinah Wisenberg Brin