Study Compares Four Incentive Plans for Smoking Cessation

Financial incentives are a tried-and-true tool to encourage positive behaviors in both the home and workplace, and notably many institutions are exploring financial reward-based programs to help employees stop smoking.

What employers want to know, of course, is what combination of reward and intervention can bring the biggest return.

Researchers at the University of Pennsylvania Perelman School of Medicine have carried out one of the most comprehensive studies on this topic by comparing four programs tailored around two variables: participant size and payout system. The study was published May 13 in the New England Journal of Medicine.

In the first program, individuals received cash ($200) if they remained smoke-free at specified time points following their quit date, with a maximum possible payout of $800; the second program was identical, except that individuals had to deposit $150 of their own money into the pot (making their maximum possible return $650).

The other two programs were designed around groups of six. The group reward program paid each person $100 for every person in the group who was smoke-free at a follow-up session, thus encouraging collaboration and support. Meanwhile, the group deposit program (each group member again staked $150) distributed money only to the group members who were smoke-free at each session (so if only one person in the group had quit smoking, that person would pocket all the money); this program was designed to encourage participants’ competitive nature.

The researchers tested these approaches, along with a control program that consisted of free cessation guides and access to nicotine replacement therapies, on 2,538 employees of CVS Caremark over a six-month period. Each participant was randomly placed into one of the groups, though measures were taken to ensure each group had roughly the same composition in terms of income stratification.

Participants were then told what their particular financial program would be, and they could voluntarily choose to participate or not (all those who declined received the same assistance as the control group).

“How well a cessation program works is based on both how well it motivates people to change a behavior and how willing they are to participate in the first place,” said study co-author Kathryn Saulsgiver, Ph.D., an investigator at the University of Pennsylvania’s Center for Health Incentives and Behavioral Economics. “The design of this study allowed us to measure both of these important variables.”

Overall, both of the reward-based programs had higher abstinence rates after six months (about 16 percent each) than the deposit-based programs (about 10 percent each), and both were far superior to standard care, which achieved 6 percent abstinence.

There were no real differences between an individual or group approach for either program, suggesting that social factors like cooperation or competition do not strongly influence cessation success.

However, the higher rates seen in the reward groups were largely due to the significant difference in acceptance rates; around 90 percent of the employees selected for a reward program chose to opt in, whereas only 14 percent of participants in the deposit programs did so.

Thus, when comparing only people who actively participated in one of the programs, the deposit-based strategy was far more effective; at six months, over 50 percent of the people who had accepted deposits were abstaining from smoking compared with 17 percent of people who had accepted the rewards program.

“In a real-world workplace situation, a reward model works best since you get a lot of people to buy in and try to quit,” said Saulsgiver. “But from a pure efficacy standpoint, a deposit-based model has a better chance of promoting sustained abstinence, because participants feel like they have some skin in the game.”

Looking ahead, Saulsgiver stated that further work should be done with the deposit framework to find “sweet spots” that maximize participation and results, though she noted that individual variation due to economic status or personal values will always be a factor. “Everyone is sensitive to monetary loss in his or her own way,” she told Psychiatric News.

This study was supported by grants from the National Cancer Institute, National Institute on Aging, and CVS Caremark. ■