Money Talks: Financial Incentives Help Smokers Quit

Liam Davenport

May 13, 2015

Reward-based financial incentive programs are more acceptable to smokers who would like to quit smoking than deposit-based programs, although the latter achieve higher rates of 6-month abstinence, new research shows.

Researchers from the Perelman School of Medicine at the University of Pennsylvania, in Philadelphia, found that all types of financial incentive schemes were more successful than standard smoking cessation care, regardless of whether they were individual- or group-based or used only rewards or refundable deposits in addition to rewards.

However, reward-based programs were more than six times more acceptable to smokers, indicating that, despite deposit-based programs ultimately being more successful, reward programs will be more successful overall.

Lead author Scott D. Halpern, MD, PhD, deputy director of the Center for Health Incentives and Behavioral Economics, at the Perelman School of Medicine, University of Pennsylvania, spoke to Medscape Medical News to discuss the findings. Noting that the deposit contracts were both much less attractive and much more efficacious than reward programs, he said: "In other words, adding a bit of a stick is much better than using a pure carrot."

"So the trick now is to refine deposit programs so that they will be more attractive without losing much, if any, of their effectiveness," he added.

The article was published online on May 13 by the New England Journal of Medicine.

700 Good Reasons to Quit

The researchers randomly assigned 2538 employees of CVS Caremark (now CVS Health) or their relatives or friends to one of four financial incentive programs or to usual care for smoking cessation. Usual care consisted of offering information resources and free smoking-cessation aids.

Two of the incentive programs targeted individuals, and two targeted groups of six participants. Of the individual and group programs, one of each involved rewards of approximately $800 for smoking cessation; the other entailed refundable deposits of $150 plus $650 in reward payments, if participants were successful.

Interestingly, 90% of participants who were assigned to the reward-based programs accepted the assignment vs only 13.7% of those assigned to deposit-based programs (P < .001).

The rates of smoking abstinence being sustained for up to 6 months were significantly higher with each of the incentive programs compared with usual care, at 9.4% to 16.0% vs 6.0% (P < .05), with the superiority of reward-based programs maintained to 12 months.

Although group and individual programs were equally successful in enabling patients to achieve 6-month abstinence, at 13.7% and 12.1%, respectively (P = .29), reward-based programs enabled patients to achieve higher abstinence rates than deposit-based programs, at 15.7% vs 10.2% (P < .001).

However, the researchers found that when they restricted their analysis to the 13.7% of participants who would accept either type of program, 6-month abstinence rates were 13.2% higher with deposit-based programs than with reward-based programs.

Dr Halpern noted that CVS Health will roll out a 700 Good Reasons campaign to encourage smoking cessation next month, which will require an up-front deposit of only $50, rather than the $150 used in the study.

"We would expect that a $50 deposit would be much more attractive while still making participants feel that they have some skin in the game," Dr Halpern said.

"Many insurers are employing or considering similar programs for their policy holders. However, most of these programs assume that the critical decision is how much money to offer and are therefore relatively blind to human psychology, which suggests that how you deliver incentives may be just as important as how much you offer," he added.

"Our study shows that one basic aspect of psychology ― people's preferences to avoid loss rather than seek equally sized gains ― can go a long way toward determining the effectiveness of incentives."

One critical question for such programs is how long they should be continued. Dr Halpern said that incentives would not be expected to work for longer than they are active, any more than one would expect drugs for high blood pressure to work once people stop taking them.

"This is the experience to date with incentives for weight loss ― once you stop giving them, people regain at least some of the lost weight," he added.

"Fortunately, when it comes to smoking cessation, the grass is a bit greener, because if you can get people to stop smoking for about 6 months, the majority of them will never start again, even without ongoing incentives."

Dr Halpern emphasized that financial incentive programs have an important role to play in public health, inasmuch as the majority of people would like to be healthier but struggle with achieving better health.

He said: "Incentive programs help people do what they want to do anyway."

"As long as incentive programs are offered fairly to all those who might benefit from them, they represent a win/win by giving people the extra motivation they need to help themselves while also serving the interests of employers, insurers, and society in promoting public health."

"A Lot of Good News"

In an accompanying editorial, Cass R. Sunstein, JD, Robert Walmsley University Professor, Harvard University, Cambridge, Massachusetts, notes that the findings have implications for both future research and future policy.

"With respect to research, it would be valuable to know whether a smaller deposit might increase participation without reducing efficacy," he writes.

"With respect to public policy, deposit programs, which enlist loss aversion, are the better way to help people to quit smoking (and perhaps to alter many kinds of health-related behavior)."

"The challenge is to find a way to nudge people to enroll in such programs."

Prof Sunstein told Medscape Medical News that the findings contained "a lot of good news." He noted that the study shows that smoking cessation programs "can work, and they are especially likely to work if people have some money on the line."

"The challenge is to convince people to participate in programs that put their own money at risk. That is not easy. But further good news is that rewards programs, which do not trigger the fascinating behavioral phenomenon of loss aversion, can work pretty well too," he added.

Prof Sunstein believes that the approaches used in the study could be relevant to other areas of health.

"Of course, these findings can generalize to other contexts in which people might want to change their own behavior, including alcohol abuse and efforts to increase exercise," he said.

"We are just at the early stages of realizing the potential of voluntary 'nudges' in the domain of public health. The study provides some important and promising clues," he concluded.

The study was supported by a grant from the National Cancer Institute and a grant from the National Institute on Aging and by in-kind support from CVS Health.

New Engl J Med. Published online May 13, 2015. Full text, Editorial

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