The money or the cigarette?

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Four different financial incentive programmes, each worth roughly $800 over six months, all help more smokers kick the habit than providing free access to behavioural counselling and nicotine replacement therapy. Further, the way in which equally-sized payouts are structured influences their effectiveness.

The findings are the result of a year-long randomised trial among CVS Caremark (now CVS Health) employees that was conducted by researchers at the Perelman School of Medicine at the University of Pennsylvania, which enrolled 2,538 participants from across the US during an eight-month period in 2012. Participants were then assigned to one of five groups: individual reward (reward based on individual performance), collaborative reward (reward based on group performance), individual deposit (requiring an upfront deposit of $150 with subsequent matching funds), competitive deposit (competing for other participants' deposits and matching funds) or usual care (including informational resources and free smoking cessation aids).

Of the participants assigned to the reward-based programmes, 90% accepted the assignment, compared to just 14% of those assigned to the deposit-based programmes. As a result, 16% of those assigned to reward programmes remained smoke-free for six months, compared with 10% in the deposit programmes, and 6% in the usual care group. Contrary to the authors’ expectations, the group-oriented programmes were not significantly more successful than the individual-oriented programmes (14% vs 12%).

Among the 14% of people who accepted deposits, 55% of them were still smoke-free at six months. Although the authors caution that this is a select group, analyses that took such selection into account still found that for any given person who would accept deposits, such programmes were by far the most effective.

"We found that the reward-based programmes were more effective than deposits overall because more people accepted them in the first place," said lead author Dr Scott D Halpern, an assistant professor of medicine, epidemiology, and medical ethics and health policy, and deputy director of the Center for Health Incentives and Behavioral Economics (CHIBE). "However, among people who would have accepted any programme we offered them, the deposit contracts were twice as effective as rewards, and five times more effective than free information and nicotine replacement therapy, likely because they leveraged people’s natural aversion to losing money. With such unprecedented rates of success, the trick now is to figure out how to get more people to sign up – to feel like they have skin in the game."

CVS Health, which partnered on the trial, will be the first to try out this approach. Based on the study’s results, they will soon launch a campaign called 700 Good Reasons, in which all employees who smoke will be able to deposit just $50, and if they test negative for tobacco 12 months later, they will get back their $50 plus $700 more.

"As we continue to see smoking as the number one cause of preventable death in the US, it’s important for employers to consider different options to use benefit design to help their workers quit," said senior author Dr Kevin Volpp, a professor of medicine and health care management in the school of medicine and Wharton, director of CHIBE, and vice chair of health policy in the department of medical ethics and health policy. "When compared to the estimated $4,000 to 6,000 incremental annual cost associated with employing a smoker over a non-smoker, a $700 to 800 incentive paid only to those who quit seems well worth the cost."

Additional research in this area will focus on how to make deposit contracts more appealing, and how to tailor different programs to best match the psychological and behavioural profiles of different smokers. "Just as people's genes may determine their response to certain drugs, people's mindsets and behaviour patterns likely dictate which types of incentive programs will work best for them," Halpern said.

University of Pennsylvania material New England Journal of Medicine article summary

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