Paying people to quit smoking promotes sustained abstinence

Offering people financial incentives to quit can promote sustained abstinence from smoking, but the results differ depending on the type of programme on offer, according to research published in The New England Journal of Medicine
^[1]
on 13 May 2015.

In a six-month US study involving 2,538 participants, people were randomised to a “deposit” programme or to a “reward” based programme. In both programmes they would receive US$800 if they stopped smoking.

The researchers found that if participants are required to put down a deposit at the beginning of the programme, participation is slashed. However, programme success rates were dramatically higher for those who agreed to pay a deposit.

When offered a reward programme, 90.0% of smokers agreed to participate in the study and 17.1% of these had sustained abstinence. In contrast, only 13.7% were willing to participate in the deposit programme but of those that did, 52.3% had sustained abstinence.

Commenting on the study in an accompanying editorial^[2]
, Cass Sunstein, a professor at Harvard Law School, says the researchers ended up showing the importance of loss aversion in two different ways.

“The more obvious is that smokers are far more likely to quit if they stand to lose money if they fail,” he writes. “The more subtle is that the very prospect of incurring losses makes people far less willing to enter a smoking-cessation programme.”

The researchers, from the University of Pennsylvania, Philadelphia, recruited smokers who had a desire to quit into a randomised control trial of five different programmes. Smokers were CVS Caremark employees, or their family or friends.

Participants were offered either usual care alone (n=468), individual reward (n=498), collaborative reward (n=519), individual deposit (n=582) or competitive deposit (n=471) schemes. In the collaborative and competitive programmes, financial incentives given to the individual were linked to their performance as part of a small group. The results for individual and group arms were not found to have a significant effect on the outcomes of the reward or deposit programmes overall.

All participants were offered usual care as well, including information about local smoking-cessation resources, cessation guides from the American Cancer Society and, if they had insurance cover, free nicotine replacement services and a behavioural modification programme.

People that were randomised to the reward schemes could receive US$800 if they remained abstinent during the study. People offered the deposit scheme had to put down US$150 at beginning of the programme, which they would get back, along with a reward of US$650, for not smoking.

“Despite the greater comparative effectiveness of the deposit programme, the reward programme is likely to be more successful, because far more people will sign up for it,” says Sunstein.

Overall, when the people who declined to participate are included in the analysis, the abstinence rates for the reward and deposit schemes were 15.7% and 10.2%, respectively. Both financial-incentive programmes were more effective than people offered usual care on its own, which resulted in a 6.0% abstinence rate at six months.

Sunstein says that with respect to further research “it would be valuable to know whether a smaller deposit might increase participation without reducing efficacy”.

He believes that deposit programmes, which enlist loss aversion, are a better way of helping people to quit smoking. But the challenge is to find a way to “nudge” people to enrol in such programmes. “If that challenge cannot be met, reward programmes are much better bets.”