Paying people to quit smoking

It’s one of those things that I think we consider too rarely: paying patients to be healthier. After all, we have no problem penalizing them for being unhealthy (ie wellness programs). But the latter is totally accepted, and the former is often considered ridiculous. But here’s the NEJM with a study to change your mind. “Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation“:

BACKGROUND: Financial incentives promote many health behaviors, but effective ways to deliver health incentives remain uncertain.

METHODS: We randomly assigned CVS Caremark employees and their relatives and friends to one of four incentive programs or to usual care for smoking cessation. Two of the incentive programs targeted individuals, and two targeted groups of six participants. One of the individual-oriented programs and one of the group-oriented programs entailed rewards of approximately $800 for smoking cessation; the others entailed refundable deposits of $150 plus $650 in reward payments for successful participants. Usual care included informational resources and free smoking-cessation aids.

So here’s the deal. Researchers randomly assigned employees, along with their relatives and friends, to one of four programs to help them quit, or to “usual care”. The randomization was stratified over two variables, whether they had full healthcare benefits through the employer and whether their annual household income was at least $60,000. This was to balance recruitment in those areas.

Two of the programs involved an individual incentive. The first was a straight payment system, with participants getting $200 at 14 days, 30 days, and 6 months, with a potential $200 bonus at the end of their enrollment if they were still not smoking. So they could get $800 total potentially. They were checked by laboratory testing to see if they were smoke free. The second individual assessment was the same, but involved requiring the participants to pony up a refundable $150 at the start of the trial They’d get that back if they didn’t smoke.

The other two groups were collective. The first was collaborative. Participants were enrolled in groups of six. At each time point, they all received $100 for each member that was still smoke free. In this way, they could earn up to $600 per check, with the $200 bonus still available. Thus, there was $2000 total potentially available, depending on how many in the group stuck with it. This was supposed to see if getting people incentivized to work together might help.

The last group was competitive, and also involved deposits. Everyone had to pony up $150. People were paid more if others failed. They could receive between $2000 and $1200 at each time period, with the $200 bonus at the end, for a potential $3800 dollars. Again, though, they’d get more money if fewer people quit. They were kept anonymous, though, so people couldn’t sabotage each other.

They got more than 1000 people to participate. Overall, people liked the rewards based programs much more than they liked the deposit based programs. About 90% agreed to participate in the rewards program, versus only about 14% agreeing to the deposit programs. In other words, they didn’t like the idea of risking their own money. But what we really care about was the different quit rates. In an intention to treat analysis, the quite rates were significantly higher with all of the incentive programs than with usual care, which had a quit rate of 6%.

At 6 months, the individual deposit program had a quit rate of 9.4%, and the competitive deposit program had a quit rate of 11.1%. The individual rewards program had a quit rate of 15.4%, and the collaborative rewards program had a quit rate of 16%. All much better than the 6% in usual care.

The sad news is that almost all of these pretty much halved at 12 months, but still – the programs were generally better than usual care.

And let’s not forget, more quitting is better. So how much did it cost for each 6-month quit?  It was $122 in usual care, $1,058 in individual rewards, $1,193 in collaborative rewards, $542 in individual deposits, and $858 in competitive deposits. Is that worth it? Might be. We pay a lot more for things that do us a lot less good than quitting smoking would.



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