Incentives for smoking cessation

Goal-directed versus outcome-based financial incentives for smoking cessation among low-income, hospitalised patients: rationale and design of the Financial Incentives for Smoking Treatment II (FIESTA II) randomised controlled trial

INTRODUCTION

Smoking remains the leading preventable cause of death in the USA. Low utilisation of treatments for smoking cessation remains a major barrier for reducing smoking rates. Financial incentives represent an innovative approach to increasing use of therapies for smoking cessation. This paper will describe the rationale and design of the Financial Incentives for Smoking Treatment II (FIESTA II) study, a randomised controlled trial to evaluate the effectiveness and feasibility of goal-directed and outcome-based financial incentives to promote smoking cessation among hospitalised smokers.

METHODS AND ANALYSIS

We are recruiting adult participants who smoked tobacco in the 30 days prior to initial interview and are contemplating quitting smoking. These participants will come from two hospitals in underserved communities in New York City and Los Angeles. They will be randomised into one of three arms. The first arm consists of goal-directed financial incentives plus enhanced usual care, which includes hospital-directed information about quitting smoking, nicotine replacement therapy and referral to a Quitline. The second arm involves outcome-based financial incentives plus enhanced usual care. The third arm consists of enhanced usual care alone. Multiple phone interviews with the participants will be completed after randomisation to assess smoking cessation. Participants will earn $20 for each follow-up interview completed and $30 for each smoking cessation test completed. Those who are randomised to the financial incentive groups can earn an additional $700. The participants in the outcome-based group will receive payments solely for exhibiting cessation, whereas the participants in the goal-based group are also eligible for receiving payments after meeting milestones such as speaking with a helpline coach.

ETHICS

Human research protection committees at New York University School of Medicine and the University of California Los Angeles (UCLA) David Geffen School of Medicine granted ethics approval.Protocol number: IRB#19-000 084.

TRIAL REGISTRATION NUMBER

NCT03979885.

Nicotine replacement therapy 'gift cards' for hospital inpatients who smoke: a prospective before-and-after controlled pilot evaluation

INTRODUCTION

A common barrier identified by individuals trying to quit smoking is the cost of cessation pharmacotherapies. The purpose of this evaluation was to: (1) Assess the feasibility of offering nicotine replacement therapy (NRT) 'gift cards' to hospitalised smokers for use posthospitalisation; and, (2) Estimate the effect of providing NRT gift cards on 6-month smoking abstinence.

METHODS

A prospective, quasi-experimental, before-and-after controlled cohort design with random sampling was used to compare patients who had received the Ottawa Model for Smoking Cessation (OMSC) intervention ('control') with patients who received the OMSC plus a $C300 Quit Card ('QCI'), which they could use to purchase any brand or form of NRT from any Canadian pharmacy.

RESULTS

750 Quit Cards were distributed to the three participating hospitals of which 707 (94.3%) were distributed to patients. Of the cards received by patients, 532 (75.2%) were used to purchase NRT. A total of 272 participants completed evaluation surveys (148 control; 124 QCI).Point prevalence abstinence rates adjusted for misreporting among survey responders were 15.3% higher in the QCI group, compared with controls (44.4% vs 29.1%; OR 1.95, 1.18-3.21; p=0.009). Satisfaction was high among participants in both groups, and among staff delivering the QCI. QCI participants rated the intervention as high in terms of motivation, ease of use and helpfulness.

CONCLUSIONS

The NRT gift card appears to be a feasible and effective smoking cessation tool that removes a primary barrier to the use of evidence-based smoking cessation pharmacotherapies, while motivating both patients and health providers.

Effectiveness of including weight management in smoking cessation treatments: A meta-analysis of behavioral interventions

INTRODUCTION

The potential of weight gain after smoking cessation reduces the incentive to quit. This meta-analysis examines the efficacy of behavioral interventions for smoking cessation that also address post-cessation weight gain.

METHODS

Medline, Web of Science, PsycINFO, and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials on behavioral treatments targeting both health outcomes. Six separate meta-analyses were undertaken to assess treatment efficacy on smoking abstinence and weight outcomes at end of treatment (EOT), short-term, and long-term follow-up. Individual and treatment moderators were examined as well as methodological quality and publication bias of studies.

RESULTS

A total of 28 studies were included in the meta-analysis. There was a statistically significant positive impact of treatments addressing both targets on smoking outcomes at EOT (RR = 1.279, 95% CI: 1.096, 1.492, p = .002), but not at follow-ups. Age impacted on EOT abstinence rates Q (1) = 4.960, p = .026) while increasing the number of sessions significantly improved EOT abstinence rates (p = .020). There was no statistically significant impact of these treatments on weight at EOT (Hedges' g = -0.015, 95% CI: -.164, 0.135, p = .849) or follow-ups (short term: Hedges' g = 0.055, 95% CI: -0.060, 0.170, p = .347; long term: Hedges' g = -0.320, 95% CI: -.965, 0.325, p = .331). There were minimal impacts of publication bias, mostly related to sample size, meaning studies including small sample sizes revealed larger effect sizes on abstinence at EOT.

DISCUSSION

Addressing post-cessation weight management in treatments for smoking cessation significantly enhances tobacco abstinence at EOT though it was not found to have a lasting impact after treatment.

Women and health professionals' perspectives on a conditional cash transfer programme to improve pregnancy follow-up: a qualitative analysis of the NAITRE randomised controlled study

OBJECTIVES

Women of low socioeconomic status have been described as having suboptimal prenatal care, which in turn has been associated with poor pregnancy outcomes. Many types of conditional cash transfer (CCT) programmes have been developed, including programmes to improve prenatal care or smoking cessation during pregnancy, and their effects demonstrated. However, ethical critiques have included paternalism and lack of informed choice. Our objective was to determine if women and healthcare professionals (HPs) shared these concerns.

DESIGN

Prospective qualitative research.

SETTING

We included economically disadvantaged women, as defined by health insurance data, who participated in the French NAITRE randomised trial assessing a CCT programme during prenatal follow-up to improve pregnancy outcomes. The HP worked in some maternities participating in this trial.

PARTICIPANTS

26 women, 14 who received CCT and 12 who did not, mostly unemployed (20/26), and - 7 HPs.

INTERVENTIONS

We conducted a multicentre cross-sectional qualitative study among women and HPs who participated in the NAITRE Study to assess their views on CCT. The women were interviewed after childbirth.

RESULTS

Women did not perceive CCT negatively. They did not mention feeling stigmatised. They described CCT as a significant source of aid for women with limited financial resources. HP described the CCT in less positive terms, for example, expressing concern about discussing cash transfer at their first medical consultation with women. Though they emphasised ethical concerns about the basis of the trial, they recognised the importance of evaluating CCT.

CONCLUSIONS

In France, a high-income country where prenatal follow-up is free, HPs were concerned that the CCT programme would change their relationship with patients and wondered if it was the best use of funding. However, women who received a cash incentive said they did not feel stigmatised and indicated that these payments helped them prepare for their baby's birth.

TRIAL REGISTRATION NUMBER

NCT02402855.

Contingency management to promote smoking cessation in people experiencing homelessness: Leveraging the electronic health record in a pilot, pragmatic randomized controlled trial

BACKGROUND

Cigarette smoking is disproportionately high among people experiencing homelessness (PEH). Contingency management (CM) is a strategy that has shown considerable efficacy for smoking cessation and has been used in short-term studies of smoking abstinence in PEH. We describe a pilot, pragmatic randomized controlled trial protocol, which leverages an electronic health record (EHR) infrastructure to assess the feasibility and acceptability of an extended CM intervention to improve long-term abstinence in PEH.

METHODS

We will conduct the study at three safety-net clinics in San Francisco among 90 adults experiencing homelessness who smoke cigarettes currently and have a desire to quit. We will encourage all participants to receive smoking cessation services that include behavioral counseling and pharmacotherapy through their clinics. We will randomly assign participants to an extended CM intervention group with escalating incentives contingent on abstinence or to a control group with fixed incentives for attending study visits. We will use the EHR to recruit participants, track receipt of counseling and pharmacotherapy during clinical care, and communicate with providers on participants' progress. CM participants will get escalating incentives for demonstration of carbon monoxide-verified abstinence over 6 months, with a total possible earnings of $475. Control participants will receive a fixed incentive of $5 for attending study visits, totaling $125. We will conduct the carbon-monoxide verified abstinence assessments-which will determine CM incentive amounts-daily during week 1, bi-weekly through week 4, weekly through week 13, and monthly through week 24. Measures of feasibility and acceptability, both quantitative and qualitative, will include assessments of screening and recruitment, adherence to study visits, engagement in smoking cessation clinical care, retention, and participant satisfaction. One of the primary clinical outcomes will be biochemically verified 7-day point prevalence abstinence at 6 months. We will measure secondary outcomes, which will include 7-day point prevalence abstinence at 2 weeks, 3 and 12 months.

DISCUSSION

This trial will allow us to assess the feasibility and acceptability of a CM cessation intervention among PEH. The protocol's clinical setting and use of EHRs gives it significant potential for scalability. If found to be feasible, acceptable, and subsequently efficacious in a larger trial, the intervention could reduce tobacco-related health disparities by increasing long-term smoking abstinence among this vulnerable population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04982952. Registered on July 29, 2021.

How and why do financial incentives contribute to helping people stop smoking? A realist review protocol

INTRODUCTION

Smoking is harmful to human health and programmes to help people stop smoking are key public health efforts that improve individual and population health outcomes. Research shows that financial incentives improve the success of stop smoking programmes. However, a better understanding of how they work is needed to better inform policy and to support building capability for implementation.The aims of this study: (1) To review the international literature to understand: How, why, in what circumstances and for whom financial incentives improve the success of stop smoking interventions among general population groups and among pregnant women. (2) To provide recommendations for how to best use financial incentives in efforts to promote smoking cessation.

METHODS AND ANALYSIS

A realist review of published international literature will be undertaken to understand how, why, for whom and in which circumstances financial incentives contribute to success in stopping smoking for general population groups and among pregnant women. Systematic searches were undertaken on 16 February 2022 of five academic databases: MEDLINE (ovid), Embase.com, CIHAHL, Scopus and PsycINFO. Iterative searching using citation tracking and of grey literature will be undertaken as needed. Using Pawson and Tilley's iterative realist review approach, data collected will be screened, selected, coded, analysed and synthesised into a set of explanatory theoretical findings.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review as data sources to be included are previously published. The study will provide important findings for policy-makers and health system leaders to guide the development of stop smoking services which use incentives, for example, as part of the Health Service Executive's Tobacco Free Programme in Ireland. Understanding how contextual factors impact implementation and programmatic success is key to developing a more effective public health approach to stop smoking. Our dissemination strategy will be developed with our stakeholders.

PROSPERO REGISTRATION NUMBER

CRD42022298941.

Effect of Smartphone-Based Financial Incentives on Peripartum Smoking Among Pregnant Individuals: A Randomized Clinical Trial

This randomized clinical trial assesses the effect of a smartphone-based intervention with financial incentive on peripartum smoking among pregnant individuals.

Tobacco and nicotine use

Tobacco smoking is a major determinant of preventable morbidity and mortality worldwide. More than a billion people smoke, and without major increases in cessation, at least half will die prematurely from tobacco-related complications. In addition, people who smoke have a significant reduction in their quality of life. Neurobiological findings have identified the mechanisms by which nicotine in tobacco affects the brain reward system and causes addiction. These brain changes contribute to the maintenance of nicotine or tobacco use despite knowledge of its negative consequences, a hallmark of addiction. Effective approaches to screen, prevent and treat tobacco use can be widely implemented to limit tobacco's effect on individuals and society. The effectiveness of psychosocial and pharmacological interventions in helping people quit smoking has been demonstrated. As the majority of people who smoke ultimately relapse, it is important to enhance the reach of available interventions and to continue to develop novel interventions. These efforts associated with innovative policy regulations (aimed at reducing nicotine content or eliminating tobacco products) have the potential to reduce the prevalence of tobacco and nicotine use and their enormous adverse impact on population health.

Strategies to increase downloads of COVID-19 exposure notification apps: A discrete choice experiment

Exposure notification apps have been developed to assist in notifying individuals of recent exposures to SARS-CoV-2. However, in several countries, such apps have had limited uptake. We assessed whether strategies to increase downloads of exposure notification apps should emphasize improving the accuracy of the apps in recording contacts and exposures, strengthening privacy protections and/or offering financial incentives to potential users. In a discrete choice experiment with potential app users in the US, financial incentives were more than twice as important in decision-making about app downloads, than privacy protections, and app accuracy. The probability that a potential user would download an exposure notification app increased by 40% when offered a $100 reward to download (relative to a reference scenario in which the app is free). Financial incentives might help exposure notification apps reach uptake levels that improve the effectiveness of contact tracing programs and ultimately enhance efforts to control SARS-CoV-2. Rapid, pragmatic trials of financial incentives for app downloads in real-life settings are warranted.

The INITIATE trial protocol: a randomized controlled trial testing the effectiveness of a "quit card" intervention on long-term abstinence among tobacco smokers presenting to the emergency department

BACKGROUND

Smoking cessation interventions implemented in emergency department (ED) settings have resulted in limited success, owing to factors such as lack of time, motivation, and incentives. A dynamic yet simple and effective approach that addresses the fast-paced nature of acute-care ED settings is needed. This study proposes a multi-center randomized controlled trial (RCT) to compare the effectiveness of an easy to deliver proactive, multi-component tobacco treatment intervention to usual care in the ED setting.

METHODS

This will be a prospective four-site, single-blind, blinded-endpoint (PROBE) RCT. Participants will be recruited directly in the ED and will be approached strictly in order of arrival time. Those randomized to the Quit Card Intervention (QCI) group will receive a "quit kit" which will include: a "Quit Card" worth $300 that can be used at any Canadian pharmacy to purchase any form of nicotine replacement therapy (NRT); a self-help booklet; and proactive enrolment in 6 months of telephone follow-up counseling. The usual care (UC) group will receive a "quit kit" which will include a brochure for a local smoking cessation program. Quit kits for both groups will be delivered in opaque, sealed envelopes, and identical in size and weight so to conceal group allocation from the blinded research coordinator. Randomization will be stratified by site and by the Canadian Triage Acuity Scale (CTAS), a value assigned to each ED patient based on the severity of the condition. An equal number of quit kits will be prepared for each CTAS level. The primary outcome will be bio-chemically verified smoking abstinence at 26 weeks. Secondary outcomes include smoking behavior at weeks 4, 52, and 104 as well as mortality and health care utilization outcomes. Investigators, outcome assessors, and data analysts will be blinded to group allocation until after primary analyses are completed. It is hypothesized that the QCI group will have higher a abstinence rate, improved health outcomes, and decreased healthcare utilization.

DISCUSSION

There are few examples of hospital EDs in Canada that systematically initiate tobacco cessation interventions for patients who smoke. Given the high smoking prevalence among ED patients and the relation of tobacco smoking to the majority of ambulatory care sensitive conditions, EDs are a missed opportunity in the initiation of tobacco treatment interventions. We have designed and will test an evidence-based tobacco treatment intervention that is simple and highly scalable.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04163081 . Registered on November 14, 2019.

Remote Patient Monitoring and Incentives to Support Smoking Cessation Among Pregnant and Postpartum Medicaid Members: Three Randomized Controlled Pilot Studies

BACKGROUND

Smoking rates among low-income individuals, including those eligible for Medicaid, have not shown the same decrease that is observed among high-income individuals. The rate of smoking among pregnant women enrolled in Medicaid is almost twice that among privately insured women, which leads to significant disparities in birth outcomes and a disproportionate cost burden placed on Medicaid. Several states have identified maternal smoking as a key target for improving birth outcomes and reducing health care expenditures; however, efficacious, cost-effective, and feasible cessation programs have been elusive.

OBJECTIVE

This study aims to examine the feasibility, acceptability, and effectiveness of a smartwatch-enabled, incentive-based smoking cessation program for Medicaid-eligible pregnant smokers.

METHODS

Pilot 1 included a randomized pilot study of smartwatch-enabled remote monitoring versus no remote monitoring for 12 weeks. Those in the intervention group also received the SmokeBeat program. Pilot 2 included a randomized pilot study of pay-to-wear versus pay-to-quit for 4 weeks. Those in a pay-to-wear program could earn daily incentives for wearing the smartwatch, whereas those in pay-to-quit program could earn daily incentives if they wore the smartwatch and abstained from smoking. Pilot 3, similar to pilot 2, had higher incentives and a duration of 3 weeks.

RESULTS

For pilot 1 (N=27), self-reported cigarettes per week among the intervention group declined by 15.1 (SD 27) cigarettes over the study; a similar reduction was observed in the control group with a decrease of 17.2 (SD 19) cigarettes. For pilot 2 (N=8), self-reported cigarettes per week among the pay-to-wear group decreased by 43 cigarettes (SD 12.6); a similar reduction was seen in the pay-to-quit group, with an average of 31 (SD 45.6) fewer cigarettes smoked per week. For pilot 3 (N=4), one participant in the pay-to-quit group abstained from smoking for the full study duration and received full incentives.

CONCLUSIONS

Decreases in smoking were observed in both the control and intervention groups during all pilots. The use of the SmokeBeat program did not significantly improve cessation. The SmokeBeat program, remote cotinine testing, and remote delivery of financial incentives were considered feasible and acceptable. Implementation challenges remain for providing evidence-based cessation incentives to low-income pregnant smokers. The feasibility and acceptability of the SmokeBeat program were moderately high. Moreover, the feasibility and acceptability of remote cotinine testing and the remotely delivered contingent financial incentives were successful.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03209557; https://clinicaltrials.gov/ct2/show/NCT03209557.

A qualitative study to assess perceptions, barriers, and motivators supporting smokeless tobacco cessation in the US fire service

While firefighters currently have low smoking rates, rates of smokeless tobacco (SLT) use among this population are remarkably high and substantially greater than similar occupational groups, and the general population. This study explored determinants associated with SLT use, barriers to cessation, and motivators for SLT cessation in the fire service. Key informant interviews were conducted in 23 career firefighters who were current (n = 14) and former (n = 9) SLT users from across the U.S. Discussions were recorded and independently coded according to questions and themes. Major themes that developed among firefighters regarding SLT use determinants included positive perceptions of SLT products, social influences from their peers and family members, acceptability of SLT use in the fire service, and a coping resource for job stress. Firefighters discussed several barriers to SLT cessation, including intrapersonal barriers such as SLT use habits and its dependency, concerns about withdrawal symptoms; and social-environmental barriers including lack of support from health and other services providers, and lack of enforcement of existing tobacco policies regarding SLT use. Firefighters also mentioned both internal and external motivators for cessation. Internal motivators included self-motivation and their health concerns while external motivators included friends and family support, incentives or rewards, and price of SLT products. Findings provide unique perspectives from firefighters on factors that influence SLT use and barriers and motivators to SLT cessation. These are insufficiently assessed and considered by the fire service organizations and their health care providers. Thus, the organizations must understand these issues in order to mitigate barriers and motivate the personnel to quit using SLT. Information gained from firefighters who were current and former SLT users can be used to develop an effective, culturally-tailored intervention that is acceptable to fire service personnel.

Smoking Treatment: A Report Card on Progress and Challenges

The impact of tobacco smoking treatment is determined by its reach into the smoking population and the effectiveness of its interventions. This review evaluates the reach and effectiveness of pharmacotherapy and psychosocial interventions for smoking. Historically, the reach of smoking treatment has been low, and therefore its impact has been limited, but new reach strategies such as digital interventions and health care system changes offer great promise. Pharmacotherapy tends to be more effective than psychosocial intervention when used clinically, and newer pharmacotherapy strategies hold great promise of further enhancing effectiveness. However, new approaches are needed to advance psychosocial interventions; progress has stagnated because research and dissemination efforts have focused too narrowly on skill training despite evidence that its core content may be inconsequential and the fact that its mechanisms are either unknown or inconsistent with supporting theory. Identifying effective psychosocial content and its mechanisms of action could greatly enhance the effectiveness of counseling, digital, and web interventions.

Evaluation of Combined Financial Incentives and Deposit Contract Intervention for Smoking Cessation: A Randomized Controlled Trial

INTRODUCTION

We evaluate whether a combination of financial incentives and deposit contracts improves cessation rates among low- to moderate-income smokers.

METHODS

We randomly assigned 311 smokers covered by Medicaid at 12 health clinics in Connecticut to usual care or one of the three treatment arms. Each treatment arm received financial incentives for two months and either (i) nothing further ("incentives only"), (ii) the option to start a deposit contract with incentive earnings after the incentives ended ("commitment"), or (iii) the option to precommit any earned incentives into a deposit contract starting after the incentives ended ("precommitment"). Smoking cessation was confirmed biochemically at two, six, and twelve months.

RESULTS

At two, six, and twelve months after baseline, our estimated treatment effects on cessation are positive but imprecise, with confidence intervals containing effect sizes estimated by prior studies of financial incentives alone and deposit contracts alone. At two months, the odds ratio for quitting was 1.4 in the incentive-only condition (95% CI: 0.5 to 3.5), 2.0 for incentives followed by commitment (95% CI: 0.6 to 6.1), and 1.9 for incentives and precommitment (95% CI: 0.7 to 5.3).

CONCLUSIONS

A combined incentive and deposit contract program for Medicaid enrollees, with incentives offering up to $300 for smoking cessation and use of support services, produced a positive but imprecisely estimated effect on biochemically verified cessation relative to usual care and with no detectable difference in cessation rates between the different treatment arms.

How Financial Incentives Increase Smoking Cessation: A Two-Level Path Analysis

Introduction

Financial incentives effectively increase smoking cessation rates, but it is unclear via which psychological mechanisms incentives influence quit behavior. The current study examines how receiving financial incentives for smoking cessation leads to quitting smoking and investigates several mediators and moderators of that relationship.

Aims and Methods

The study sample consisted of 604 tobacco-smoking employees from 61 companies in the Netherlands who completed a baseline and follow-up questionnaire. The current study is a secondary analysis from a cluster randomized trial where employees received smoking cessation group counseling at the workplace. Participants in the intervention group additionally received financial incentives of €350 in total for 12-month continuous smoking abstinence. We used a two-level path analysis to test a model that assesses the effects of financial incentives through smoking cessation program evaluation, medication use, nicotine replacement use, attitudes, self-efficacy, and social influences on quit success. We additionally tested whether an individual’s reward responsiveness moderated the influence of incentives on quit success.

Results

The effect of financial incentives on quit success was mediated by a higher self-efficacy. Financial incentives were also associated with a higher use of cessation medication. A more positive program evaluation was related to higher self-efficacy, more social influence to quit, and more positive attitudes about quitting. The results did not differ significantly by individual reward responsiveness.

Conclusions

The results of the current study suggest that financial incentives may be used to increase medication use and self-efficacy for quitting smoking, which offers an indirect way to increase successful smoking cessation.

Implications

(1) This is the first study investigating via which psychological pathways financial incentives for quitting smoking can lead to long-term quit success. (2) The results showed a path between financial incentives and a higher likelihood of medication use. Incentives may encourage smokers to use medication in order to increase their chance of quitting smoking and receive the reward. (3) There was a path from financial incentives to quit success via a higher self-efficacy. (4) The effects of financial incentives did not depend on individual reward responsiveness.

Smartphone-based financial incentives to promote smoking cessation during pregnancy: A pilot study

Cigarette smoking during pregnancy increases risk for pregnancy complications, growth restriction, and other adverse health outcomes. The most effective intervention for reducing smoking during pregnancy is financial incentives contingent on biochemically-verified smoking abstinence. The present study examined the efficacy of a smartphone-based intervention whereby smoking monitoring and incentive delivery occurred remotely using a mobile app. If efficacious, this remote intervention would allow pregnant women residing in geographically remote areas to benefit from incentives-based cessation interventions. Sixty U.S. pregnant smokers were recruited between May 2018 to May 2019 via obstetrical clinics, Women, Infants, and Children (WIC) offices, and Facebook. Participants were assigned sequentially to one of two treatments: best practices alone (N = 30) or best practices plus financial incentives (N = 30). Outcomes were analyzed using repeated measures analysis based on generalized estimating equations (GEE). Seven-day point prevalence abstinence rates were greater in the incentives versus best practices arms early- (46.7% vs 20.0%, OR = 3.50, 95%CI = 1.11,11.02) and late-antepartum (36.7% vs 13.3%, OR = 3.76, 95%CI = 1.04,13.65), and four- (36.7% vs 10.0%, OR = 5.21, 95%CI = 1.28,21.24) and eight-weeks postpartum (40.0% vs 6.7%, OR = 9.33, 95%CI = 1.87,46.68), although not at the 12- (23.3% vs 10.0%, OR = 2.74, 95%CI = 0.63,11.82) or 24-week (20.0% vs 6.7%, OR = 3.50, 95%CI = 0.65,18.98) postpartum assessments likely due to this pilot study being underpowered for discerning differences at the later assessments, especially 24-weeks postpartum which was three months after treatment completion. These results support the efficacy of this remote, incentives-based intervention for pregnant smokers. Further research evaluating its efficacy and cost-effectiveness in a well-powered, randomized controlled trial appears warranted.

Decreasing smoking during pregnancy: Potential economic benefit of reducing sudden unexpected infant death

Sudden Unexpected Infant Death (SUID) remains the leading cause of death among U.S. infants age 1-12 months. Extensive epidemiological evidence documents maternal prenatal cigarette smoking as a major risk factor for SUID, but leaves unclear whether quitting reduces risk. This Commentary draws attention to a report by Anderson et al. (Pediatrics. 2019, 143[4]) that represents a breakthrough on this question and uses their data on SUID risk reduction to delineate potential economic benefits. Using a five-year (2007-11) U.S. CDC Birth Cohort Linked Birth/Infant Death dataset, Anderson et al. demonstrated that compared to those who continued smoking, women who quit or reduced smoking by third trimester decreased the adjusted odds of SUID risk by 23% (95% CI, 13%-33%) and 12% (95% CI, 2%-21%), respectively. We applied these reductions to the U.S. Department of Health and Human Services' recommended value of a statistical life in 2020 ($10.1 million). Compared to continued smoking during pregnancy, the economic benefits per woman of quitting or reducing smoking are $4700 (95% CI $2700-$6800) and $2500 (95% CI, $400-$4300), respectively. While the U.S. obtained aggregate annual economic benefits of $0.58 (95% CI, 0.35-0.82) billion from pregnant women who quit or reduced smoking, it missed an additional $1.16 (95%CI 0.71-1.60) billion from the women who continued smoking. Delineating the health and economic impacts of decreasing smoking during pregnancy using large epidemiological studies like Anderson et al. is critically important for conducting meaningful economic analyses of the benefits-costs of developing more effective interventions for decreasing smoking during pregnancy.

Development of an Evidence and Gap Map (EGM) of interventions to increase smoking cessation: A study protocol

Smoking remains one of the leading risk factors contributing to the global burden of disease. Sub-optimal implementation of evidence-based tobacco control and smoking cessation practice is a major challenge despite a substantial evidence base for interventions to increase smoking cessation globally. We aim to develop an Evidence and Gap Map (EGM) to collate the existing evidence and identify the gap in research on interventions to increase smoking cessation worldwide. A conceptual framework was developed followed by the formulation of a search strategy with key search terms and search period (1970 – date of search). The search will be conducted in relevant bibliographic databases (e.g. MEDLINE, Embase, SCOPUS), systematic reviews databases (e.g. Cochrane Library, Joanna Briggs systematic reviews, EPPI-Reviewer) and impact evaluation databases (e.g. 3ie Impact Evaluation repository and Cochrane tobacco addiction group specialized register) with support from a research librarian. Subsequently, two coders will screen and retrieve systematic reviews and individual impact evaluation studies. The adapted SURE (Supporting the Use of Research Evidence) checklist will be used to evaluate the quality of the included systematic reviews. A narrative synthesis from the systematic review findings and line listing of the impact evaluations will form the basis of this EGM. The EGM report will be presented in an interactive visual format. The proposed EGM will organise the pieces of evidence generated in systematic reviews and impact evaluations on smoking cessation interventions and identify the current research gaps, if any. The findings will inform evidence-based practice and future research.

Incentive programmes for smoking cessation: cluster randomized trial in workplaces in Thailand

OBJECTIVE

To compare several monetary incentive programmes for promoting smoking abstinence among employees who smoke at workplaces in a middle income country.

DESIGN

Parallel group, open label, assessor blinded, cluster randomized controlled trial.

SETTING

Large industrial workplaces in metropolitan Bangkok, Thailand.

PARTICIPANTS

Employees who smoked cigarettes and planned to quit within six months recruited from 101 worksite clusters (84 different companies).

INTERVENTIONS

Worksites were digitally cluster randomized by an independent investigator to usual care or usual care plus one of eight types of incentive programmes. Usual care consisted of one time group counseling and cessation support through a 28 day text messaging programme. The incentive programmes depended on abstinence at three months and varied on three intervention components: refundable deposits, assignment to a teammate, and bonus size ($20 (£15; €17) or $40).

MAIN OUTCOME MEASURES

The primary outcome was biochemically verified seven day point prevalence smoking abstinence at 12 months. Secondary outcomes were programme acceptance at enrollment and smoking abstinence at three months (end of intervention) and at six months. All randomized participants who had complete baseline information were included in intention-to-treat analyses; participants with missing outcomes were coded as continuing smokers.

RESULTS

Between April 2015 and August 2016, the trial enrolled 4190 participants. Eighteen were omitted because of missing baseline covariates and death before the primary endpoint, therefore 4172 participants were included in the intention-to-treat analyses. Programme acceptance was relatively high across all groups: 58.7% (2451/4172) overall and 61.3% (271/442) in the usual care group. Abstinence rates at 12 months did not differ among deposit programmes (336/2253, 14.9%) and non-deposit programmes (280/1919, 14.6%; adjusted difference 0.8 points, 95% confidence interval -2.7 to 4.3, P=0.65), but were somewhat lower for team based programmes (176/1348, 13.1%) than individual based programmes (440/2824, 15.6%; -3.2 points, -6.6 to -0.2, P=0.07), and higher for $40 bonus programmes (322/1954, 16.5%) than programmes with no bonus (148/1198, 12.4%; 5.9 points, 2.1 to 9.7, P=0.002). The $40 individual bonus was the most efficacious randomization group at all endpoints. Intervention components did not strongly interact with each other.

CONCLUSIONS

Acceptance of monetary incentive programmes for promoting smoking abstinence was high across all groups. The $40 individual bonus programmes increased long term smoking abstinence compared with usual care, although several other incentive designs did not, such as team based programmes and deposit programmes. Incentive design in workplace wellness programmes might influence their effectiveness at reducing smoking rates in low resource settings.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02421224).

A contingency management intervention to reduce cannabis use and time to relapse in early psychosis: the CIRCLE RCT

BACKGROUND

Cannabis is the most prevalent illicit substance among people with psychosis, and its use is associated with poorer clinical and social outcomes. However, so far, there has been limited evidence that any treatment is effective for reducing use. Contingency management (CM) is an incentive-based intervention for substance misuse that has a substantial evidence base across a range of substances and cohorts. However, to date there have been no randomised controlled trials (RCTs) of CM as a treatment for cannabis use specifically in psychosis.

OBJECTIVE

To conduct a RCT investigating the clinical effectiveness and cost-effectiveness of CM in reducing cannabis use among Early Intervention in Psychosis (EIP) service users.

DESIGN

The CIRCLE (Contingency Intervention for Reduction of Cannabis in Early Psychosis) trial was a rater-blinded, multicentre RCT with two arms. Participants were randomised 1 : 1 to either an CM arm, in which participants received CM for cannabis use alongside an optimised treatment-as-usual programme including structured psychoeducation, or a control arm in which participants received the treatment as usual only.

SETTING

EIP services across the Midlands and the south-east of England.

PARTICIPANTS

The main eligibility criteria were EIP service users with a history of psychosis, aged 18-36 years, and having used cannabis at least once per week during 12 of the previous 24 weeks.

INTERVENTION

The CM intervention offered financial incentives (i.e. shopping vouchers) for cannabis abstinence over 12 once-weekly sessions, confirmed using urinalysis. The maximum value in vouchers that participants could receive was £240.

MAIN OUTCOME MEASURES

The main outcome was time to relapse, operationalised as admission to an acute mental health service or hospital. The primary outcome was assessed at 18 months post inclusion using electronic patient records. Secondary outcomes assessed the clinical effectiveness and cost-effectiveness of the intervention, for which data were collected at 3 and 18 months.

RESULTS

A total of 278 participants were randomised to the CM arm and 273 were randomised to the control arm. In total, 530 (96%) participants were followed up for the primary outcome. There was no significant difference in time to admission between trial arms by 18 months following consent (hazard ratio 1.03, 95% confidence interval 0.76 to 1.40). There were no statistically significant differences in most secondary outcomes, including cannabis use, at either follow-up assessment. There were 58 serious adverse events, comprising 52 inpatient episodes, five deaths and one arrest.

LIMITATIONS

Participant retention was low at 18 months, limiting the assessment of secondary outcomes. A different CM intervention design or reward level may have been effective.

CONCLUSIONS

The CM intervention did not appear to be effective in reducing cannabis use and acute relapse among people with early psychosis and problematic cannabis use.

FUTURE WORK

Cannabis use is still a significant clinical concern in this population. A pressing need remains to identify suitable treatments. A wider perspective on the social circumstances of young people with psychosis may be needed for a successful intervention to be found.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN33576045.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 45. See the NIHR Journals Library website for further project information.

Reducing tobacco use among women of childbearing age: Contributions of tobacco regulatory science and tobacco control

Tobacco use has unique, adverse health consequences for reproductive-aged women, particularly should these women become pregnant. Thus, successful efforts to reduce tobacco use among this population have strong potential to improve public health and reduce health disparities. The present review examines contributions to reducing tobacco use among women of childbearing age spanning the domains of tobacco regulatory science and tobacco control from the passage of the Family Smoking Prevention and Tobacco Control Act in 2009 through September 2019. In the domain of tobacco regulatory science, such efforts include research conducted by various National Institutes of Health/Food and Drug Administration (FDA)-supported Tobacco Centers of Regulatory Science, epidemiological surveillance studies, as well as studies examining the potential impact of tobacco regulatory policies currently under consideration by the FDA (e.g., reduced nicotine content cigarettes, health warning labels). Tobacco control efforts within this same 10-year timeframe include developments in pharmacological and psychosocial approaches to promoting tobacco cessation, mHealth interventions, and tobacco control policy. Emerging issues pertinent to ongoing efforts to reduce tobacco use within the domains of both tobacco regulatory science and tobacco control are also reviewed, including e-cigarettes, comorbid health conditions, course of tobacco and other drugs of abuse, and obstacles to the dissemination and implementation of evidence-based treatment and policy. Although the past decade has seen numerous important contributions to reducing tobacco use among reproductive-aged women within both domains, existing obstacles must be surmounted to continue reducing tobacco use and protecting health among this population. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Pilot feasibility trial of dual contingency management for cigarette smoking cessation and weight maintenance among weight-concerned female smokers

Many women who smoke cigarettes report that concern about weight gain is a barrier to quitting. Indeed, most quitters gain weight and some attribute relapses to weight gain concern. Contingency management (CM), which refers to reinforcing a target behavior with financial incentives, has been demonstrated effective for promoting smoking abstinence and weight management independently. We conducted a pilot trial to establish the feasibility of dual CM, in which both smoking cessation and weight maintenance were incentivized, as a smoking cessation intervention for female weight-concerned smokers. Participants (N = 10) received a 12-week intervention during which they earned financial incentives for smoking abstinence, verified by breath carbon monoxide (CO) testing, and for maintaining their weight (larger incentives for gaining less than five pounds, smaller incentives for 5-10 pound gain) while abstaining from smoking. They attended an end of intervention visit at week 13 and a follow-up visit at week 26. Total compensation was up to $550 ($255 for participation independent of smoking and weight, $145 for smoking abstinence incentives, and $150 for weight maintenance incentives). Results indicated that five of the 10 participants (50%) were continuously abstinent for at least 4 weeks and received at least 2 weight maintenance incentives. Three participants (33%) were abstinent at every visit they attended from quit date through week 26; 2 of these 3 had gained more than 10 pounds by week 26. Additional formative research to test alternative incentive schedules and modalities should be conducted before CM-W is evaluated in a larger trial. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Participation in a workplace smoking cessation program incentivized by lowering the cost of health care coverage: Findings from the LLUH BREATHE cohort

INTRODUCTION

Systematic analyses of workplace smoking cessation programs indicate that efficacy can be enhanced by using incentives. There is variation in the type of incentives used and their effect on participation and efficacy. The aim of our study was to examine whether lowering employee health plan costs (employee contributions, co-pays) encourage employee smokers to participate in workplace smoking cessation.

METHODS

We conducted a 2014-2015 prospective cohort study of 415 employee smokers of Loma Linda University Health (LLUH). The employees were offered participation in a workplace smoking cessation program (LLUH BREATHE Initiative) with the incentive of enrollment in an employer-provided health plan that had a 50% lower employee monthly contribution and co-payment relative to the employer-provided health plan for non-participants. Participation rates and variables associated with participation were analyzed.

RESULTS

In the LLUH BREATHE cohort, we found a very high rate of participation (72.7%; 95% CI: 69-77%) in workplace smoking cessation that was encouraged by a lower out-of-pocket health plan cost for the participating employee and/or spouse. Participation did, however, vary by gender and spouse, whereby female employee households with a qualifying smoker were more than two times more likely (employee: OR=2.89, 95% CI: 1.59-5.24; or spouse: OR=2.71, 95% CI: 1.47-5.00) to participate in smoking cessation than male employee households. The point prevalence, at four months, of abstinence from smoking among the participants was 48% (95% CI: 42-54%).

CONCLUSIONS

Our findings indicate that a workplace smoking cessation program that uses a novel reward-based incentive of lower out-of-pocket health plan costs results in a participation rate that is much higher than US norms.

Impact of a Patient-Centered Behavioral Economics Intervention on Hypertension Control in a Highly Disadvantaged Population: a Randomized Trial

BACKGROUND

Uncontrolled hypertension contributes to disparities in cardiovascular outcomes. Patient intervention strategies informed by behavioral economics and social psychology could improve blood pressure (BP) control in disadvantaged minority populations.

OBJECTIVE

To assess the impact on BP control of an intervention combining short-term financial incentives with promotion of intrinsic motivation among highly disadvantaged patients.

DESIGN

Randomized controlled trial.

PARTICIPANTS

Two hundred seven adults (98% African American or Latino) aged 18 or older with uncontrolled hypertension attending Federally Qualified Health Centers.

INTERVENTION

Six-month intervention, combining financial incentives for measuring home BP, recording medication use, BP improvement, and achieving target BP values with counseling linking hypertension control efforts to participants' personal reasons to stay healthy.

MAIN MEASURES

Primary outcomes: percentage achieving systolic BP (SBP) < 140 mmHg, percentage achieving diastolic BP (DBP) < 90 mmHg, and changes in SBP and DBP, all after 6 months. Priority secondary outcomes were SBP < 140 mmHg, DBP < 90 mmHg, and BP change at 12 months, 6 months after the intervention ended.

KEY RESULTS

After 6 months, rates of achieving target BP values for intervention and control subjects respectively was 57.1% vs. 40.2% for SBP < 140 mmHg (adjusted odds ratio (AOR) 2.53 (1.13-5.70)), 79.8% vs 70.1% for DBP < 90 mmHg (AOR 2.50 (0.84-7.44)), and 53.6% vs 40.2% for achieving both targets (AOR 2.04 (0.92-4.52)). However, at 12 months, the groups did not differ significantly in these 3 measures: 39.5% vs 35.0% for SBP (AOR 1.20 (0.51-2.83)), 68.4% vs 75.0% for DBP (AOR 0.70 (0.24-2.09)), and 35.5% vs 33.8% for both (AOR 1.03 (0.44-2.42)). Change in absolute SBP and DBP did not differ significantly between the groups at 6 or 12 months. Exploratory post hoc analysis revealed intervention benefit only occurred among individuals whose providers intensified their regimens, but not among those with intensification but no intervention.

CONCLUSIONS

The intervention achieved short-term improvement in SBP control in a highly disadvantaged population. Despite attempts to enhance intrinsic motivation, the effect was not sustained after incentives were withdrawn. Future research should evaluate combined patient/provider strategies to enhance such interventions and sustain their benefit.

TRIAL REGISTRATION

NCT01402453; http://clinicaltrials.gov/show/NCT01402453.

Designing and using incentives to support recruitment and retention in clinical trials: a scoping review and a checklist for design

Background

Recruitment and retention of participants are both critical for the success of trials, yet both remain significant problems. The use of incentives to target participants and trial staff has been proposed as one solution. The effects of incentives are complex and depend upon how they are designed, but these complexities are often overlooked. In this paper, we used a scoping review to ‘map’ the literature, with two aims: to develop a checklist on the design and use of incentives to support recruitment and retention in trials; and to identify key research topics for the future.

Methods

The scoping review drew on the existing economic theory of incentives and a structured review of the literature on the use of incentives in three healthcare settings: trials, pay for performance, and health behaviour change. We identified the design issues that need to be considered when introducing an incentive scheme to improve recruitment and retention in trials. We then reviewed both the theoretical and empirical evidence relating to each of these design issues. We synthesised the findings into a checklist to guide the design of interventions using incentives.

Results

The issues to consider when designing an incentive system were summarised into an eight-question checklist. The checklist covers: the current incentives and barriers operating in the system; who the incentive should be directed towards; what the incentive should be linked to; the form of incentive; the incentive size; the structure of the incentive system; the timing and frequency of incentive payouts; and the potential unintended consequences. We concluded the section on each design aspect by highlighting the gaps in the current evidence base.

Conclusions

Our findings highlight how complex the design of incentive systems can be, and how crucial each design choice is to overall effectiveness. The most appropriate design choice will differ according to context, and we have aimed to provide context-specific advice. Whilst all design issues warrant further research, evidence is most needed on incentives directed at recruiters, optimal incentive size, and testing of different incentive structures, particularly exploring repeat arrangements with recruiters.

Additive effectiveness of contingency management on cognitive behavioural treatment for smokers with depression: Six-month abstinence and depression outcomes

BACKGROUND

Depression and smoking co-occur at high rates and there is a lack of evidence on the efficacy of treatments specifically tailored to this population. This randomized controlled trial sought to compare the effectiveness of cognitive behavioural treatment (CBT) combined with behavioural activation (BA) and the same treatment protocol plus contingency management (CM).

METHODS

A sample of 120 adult smokers (70.8%: females) with severe depressive symptoms were randomly allocated to: CBT + BA (n = 60) or CBT + BA + CM (n = 60). Smoking and depression outcomes were reported at end of treatment, 1-, 2-, 3-, and 6-month follow-ups. Self-reported smoking status was biochemically verified, and depression was assessed using the Beck Depression Inventory-II.

RESULTS

At end of treatment, the overall quit rate was 69.2% (83/120). CM showed an additive effect on CBT + BA in enhancing abstinence rates. The significant effect of group [F(1,155) = 9.55, p =  .0024], time [F(4,96) = 7.93, p < .0001], and group by time interaction [F(4,96) = 6.12, p =  .0002], indicated that CM is more effective for generating longer durations of abstinence beyond those of CBT+BA. All treatment conditions equally promoted sustained reductions in depression across time [F(1,111) = 0.53, p =  .4665]. A greater number of days of continuous abstinence and lower depressive symptoms mutually influenced each other.

CONCLUSIONS

Depressed smokers achieve high cessation rates without suffering negative mood changes. Quitting smoking is not detrimental and adding CM to CBT + BA enhances long-lasting abstinence rates while promoting large depression improvements.

How To Support Smoking Cessation In Primary Care And The Community: A Systematic Review Of Interventions For The Prevention Of Cardiovascular Diseases

Introduction

Smoking is a major risk factor for cardiovascular diseases (CVDs) and for many types of cancers. Despite recent policies, 1.1 billion people are active smokers and tobacco is the leading cause of mortality and illness throughout the world. The aim of this work was to identify smoking cessation interventions which could be implemented in primary care and/or at a community level.

Methods

A systematic review of CVDs prevention guidelines was realized using the ADAPTE Process. These were identified on G-I-N and TRIP databases. Additionally, a purposive search for national guidelines was successfully undertaken. Guidelines focusing on non-pharmacological lifestyle interventions, published or updated after 2011, were included. Exclusion criteria were specific populations, management of acute disease and exclusive focus on pharmacological or surgical interventions. After appraisal with the AGREE II tool, high-quality guidelines were included for analysis. High-grade recommendations and the supporting bibliographic references were extracted. References had to be checked in detail where sufficient information was not available in the guidelines.

Results

Nine hundred and ten guidelines were identified, 47 evaluated with AGREE II and 26 included. Guidelines recommended that patients quit smoking and that health care professionals provided advice to smokers but failed to propose precise implementation strategies for such recommendations. Only two guidelines provided specific recommendations. In the guideline bibliographic references, brief advice (BA) and multiple session strategies were identified as effective interventions. These interventions used Prochaska theory, motivational interviewing or cognitive-behavioral therapies. Self-help documentation alone was less effective than face-to-face counseling. Community-based or workplace public interventions alone did not seem effective.

Discussion

Behavioral change strategies were effective in helping patients to give up smoking. BA alone was less effective than multiple session strategies although it required fewer resources. Evidence for community-based interventions effectiveness was weak, mainly due to the lack of robust studies.

Voucher-Based Contingency Management is Efficacious but Underutilized in Treating Addictions

The United States lags far behind other industrialized countries on major markers of population health. Population health experts identify unhealthy behavior patterns (e.g., cigarette smoking, other substance use disorders, physical inactivity and poor food choices, nonadherence with recommended medical regimens) as the largest contributor to the status quo. Because these risk behaviors are overrepresented in socioeconomically disadvantaged and other vulnerable populations, they also increase health disparities. Hence, identifying evidence-based strategies to promote and sustain health-related behavior change is critical to improving U.S. population health. In this report, we review research demonstrating the efficacy of voucher-based contingency management delivered alone or in combination with other interventions for treating substance use disorders and other health-related behavior problems. The efficacy supporting these interventions is robust and discernible at the level of controlled randomized clinical trials and meta-analyses. Unfortunately, these evidence-based interventions are being underutilized in routine clinical care for substance use disorders, although they are used broadly in private-sector wellness programs and international programs to reduce chronic poverty. This report reviews the evidence supporting the efficacy of voucher-based contingency management using projects developed at the University of Vermont as exemplars and discusses dissemination of the model to public and private sector efforts to improve individual and population health.

Clinical and cost-effectiveness of contingency management for cannabis use in early psychosis: the CIRCLE randomised clinical trial

BACKGROUND

Cannabis is the most commonly used illicit substance amongst people with psychosis. Continued cannabis use following the onset of psychosis is associated with poorer functional and clinical outcomes. However, finding effective ways of intervening has been very challenging. We examined the clinical and cost-effectiveness of adjunctive contingency management (CM), which involves incentives for abstinence from cannabis use, in people with a recent diagnosis of psychosis.

METHODS

CIRCLE was a pragmatic multi-centre randomised controlled trial. Participants were recruited via Early Intervention in Psychosis (EIP) services across the Midlands and South East of England. They had had at least one episode of clinically diagnosed psychosis (affective or non-affective); were aged 18 to 36; reported cannabis use in at least 12 out of the previous 24 weeks; and were not currently receiving treatment for cannabis misuse, or subject to a legal requirement for cannabis testing. Participants were randomised via a secure web-based service 1:1 to either an experimental arm, involving 12 weeks of CM plus a six-session psychoeducation package, or a control arm receiving the psychoeducation package only. The total potential voucher reward in the CM intervention was £240. The primary outcome was time to acute psychiatric care, operationalised as admission to an acute mental health service (including community alternatives to admission). Primary outcome data were collected from patient records at 18 months post-consent by assessors masked to allocation. The trial was registered with the ISRCTN registry, number ISRCTN33576045.

RESULTS

Five hundred fifty-one participants were recruited between June 2012 and April 2016. Primary outcome data were obtained for 272 (98%) in the CM (experimental) group and 259 (95%) in the control group. There was no statistically significant difference in time to acute psychiatric care (the primary outcome) (HR 1.03, 95% CI 0.76, 1.40) between groups. By 18 months, 90 (33%) of participants in the CM group, and 85 (30%) of the control groups had been admitted at least once to an acute psychiatric service. Amongst those who had experienced an acute psychiatric admission, the median time to admission was 196 days (IQR 82, 364) in the CM group and 245 days (IQR 99, 382) in the control group. Cost-effectiveness analyses suggest that there is an 81% likelihood that the intervention was cost-effective, mainly resulting from higher mean inpatient costs for the control group compared with the CM group; however, the cost difference between groups was not statistically significant. There were 58 adverse events, 27 in the CM group and 31 in the control group.

CONCLUSIONS

Overall, these results suggest that CM is not an effective intervention for improving the time to acute psychiatric admission or reducing cannabis use in psychosis, at least at the level of voucher reward offered.

Changing health behaviors using financial incentives: a review from behavioral economics

BACKGROUND

Incentives are central to economics and are used across the public and private sectors to influence behavior. Recent interest has been shown in using financial incentives to promote desirable health behaviors and discourage unhealthy ones.

MAIN TEXT

If we are going to use incentive schemes to influence health behaviors, then it is important that we give them the best chance of working. Behavioral economics integrates insights from psychology with the laws of economics and provides a number of robust psychological phenomena that help to better explain human behavior. Individuals' decisions in relation to incentives may be shaped by more subtle features - such as loss aversion, overweighting of small probabilities, hyperbolic discounting, increasing payoffs, reference points - many of which have been identified through research in behavioral economics. If incentives are shown to be a useful strategy to influence health behavior, a wider discussion will need to be had about the ethical dimensions of incentives before their wider implementation in different health programmes.

CONCLUSIONS

Policy makers across the world are increasingly taking note of lessons from behavioral economics and this paper explores how key principles could help public health practitioners design effective interventions both in relation to incentive designs and more widely.

Incentives for smoking cessation

BACKGROUND

Financial incentives, monetary or vouchers, are widely used in an attempt to precipitate, reinforce and sustain behaviour change, including smoking cessation. They have been used in workplaces, in clinics and hospitals, and within community programmes.

OBJECTIVES

To determine the long-term effect of incentives and contingency management programmes for smoking cessation.

SEARCH METHODS

For this update, we searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The most recent searches were conducted in July 2018.

SELECTION CRITERIA

We considered only randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to smoking cessation incentive schemes or control conditions. We included studies in a mixed-population setting (e.g. community, work-, clinic- or institution-based), and also studies in pregnant smokers.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. The primary outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up (at least six months from the start of the intervention). In the trials of pregnant women we used abstinence measured at the longest follow-up, and at least to the end of the pregnancy. Where available, we pooled outcome data using a Mantel-Haenzel random-effects model, with results reported as risk ratios (RRs) and 95% confidence intervals (CIs), using adjusted estimates for cluster-randomised trials. We analysed studies carried out in mixed populations separately from those carried out in pregnant populations.

MAIN RESULTS

Thirty-three mixed-population studies met our inclusion criteria, covering more than 21,600 participants; 16 of these are new to this version of the review. Studies were set in varying locations, including community settings, clinics or health centres, workplaces, and outpatient drug clinics. We judged eight studies to be at low risk of bias, and 10 to be at high risk of bias, with the rest at unclear risk. Twenty-four of the trials were run in the USA, two in Thailand and one in the Phillipines. The rest were European. Incentives offered included cash payments or vouchers for goods and groceries, offered directly or collected and redeemable online. The pooled RR for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.49 (95% CI 1.28 to 1.73; 31 RCTs, adjusted N = 20,097; I² = 33%). Results were not sensitive to the exclusion of six studies where an incentive for cessation was offered at long-term follow up (result excluding those studies: RR 1.40, 95% CI 1.16 to 1.69; 25 RCTs; adjusted N = 17,058; I² = 36%), suggesting the impact of incentives continues for at least some time after incentives cease.Although not always clearly reported, the total financial amount of incentives varied considerably between trials, from zero (self-deposits), to a range of between USD 45 and USD 1185. There was no clear direction of effect between trials offering low or high total value of incentives, nor those encouraging redeemable self-deposits.We included 10 studies of 2571 pregnant women. We judged two studies to be at low risk of bias, one at high risk of bias, and seven at unclear risk. When pooled, the nine trials with usable data (eight conducted in the USA and one in the UK), delivered an RR at longest follow-up (up to 24 weeks post-partum) of 2.38 (95% CI 1.54 to 3.69; N = 2273; I² = 41%), in favour of incentives.

AUTHORS' CONCLUSIONS

Overall there is high-certainty evidence that incentives improve smoking cessation rates at long-term follow-up in mixed population studies. The effectiveness of incentives appears to be sustained even when the last follow-up occurs after the withdrawal of incentives. There is also moderate-certainty evidence, limited by some concerns about risks of bias, that incentive schemes conducted among pregnant smokers improve smoking cessation rates, both at the end of pregnancy and post-partum. Current and future research might explore more precisely differences between trials offering low or high cash incentives and self-incentives (deposits), within a variety of smoking populations.

Effect of a Workplace Wellness Program on Employee Health and Economic Outcomes: A Randomized Clinical Trial

Importance

Employers have increasingly invested in workplace wellness programs to improve employee health and decrease health care costs. However, there is little experimental evidence on the effects of these programs.

Objective

To evaluate a multicomponent workplace wellness program resembling programs offered by US employers.

Design, Setting, and Participants

This clustered randomized trial was implemented at 160 worksites from January 2015 through June 2016. Administrative claims and employment data were gathered continuously through June 30, 2016; data from surveys and biometrics were collected from July 1, 2016, through August 31, 2016.

Interventions

There were 20 randomly selected treatment worksites (4037 employees) and 140 randomly selected control worksites (28 937 employees, including 20 primary control worksites [4106 employees]). Control worksites received no wellness programming. The program comprised 8 modules focused on nutrition, physical activity, stress reduction, and related topics implemented by registered dietitians at the treatment worksites.

Main Outcomes and Measures

Four outcome domains were assessed. Self-reported health and behaviors via surveys (29 outcomes) and clinical measures of health via screenings (10 outcomes) were compared among 20 intervention and 20 primary control sites; health care spending and utilization (38 outcomes) and employment outcomes (3 outcomes) from administrative data were compared among 20 intervention and 140 control sites.

Results

Among 32 974 employees (mean [SD] age, 38.6 [15.2] years; 15 272 [45.9%] women), the mean participation rate in surveys and screenings at intervention sites was 36.2% to 44.6% (n = 4037 employees) and at primary control sites was 34.4% to 43.0% (n = 4106 employees) (mean of 1.3 program modules completed). After 18 months, the rates for 2 self-reported outcomes were higher in the intervention group than in the control group: for engaging in regular exercise (69.8% vs 61.9%; adjusted difference, 8.3 percentage points [95% CI, 3.9-12.8]; adjusted P = .03) and for actively managing weight (69.2% vs 54.7%; adjusted difference, 13.6 percentage points [95% CI, 7.1-20.2]; adjusted P = .02). The program had no significant effects on other prespecified outcomes: 27 self-reported health outcomes and behaviors (including self-reported health, sleep quality, and food choices), 10 clinical markers of health (including cholesterol, blood pressure, and body mass index), 38 medical and pharmaceutical spending and utilization measures, and 3 employment outcomes (absenteeism, job tenure, and job performance).

Conclusions and Relevance

Among employees of a large US warehouse retail company, a workplace wellness program resulted in significantly greater rates of some positive self-reported health behaviors among those exposed compared with employees who were not exposed, but there were no significant differences in clinical measures of health, health care spending and utilization, and employment outcomes after 18 months. Although limited by incomplete data on some outcomes, these findings may temper expectations about the financial return on investment that wellness programs can deliver in the short term.

Trial Registration

ClinicalTrials.gov Identifier: NCT03167658.

Competitions for smoking cessation

BACKGROUND

Competitions might encourage people to undertake and/or reinforce behaviour change, including smoking cessation. Competitions involve individuals or groups having the opportunity to win a prize following successful cessation, either through direct competition or by entry into a lottery or raffle.

OBJECTIVES

To determine whether competitions lead to higher long-term smoking quit rates. We also aimed to examine the impact on the population, the costs, and the unintended consequences of smoking cessation competitions.

SEARCH METHODS

This review has merged two previous Cochrane reviews. Here we include studies testing competitions from the reviews 'Competitions and incentives for smoking cessation' and 'Quit & Win interventions for smoking cessation'. We updated the evidence by searching the Cochrane Tobacco Addiction Group Specialized Register in June 2018.

SELECTION CRITERIA

We considered randomized controlled trials (RCTs), allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures in which participants were assigned to interventions by the investigators. Participants were smokers, of any age and gender, in any setting. Eligible interventions were contests, competitions, lotteries, and raffles, to reward cessation and continuous abstinence in smoking cessation programmes.

DATA COLLECTION AND ANALYSIS

For this update, data from new studies were extracted independently by two review authors. The primary outcome measure was abstinence from smoking at least six months from the start of the intervention. We performed meta-analyses to pool study effects where suitable data were available and where the effect of the competition component could be separated from that of other intervention components, and report other findings narratively.

MAIN RESULTS

Twenty studies met our inclusion criteria. Five investigated performance-based reward, where groups of smokers competed against each other to win a prize (N = 915). The remaining 15 used performance-based eligibility, where cessation resulted in entry into a prize draw (N = 10,580). Five of these used Quit & Win contests (N = 4282), of which three were population-level interventions. Fourteen studies were RCTs, and the remainder quasi-randomized or controlled trials. Six had suitable abstinence data for a meta-analysis, which did not show evidence of effectiveness of performance-based eligibility interventions (risk ratio (RR) 1.16, 95% confidence interval (CI) 0.77 to 1.74, N = 3201, I2 = 57%). No trials that used performance-based rewards found a beneficial effect of the intervention on long-term quit rates.The three population-level Quit & Win studies found higher smoking cessation rates in the intervention group (4% to 16.9%) than the control group at long-term follow-up, but none were RCTs and all had important between-group differences in baseline characteristics. These studies suggested that fewer than one in 500 smokers would quit because of the contest.Reported unintended consequences in all sets of studies generally related to discrepancies between self-reported smoking status and biochemically-verified smoking status. More serious adverse events were not attributed to the competition intervention.Using the GRADE system we rated the overall quality of the evidence for smoking cessation as 'very low', because of the high and unclear risk of bias associated with the included studies, substantial clinical and methodological heterogeneity, and the limited population investigated.

AUTHORS' CONCLUSIONS

At present, it is impossible to draw any firm conclusions about the effectiveness, or a lack of it, of smoking cessation competitions. This is due to a lack of well-designed comparative studies. Smoking cessation competitions have not been shown to enhance long-term cessation rates. The limited evidence suggesting that population-based Quit & Win contests at local and regional level might deliver quit rates above baseline community rates has not been tested adequately using rigorous study designs. It is also unclear whether the value or frequency of possible cash reward schedules influence the success of competitions. Future studies should be designed to compensate for the substantial biases in the current evidence base.

'Secretly, it's a competition': a qualitative study investigating what helped employees quit smoking during a workplace smoking cessation group training programme with incentives

OBJECTIVES

Smoking cessation programmes in combination with financial incentives have shown to increase quit rates in smokers, but it is not clear which elements of this intervention help smokers to succeed in their quit attempt. The aim of this study was to explore the view of successful and unsuccessful quitters about which factors had affected their ability to quit smoking.

DESIGN

Semistructured qualitative interviews were conducted and analysed using the Framework method.

SETTING

Interviews were conducted in 2017 with employees from nine different Dutch companies.

PARTICIPANTS

24 successful and unsuccessful quitters from the intervention group of a cluster randomised controlled trial (RCT) who participated in a workplace smoking cessation group training programme in which smoking abstinence was rewarded with financial incentives.

RESULTS

Themes that emerged were the workplace setting, quitting with colleagues, motivation, family support, strategies and the financial incentives. The interviewees reported that the smoking cessation programme was appreciated in general, was convenient, lowered the threshold to sign up, stimulated peer support and competition and provided strategies to resist smoking. Personal motivation and a mind set to never smoke again were regarded as important factors for quit success. The financial incentives were not considered as a main motivator to quit smoking, which contradicts the results from the RCT. The financial incentives were considered as more attractive to smokers with a low income.

CONCLUSIONS

According to participants, contributors to quitting smoking were the workplace cessation programme, personal motivation and peer support, but not the incentives. More research is needed on the contradiction between the perceived effects of financial incentives on quit success and the actual difference in quit rates.

TRIAL REGISTRATION NUMBER

NTR5657.

Contingency Management Versus Psychotherapy for Prenatal Smoking Cessation: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

Prenatal smoking is the leading preventable cause of poor obstetric outcomes, yet treatment options are limited. Past reviews of prenatal smoking cessation have often grouped all counseling into a single category, which ignores the fact that psychotherapy is distinct from brief counseling. The objective of this study was to compare the effect sizes of two intensive interventions for prenatal smoking cessation: contingency management (i.e., financial incentives for abstinence) and psychotherapy.

METHODS

A systematic search for randomized controlled trials testing the efficacy of contingency management or psychotherapy was completed using PubMed, PsycINFO, Web of Science, the Cochrane Library, and EMBASE. Independent raters extracted data and assessed trials for risk of bias. Treatment effects were analyzed for three times points: late pregnancy, early postpartum, and late postpartum.

RESULTS

The search yielded 22 studies, and meta-analytic results indicated that interventions (compared with control groups) generally increased the odds of abstinence. Moderator analyses indicated that intervention type (contingency management vs. psychotherapy) accounted for variability in effect sizes. When comparing treatment type, effects of contingency management interventions were significantly greater than those of psychotherapeutic interventions. Although psychotherapy did not affect smoking abstinence, contingency management interventions had significant treatment effects at all three time points.

CONCLUSIONS

Contingency management seems to be a safe and efficacious prenatal smoking cessation treatment. Although psychotherapy alone did not show an effect on prenatal smoking abstinence, future research may seek to combine this approach with contingency management to promote prenatal smoking cessation.

Smoking cessation in pregnancy: a continuing challenge in the United States

Despite significant population level declines, smoking during pregnancy remains a major public health issue in the United States (US). Approximately 360,000-500,000 smoke-exposed infants are born yearly, and prenatal smoking remains a leading modifiable cause of poor birth outcomes (e.g. birth < 37 gestational weeks, low birth weight, perinatal mortality). Women who smoke during pregnancy are more likely to be younger and from disadvantaged socioeconomic and racial and ethnic groups, with some US geographic regions reporting increased prenatal smoking rates since 2000. Such disparities in maternal prenatal smoking suggests some pregnant women face unique barriers to cessation. This paper reviews the current state and future direction of smoking cessation in pregnancy in the US. We briefly discuss the etiology of smoking addiction among women, the pathophysiology and effects of tobacco smoke exposure on pregnant women and their offspring, and the emerging issue of electronic nicotine delivery systems. Current population-based and individual smoking cessation interventions are reviewed in the context of pregnancy and barriers to cessation among US women. Finally, we consider interventions that are on the horizon and areas in need of further investigation.

Systematic review evaluating randomized controlled trials of smoking and alcohol cessation interventions in people with head and neck cancer and oral dysplasia

BACKGROUND

Smoking and alcohol increase the risk of head and neck cancer and affect treatment outcomes. Interventions modifying these behaviors may improve posttreatment outcomes and survival. We systematically reviewed evidence of the effectiveness of smoking/alcohol interventions in head and neck cancer and oral dysplasia.

METHODS

The AMED, CINAHL, Embase, MEDLINE, and Web of Science databases were searched for randomized controlled trials (RCTs) of smoking/alcohol interventions in people with head and neck cancer. A qualitative synthesis of the studies was conducted.

RESULTS

Three RCTs were identified: 2 smoking interventions and 1 smoking and alcohol intervention. One intervention, which was comprised of a smoking intervention based on Cognitive Behavioral Therapy and pharmacologic management compared to usual care, reduced smoking prevalence.

CONCLUSION

Further research is required into the underlying mechanisms that lead to cessation and interventions that include both pharmacological and behavioral therapy. Future RCTs should include suitable control conditions and sufficient power to assess clinical outcomes.

A scoping review and meta-analysis of psychosocial and pharmacological treatments for cannabis and tobacco use among African Americans

The rates of co-occurring cannabis and tobacco use are higher among African Americans relative to other racial/ethnic groups. One plausible approach to treating co-use among African Americans is to examine the effectiveness of treatments for the sole use of cannabis and tobacco to identify effective approaches that might be combined to treat the dual use of these substances. The current meta-analysis sought to include studies that reported cannabis and/or tobacco use outcomes from randomized clinical trials (RCTs) with 100% African American samples. A total of 843 articles were considered for inclusion, 29 were reviewed by independent qualitative coders, and 22 were included in the review. There were no articles on cannabis use treatment with a 100% African American sample, resulting in a need to lower the threshold (60%) and conduct a scoping review of cannabis studies. Preliminary evidence from a small number of studies (k = 7) supports the use of Motivational Interviewing and Cognitive-Behavioral Therapy to treat cannabis use among African Americans, but not Contingency Management. Results from a meta-analysis of 15 tobacco studies found higher rates of smoking abstinence in the treatment condition relative to control conditions overall and across short and long-term follow-up periods. Significant differences in smoking abstinence were also found when examining the effects of pharmacological treatments relative to their control conditions. The clinical and research implications of these findings for future psychosocial and pharmacological trials for cannabis and tobacco use and co-use among African Americans are described. (PsycINFO Database Record

Medicaid Incentives for Preventing Chronic Disease: Effects of Financial Incentives for Smoking Cessation

OBJECTIVE

To test the effectiveness of financial incentives for smoking cessation in the Medicaid population.

DATA SOURCES

Secondary data from the Medicaid Incentives for Prevention of Chronic Disease (MIPCD) program and Medicaid claims/encounter data from 2010 to 2015 for five states.

STUDY DESIGN

Beneficiaries were randomized into receipt or no receipt of financial incentives. We ran multivariate regression models testing the impact of financial incentives on the use of counseling services, smoking behavior, and Medicaid expenditures and utilization.

DATA EXTRACTION

Participating states provided Medicaid eligibility, claims and encounters, program enrollment, and incentivized service use data.

PRINCIPAL FINDINGS

Participants who received incentives were more likely to call the Quitline and complete counseling sessions. Incentive receipt was positively associated with self-reported quit attempts, self-reported quits, or passing cotinine tests of smoking cessation in most programs, although results were only statistically significant in a subset. There was no systematic evidence that incentives affected health care use or spending.

CONCLUSIONS

Financial incentives are a promising policy lever to motivate behavioral change in the Medicaid population, but more evidence is needed regarding optimal incentive size, effectiveness of process-versus outcome-based incentives, targeting of incentives, and long-run cost-effectiveness.

Application of a Brief Incentive Treatment for Cigarette Smoking

The application of financial incentives has proved to be a gainful treatment for cigarette smoking, yet the cost of delivering financial incentives has been a barrier to its widespread implementation. The goal of the present study is to test this treatment (with counseling) in a brief 3-week format, thereby reducing the cost. Results indicated that for one participant incentives were effective at promoting long-term abstinence from cigarette smoking. Though more research is needed, this treatment appears to be effective and can be delivered at a relatively low cost. • Financial incentives can be utilized to promote abstinence from cigarette smoking. • Regular monitoring of biomarkers of cigarette smoking is required in this treatment. • One low-cost feature of this treatment is that a participant that does not abstain from smoking does not receive incentives, as was the case for one participant in this study. • Abstinence is achieved through a combination of skill-training and reinforcing the absence cigarette smoking (differential reinforcement of other behavior; DRO).

Cost-effectiveness of increasing the reach of smoking cessation interventions in Germany: results from the EQUIPTMOD

AIMS

To evaluate costs, effects and cost-effectiveness of increased reach of specific smoking cessation interventions in Germany.

DESIGN

A Markov-based state transition return on investment model (EQUIPTMOD) was used to evaluate current smoking cessation interventions as well as two prospective investment scenarios. A health-care perspective (extended to include out-of-pocket payments) with life-time horizon was considered. A probabilistic analysis was used to assess uncertainty concerning predicted estimates.

SETTING

Germany.

PARTICIPANTS

Cohort of current smoking population (18+ years) in Germany.

INTERVENTIONS

Interventions included group-based behavioural support, financial incentive programmes and varenicline. For prospective scenario 1 the reach of group-based behavioral support, financial incentive programme and varenicline was increased by 1% of yearly quit attempts (= 57 915 quit attempts), while prospective scenario 2 represented a higher reach, mirroring the levels observed in England.

MEASUREMENTS

EQUIPTMOD considered reach, intervention cost, number of quitters, quality-of-life years (QALYs) gained, cost-effectiveness and return on investment.

FINDINGS

The highest returns through reduction in smoking-related health-care costs were seen for the financial incentive programme (€2.71 per €1 invested), followed by that of group-based behavioural support (€1.63 per €1 invested), compared with no interventions. Varenicline had lower returns (€1.02 per €1 invested) than the other two interventions. At the population level, prospective scenario 1 led to 15 034 QALYs gained and €27 million cost-savings, compared with current investment. Intervention effects and reach contributed most to the uncertainty around the return-on-investment estimates. At a hypothetical willingness-to-pay threshold of only €5000, the probability of being cost-effective is approximately 75% for prospective scenario 1.

CONCLUSIONS

Increasing the reach of group-based behavioural support, financial incentives and varenicline for smoking cessation by just 1% of current annual quit attempts provides a strategy to German policymakers that improves the population's health outcomes and that may be considered cost-effective.

Nicotine replacement therapy versus control for smoking cessation

BACKGROUND

Nicotine replacement therapy (NRT) aims to temporarily replace much of the nicotine from cigarettes to reduce motivation to smoke and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence.

OBJECTIVES

To determine the effectiveness and safety of nicotine replacement therapy (NRT), including gum, transdermal patch, intranasal spray and inhaled and oral preparations, for achieving long-term smoking cessation, compared to placebo or 'no NRT' interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register for papers mentioning 'NRT' or any type of nicotine replacement therapy in the title, abstract or keywords. Date of most recent search is July 2017.

SELECTION CRITERIA

Randomized trials in people motivated to quit which compared NRT to placebo or to no treatment. We excluded trials that did not report cessation rates, and those with follow-up of less than six months, except for those in pregnancy (where less than six months, these were excluded from the main analysis). We recorded adverse events from included and excluded studies that compared NRT with placebo. Studies comparing different types, durations, and doses of NRT, and studies comparing NRT to other pharmacotherapies, are covered in separate reviews.

DATA COLLECTION AND ANALYSIS

Screening, data extraction and 'Risk of bias' assessment followed standard Cochrane methods. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We identified 136 studies; 133 with 64,640 participants contributed to the primary comparison between any type of NRT and a placebo or non-NRT control group. The majority of studies were conducted in adults and had similar numbers of men and women. People enrolled in the studies typically smoked at least 15 cigarettes a day at the start of the studies. We judged the evidence to be of high quality; we judged most studies to be at high or unclear risk of bias but restricting the analysis to only those studies at low risk of bias did not significantly alter the result. The RR of abstinence for any form of NRT relative to control was 1.55 (95% confidence interval (CI) 1.49 to 1.61). The pooled RRs for each type were 1.49 (95% CI 1.40 to 1.60, 56 trials, 22,581 participants) for nicotine gum; 1.64 (95% CI 1.53 to 1.75, 51 trials, 25,754 participants) for nicotine patch; 1.52 (95% CI 1.32 to 1.74, 8 trials, 4439 participants) for oral tablets/lozenges; 1.90 (95% CI 1.36 to 2.67, 4 trials, 976 participants) for nicotine inhalator; and 2.02 (95% CI 1.49 to 2.73, 4 trials, 887 participants) for nicotine nasal spray. The effects were largely independent of the definition of abstinence, the intensity of additional support provided or the setting in which the NRT was offered. A subset of six trials conducted in pregnant women found a statistically significant benefit of NRT on abstinence close to the time of delivery (RR 1.32, 95% CI 1.04 to 1.69; 2129 participants); in the four trials that followed up participants post-partum the result was no longer statistically significant (RR 1.29, 95% CI 0.90 to 1.86; 1675 participants). Adverse events from using NRT were related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. Attempts to quantitatively synthesize the incidence of various adverse effects were hindered by extensive variation in reporting the nature, timing and duration of symptoms. The odds ratio (OR) of chest pains or palpitations for any form of NRT relative to control was 1.88 (95% CI 1.37 to 2.57, 15 included and excluded trials, 11,074 participants). However, chest pains and palpitations were rare in both groups and serious adverse events were extremely rare.

AUTHORS' CONCLUSIONS

There is high-quality evidence that all of the licensed forms of NRT (gum, transdermal patch, nasal spray, inhalator and sublingual tablets/lozenges) can help people who make a quit attempt to increase their chances of successfully stopping smoking. NRTs increase the rate of quitting by 50% to 60%, regardless of setting, and further research is very unlikely to change our confidence in the estimate of the effect. The relative effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the individual. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. NRT often causes minor irritation of the site through which it is administered, and in rare cases can cause non-ischaemic chest pain and palpitations.

Maternal Behavioral Health: Fertile Ground for Behavior Analysis

The World Health Organization has identified four behavioral health priorities as risk factors for noncommunicable diseases in maternal populations: tobacco use, harmful alcohol use, poor nutrition, and lack of physical activity. These risk factors also significantly affect pregnant and immediately postpartum mothers, doubling the health risk and economic burden by adversely affecting maternal and birth or infant outcomes. Psychosocial and behavioral interventions are ideal for pregnant and immediately postpartum women as opposed to pharmacotherapy. Among other behavioral interventions, the use of incentives based on the principles of reinforcement has been a successful yet controversial way to change health behaviors. Implementing an incentive-based intervention in maternal health often brings up social validity concerns. The existing guideline on how to develop and conduct research in incentive-based interventions for maternal health lacks enough information on the specific variables to control for to maintain the intervention's effectiveness. This article outlines some of the critical variables in implementing an effective behavior-analytic intervention and addressing social validity concerns to change maternal behaviors in a sustainable manner, along with specific research topics needed in the field to prevent adverse maternal, birth, and infant outcomes.

Contingency management for college student smokers: The role of drinking as a moderator and mediator of smoking abstinence during treatment

INTRODUCTION

Contingency management (CM) is effective for promoting smoking abstinence; however, moderators and mediators of CM treatment efficacy in young adult populations are under-explored. We leveraged fine-grained data from a large randomized controlled trial: 1) to determine whether early attainment of sustained abstinence mediated the effect of treatment on abstinence; 2) to test whether heavy drinking moderated the effect of treatment on abstinence; and 3) to test a serial mediation model of the effects of drinking during early treatment on sustained smoking abstinence.

METHODS

College student smokers (N=110) were randomized to receive either CM treatment or noncontingent reinforcement (NR) over a 21-day treatment period. All participants received $5 for providing twice-daily breath carbon monoxide (CO) samples. In CM, additional money was provided for samples that indicated smoking reduction (Initial Phase; first 7days), and for samples ≤5ppm (Abstinence Phase; following 14days).

RESULTS

CM treatment led to greater sustained abstinence relative to NR. Longer sustained abstinence in the Initial Phase partially mediated the effect of treatment on sustained abstinence in the Abstinence Phase. Heavier pretreatment drinkers had shorter periods of sustained abstinence in the Abstinence Phase; this effect was greater in CM. A serial mediation model determined that increased drinking during the Initial Phase led to decreased sustained abstinence, which then led to decreased sustained abstinence in the Abstinence Phase.

CONCLUSIONS

These data provide a greater understanding of how heavy drinking and early sustained abstinence may affect success during treatment in young adults undergoing contingency management treatment for smoking.

Systematic review of interventions to increase the provision of care for chronic disease risk behaviours in mental health settings: review protocol

BACKGROUND

People with a mental illness experience a higher morbidity and mortality from chronic diseases relative to the general population. A higher prevalence of risk behaviours, including tobacco smoking, poor nutrition, harmful alcohol consumption and physical inactivity, is a substantial contributor to this health inequity. Clinical practice guidelines recommend that mental health services routinely provide care to their clients to address these risk behaviours. Such care may include the following elements: ask, assess, advise, assist and arrange (the '5As'), which has been demonstrated to be effective in reducing risk behaviours. Despite this potential, the provision of such care is reported to be low internationally and in Australia, and there is a need to identify effective strategies to increase care provision. The proposed review will examine the effectiveness of interventions which aimed to increase care provision (i.e. increase the proportion of clients receiving or clinicians providing the 5As) for the chronic disease risk behaviours of clients within the context of mental health service delivery.

METHODS

Eligible studies will be any quantitative study designs with a comparison group and which report on the effectiveness of an intervention strategy (including delivery arrangements, financial arrangements, governance arrangements and implementation strategies) to increase care provision specifically for chronic disease risk behaviours (tobacco smoking, poor nutrition, harmful alcohol consumption and physical inactivity). Screening for studies will be conducted across seven electronic databases: PsycINFO, MEDLINE, Excerpta Medica database (EMBASE), Psychology and Behavioural Sciences Collection, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL) and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Two authors will independently screen studies for eligibility and extract data from included studies. Where studies are sufficiently homogenous, meta-analysis will be performed. Where considerable heterogeneity exists (I 2  ≥ 75), narrative synthesis will be used.

DISCUSSION

This review will be the first to synthesise evidence for the effectiveness of intervention approaches to facilitate care provision for chronic disease risk behaviours in the context of mental health service delivery. The results have the potential to inform the development of evidenced-based approaches to address the health inequities experienced by this population group.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017074360 .