Quit and Win contests for smoking cessation

A pilot study assessing the addition of a Quit and Win program to pharmacist-led intensive smoking cessation therapy in a predominantly underserved, minority population

INTRODUCTION

Quit and Win programs (Q&W) have been shown to improve smoking cessation rates by offering potential rewards to encourage smoking cessation. However, few studies have combined Q&W with intensive smoking cessation programs including behavioral counseling and pharmacotherapy, or studied Q&W in underserved, minority populations. This study was conducted to assess the impact on smoking cessation rates of adding a Q&W to intensive smoking cessation therapy in a largely underserved, minority population.

METHODS

This was a single-center, prospective, open-label controlled study. Current smokers received pharmacist-led behavioral counseling and smoking cessation pharmacotherapy. Intervention group patients who successfully quit (verified by self-report and exhaled carbon monoxide) at 1 month and 3 months post-quit date were entered into a draw for $1000. The control group received the same smoking cessation services, but without a monetary incentive.

RESULTS

Enrollment was 111 patients (N=85 in the intervention group), made up of predominantly underserved (82% had annual household income <$25000), minority (69.1%), and female (58%) patients. Groups were similar except the intervention group had lower educational and income levels, while the control group was more likely to smoke more than 1 pack per day. Quit rates at 3 months were 27% and 19% in the intervention and control groups, respectively (p=0.22). Female gender (OR=2.84; p=0.04) and Fagerström score (OR=0.71; p<0.01) were significant predictors of quitting.

CONCLUSIONS

The addition of Q&W to intensive smoking cessation services increased clinic referrals and numerically improved cessation rates, although this difference was not statistically significant, possibly due to high attrition of the study.

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.

Enhancing Quit & Win contests to improve cessation among college smokers: a randomized clinical trial

BACKGROUND AND AIMS

Quit & Win contests (in which smokers pledge to quit smoking for a defined period in exchange for the chance to win a prize) may be well-suited for college smokers. We tested the effectiveness of multiple versus single Quit & Win contests and that of added counseling versus no counseling in smoking cessation.

DESIGN

A two-by-two, randomized controlled trial with 6-month follow-up.

SETTING

Nineteen institutions in Minnesota, Texas, Ohio and Wisconsin.

PARTICIPANTS

College student smokers (n = 1217) were randomized within site to four conditions: single (n = 306), multiple contests alone (n = 309), single contest plus counseling (n = 296) or multiple contests with counseling (n = 306).

INTERVENTION

Participants in the standard contest condition (T1 and T2) were asked to abstain from all tobacco products for a 30-day period; those with confirmed abstinence were eligible for a lottery-based prize. Participants assigned to the multiple contest conditions (T3 and T4) participated in the 30-day contest and were enrolled automatically into two additional contest periods with an escalating prize structure. Participants randomized into the counseling conditions (T2 and T4) received up to six telephone-administered Motivation and Problem Solving (MAPS) counseling sessions over the 12-week treatment period.

MEASURES

The primary outcome was biochemically verified 30-day point prevalence (PP) abstinence rate at 6 months. Secondary outcomes were the same abstinence at end of treatment (4 months) and a proxy measure of 6-month verified continuous abstinence rate. Outcomes were based on all participants randomized.

FINDINGS

We found no evidence of an interaction between number of contests and counseling. Abstinence rates for multiple (13.5%) and single (11.7%) contests were not significantly different at 6 months [odds ratio (OR) = 1.18, 95% confidence interval (CI) = 0.84-1.66]. The addition of counseling did not improve 6-month abstinence significantly (13.7 versus 11.6%, OR = 1.21, 95% CI = 0.86-1.70). Multiple contests increased abstinence at 4 months (19.3 versus 10.3%, OR = 2.09, 95% CI = 1.50-2.91) and continuous abstinence at 6 months (7.8 versus 3.8%, OR = 2.14, 95% CI = 1.28-3.56).

CONCLUSION

Multiple Quit & Win contests may increase smoking abstinence rates in college students more than single contests, but it is not clear whether adding counseling to these interventions produces any additional benefit.

The effectiveness of financial incentives for health behaviour change: systematic review and meta-analysis

BACKGROUND

Financial incentive interventions have been suggested as one method of promoting healthy behaviour change.

OBJECTIVES

To conduct a systematic review of the effectiveness of financial incentive interventions for encouraging healthy behaviour change; to explore whether effects vary according to the type of behaviour incentivised, post-intervention follow-up time, or incentive value.

DATA SOURCES

Searches were of relevant electronic databases, research registers, www.google.com, and the reference lists of previous reviews; and requests for information sent to relevant mailing lists.

ELIGIBILITY CRITERIA

Controlled evaluations of the effectiveness of financial incentive interventions, compared to no intervention or usual care, to encourage healthy behaviour change, in non-clinical adult populations, living in high-income countries, were included.

STUDY APPRAISAL AND SYNTHESIS

The Cochrane Risk of Bias tool was used to assess all included studies. Meta-analysis was used to explore the effect of financial incentive interventions within groups of similar behaviours and overall. Meta-regression was used to determine if effect varied according to post-intervention follow up time, or incentive value.

RESULTS

Seventeen papers reporting on 16 studies on smoking cessation (n = 10), attendance for vaccination or screening (n = 5), and physical activity (n = 1) were included. In meta-analyses, the average effect of incentive interventions was greater than control for short-term (≤ six months) smoking cessation (relative risk (95% confidence intervals): 2.48 (1.77 to 3.46); long-term (>six months) smoking cessation (1.50 (1.05 to 2.14)); attendance for vaccination or screening (1.92 (1.46 to 2.53)); and for all behaviours combined (1.62 (1.38 to 1.91)). There was not convincing evidence that effects were different between different groups of behaviours. Meta-regression found some, limited, evidence that effect sizes decreased as post-intervention follow-up period and incentive value increased. However, the latter effect may be confounded by the former.

CONCLUSIONS

The available evidence suggests that financial incentive interventions are more effective than usual care or no intervention for encouraging healthy behaviour change.

TRIAL REGISTRATION

PROSPERO CRD42012002393.

Financial versus health motivation to quit smoking: a randomized field study

OBJECTIVE

Smoking is the most preventable cause of death, thus justifying efforts to effectively motivate quitting. We compared the effectiveness of financial versus health messages to motivate smoking cessation. Low-income individuals disproportionately smoke and, given their greater income constraints, we hypothesized that making financial costs of smoking more salient would encourage more smokers to try quitting. Further, we predicted that financial messages would be stronger in financial settings where pecuniary constraints are most salient.

METHODS

We conducted a field study in low-income areas of New Haven, Connecticut using brochures with separate health vs. financial messages to motivate smoking cessation. Displays were rotated among community settings-check-cashing, health clinics, and grocery stores. We randomized brochure displays with gain-framed cessation messages across locations.

RESULTS

Our predictions were confirmed. Financial messages attracted significantly more attention than health messages, especially in financial settings.

CONCLUSIONS

These findings suggest that greater emphasis on the financial gains to quitting and use of financial settings to provide cessation messages may be more effective in motivating quitting. Importantly, use of financial settings could open new, non-medical venues for encouraging cessation. Encouraging quitting could improve health, enhance spending power of low-income smokers, and reduce health disparities in both health and purchasing power.

Paying the price for an incentive: An exploratory study of smokers’ reasons for failing to complete an incentive based smoking cessation scheme

Objectives:

In 2009, one Scottish region launched a smoking cessation programme offering a weekly financial incentive of £12.50 over a 12-week period. However, a significant proportion of registered participants dropped out of the programme, some even failing to collect the financial reward they were owed. We explore reasons for disengagement and failure to re-engage within this group.

Method:

Individuals (n =14) were interviewed in depth. Transcripts from recorded interviews formed the dataset and were analysed using the “Framework” method.

Results:

Incentives appeared to introduce a potential change/reversal in the felt contractual relationship between service provider and client: the client was now the provider and being paid to quit. This led to an increased sense of obligation towards the service, and enhanced feelings of failure, guilt and shame post-relapse, and reluctance to continue engagement or re-engagement. Other service factors promoting disengagement included issues of practical delivery through location, timing, administrative burden and incentive preference.

Conclusion:

The future design of incentive-based schemes should be cognisant of the potential impact on the client-professional relationship. Increasing the value of the incentive may overcome clients’ antipathy towards bureaucracy and monitoring, but may simultaneously exacerbate the sense of failure and resultant stigma associated with relapse. It may be more cost-effective to reduce barriers/costs such as inconvenience, lack of privacy, timing and embarrassment of association of attendance at the pharmacy with methadone use. Alternatively, risks may be managed by reframing weekly rewards as three separate month-long stages, increasing a sense of achievement that a particular stage has been achieved before any relapse.

Systematic reviews on tobacco control from Cochrane and the Community Guide: different methods, similar findings

OBJECTIVES

To compare the methods and findings of systematic reviews (SRs) on common tobacco control interventions from two organizations: the Cochrane Collaboration ("Cochrane") and the US Task Force for Community Preventive Services ("the Guide").

STUDY DESIGN AND SETTING

Literature review. We retrieved all reviews pertaining to tobacco control produced by the Cochrane and the Guide. We identified seven common topics and compared methods and findings of the retrieved reviews.

RESULTS

There was considerable variability in the designs of included studies and methods of data synthesis. On average, Cochrane identified more studies than did the Guide (Mean 43.7 vs. 19.0), with only limited overlap between sets of included studies. Most Cochrane reviews (71.4%) were synthesized narratively, whereas most Guide reviews (85.7%) were synthesized using a median of effect size. Despite these differences, findings of the reviews yielded substantial agreement.

CONCLUSION

Cochrane and the Guide conduct SRs on similar tobacco control-related topics differently. The SRs of the two organizations include overlapping, but nonidentical sets, of studies. Still, they usually reach similar conclusions. Identification of all pertinent original studies seems to be a weak point in the SR process. Policy makers should use reviews from both organizations in formulating tobacco control policy.

Trends in smoking among African-Americans: a description of Nashville's REACH 2010 initiative

African Americans bear a disproportionate burden of tobacco related morbidity and mortality despite smoking less than their Caucasian counterparts. Nashville's REACH 2010 initiative developed community partnerships to promote awareness, education and participatory programs to prevent and decrease smoking among residents of the northern geographic area of Nashville, TN, a majority African American community. A social-ecological model provided the framework for interventions used during a 5 year period that included: (a) community level strategies to increase awareness and knowledge about the effects of smoking; (b) individual level strategies to enlist and train community members to become advocates, lead smoking cessation classes and encourage current smokers in quit attempts; and (c) strategies directed to changing policy through education and partnership building. Smoking prevalence among residents was examined from 2001 through 2005 based on data from the Nashville CDC REACH 2010 Risk Factor Survey and the Tennessee CDC Behavioral Risk Factor Survey. Tests for linear trends indicated a significant decreasing trend (P < .02) of daily smoking and smoking uptake (P < .03) in North Nashville. In contrast to our community an increasing trend was observed in quitting smoking (P < .01). No trends were significant for African Americans in Tennessee. This study suggests that consistent, multiple and multi-level strategies targeted to an African American community may impact smokers who are not ready to quit but willing to reduce their level of smoking. This study underscores the importance of developing and implementing community wide campaigns to address the needs of African Americans.