Competitions for smoking cessation

Non-pharmacological interventions for smoking cessation: analysis of systematic reviews and meta-analyses

BACKGROUND

Although non-pharmacological smoking cessation measures have been widely used among smokers, current research evidence on the effects of smoking cessation is inconsistent and of mixed quality. Moreover, there is a lack of comprehensive evidence synthesis. This study seeks to systematically identify, describe, and evaluate the available evidence for non-pharmacological interventions in smoking populations through evidence mapping (EM), and to search for best-practice smoking cessation programs.

METHODS

A comprehensive search for relevant studies published from the establishment of the library to January 8, 2023, was conducted in PubMed, Web of Science, Embase, the Cochrane Library, CNKI, CBM, Wan Fang, and VIP. Two authors independently assessed eligibility and extracted data. The PRISMA statement and AMSTAR 2 tool were used to evaluate the report quality and methodology quality of systematic reviews/meta-analyses (SRs/MAs), respectively. Bubble plots were utilized to display information, such as the study population, intervention type, evidence quality, and original study sample size.

RESULTS

A total of 145 SRs/MAs regarding non-pharmacological interventions for smoking cessation were investigated, with 20 types of interventions identified. The most commonly used interventions were cognitive behaviour education (n = 32, 22.07%), professional counselling (n = 20, 13.79%), and non-nicotine electronic cigarettes (e-cigarettes) (n = 13, 8.97%). Among them, counselling and behavioural support can improve smoking cessation rates, but the effect varies depending on the characteristics of the support provided. These findings are consistent with previous SRs/MAs. The general population (n = 108, 74.48%) was the main cohort included in the SRs/MAs. The total score of PRISMA for the quality of the reports ranged from 8 to 27, and 13 studies (8.97%) were rated as high confidence, and nine studies (6.21%) as moderate confidence, in the AMSTAR 2 confidence rating.

CONCLUSIONS

The abstinence effect of cognitive behaviour education and money incentive intervention has advantages, and non-nicotine e-cigarettes appear to help some smokers transition to less harmful replacement tools. However, the methodological shortcomings of SRs/MAs should be considered. Therefore, to better guide future practice in the field of non-pharmacological smoking cessation, it is essential to improve the methodological quality of SRs and carry out high-quality randomized controlled trials (RCTs).

Smoking relapse reasons among current smokers with previous cessation experience in Shanghai: A cross-sectional study

INTRODUCTION

Quitting smoking can lead to substantial health gains, even later in life. Many smokers who attempt to quit experience several relapses before achieving sustainable cessation. This study aims to ascertain the differences between quitters with short and long abstinence time and to explore relapse reasons among smokers with cessation experience in Shanghai.

METHODS

From January to December 2022, 1745 current smokers were recruited in Minhang, Jiading, Qingpu and Songjiang districts of Shanghai. We used an electronic questionnaire to collect data. We implemented logistic regression for odds ratio (OR) and 95% confidence interval (CI) calculation to explore factors associated with long cessation time among smokers with cessation experience of ≥3 months, ≥6 months, and ≥12 months.

RESULTS

Of the 1745 smokers included, 1452 (83.2%) were males, with an average age of 44.2 years, and 48.0% (838/1745) had cessation experience but relapsed. Logistic regression indicated that smokers aged ≥45 years had a longer cessation duration (adjusted odds ratio, AOR=3.10; 95% CI: 1.97-4.88). Moreover, longer cessation duration among smokers was positively associated with low education level of junior high or lower (AOR=2.30; 95% CI: 1.42-3.72) and senior high (AOR=2.19; 95% CI: 1.53-3.15), older age at first tobacco smoking (AOR=1.62; 95% CI: 1.1.16-2.25), but was negatively associated with longer smoking duration (AOR=0.67; 95% CI: 0.43-0.00) and higher smoking burden (AOR=0.44; 95% CI: 0.28-0.72). The main reasons for cessation relapse were social interaction needs (34.5%) and discomfort due to abstinence (29.1%).

CONCLUSIONS

The relapse rate was high among smokers even after 12 months of abstinence. Smokers with older age, lower education level, shorter smoking duration and lower tobacco burden had longer cessation duration. Social interaction needs and withdrawal symptoms were the main relapse reasons. It is highly recommended that health bureaux consistently conduct tobacco control initiatives to spread awareness about the detrimental effects of tobacco smoke and the advantages of quitting smoking, even after achieving cessation.

Behavioral Economic Strategies to Improve Enrollment Rates in Clinical Research: Embedded Recruitment Pilot Trial

BACKGROUND

Nearly 1 in 3 clinical trials end prematurely due to underenrollment. Strategies to enhance recruitment are often implemented without scientific rigor to evaluate efficacy. Evidence-based, cost-effective behavioral economic strategies designed to influence decision-making may be useful to promote clinical trial enrollment.

OBJECTIVE

This study evaluated 2 behavioral economic strategies to improve enrollment and retention rates across 4 clinical trials: information provision (IP) and contingency management (CM; ie, lottery). IP targets descriptive and injunctive norms about participating in research and CM provides participants incentives to reinforce a target behavior.

METHODS

A sample of 212 participants was enrolled across 4 clinical trials focused on tobacco use: 2 focused on HIV and 2 focused on neuroimaging. The CM condition included a lottery: for each study visit completed, participants received 5 "draws" from a bowl containing 500 "chips" valued at US $0, US $1, US $5, or US $100. In the IP condition, text messages that targeted injunctive norms about research (eg, "Many find it a rewarding way to advance science and be part of a community") were sent through the Way to Health platform before all study visits. Participants were randomized to 1 of 4 conditions: IP, CM, IP+CM, or standard recruitment (SR). We performed logistic regression, controlling for sex and study, with condition as a between-subject predictor. Outcomes were the percentage of participants who attended a final eligibility visit (primary), met intent-to-treat (ITT) criteria (secondary), and completed the study (secondary). Recruitment was evaluated by the percentage of participants who attended a final eligibility visit, enrollment by ITT status, and retention by the percentage of participants who completed the study.

RESULTS

Rates of attending the eligibility visit and meeting ITT status were 58.9% (33/56) and 33.9% (19/56) for IP+CM; 45.5% (25/55) and 18.2% (10/55) for IP only; 41.5% (22/53) and 18.9% (10/53) for CM only; and 37.5% (18/48) and 12.5% (6/48) for SR, respectively. In the logistic regression, females were more likely to meet ITT status than males (odds ratio [OR] 2.7, 95% CI 1.2-5.7; P=.01). The IP+CM group was twice as likely to attend the final eligibility visit than the SR group (OR 2.4, 95% CI 1.1-5.2; P=.04). The IP+CM group was also significantly more likely to reach ITT status than the SR condition (OR 3.9, 95% CI 1.3-11.1; P=.01). Those who received any active intervention (IP, CM, or IP+CM) had a higher study completion rate (33/53, 63.5%) compared to those who received SR (5/12, 41.7%), but this difference was not significant (P=.26).

CONCLUSIONS

Combining IP and CM strategies may motivate participants to participate in research and improve recruitment and retention rates. Evidence from this study provides preliminary support for the utility of behavioral economics strategies to improve enrollment and reduce attrition in clinical trials.

Lottery incentives for smoking cessation at the workplace: design and protocol of the smoke-free lottery - a cluster randomized trial

BACKGROUND

Smoking is the leading behavioral risk factor for the loss of healthy life years. Many smokers want to quit, but have trouble doing so. Financial incentives in workplace settings have shown promising results in supporting smokers and their design influences their impact. Lotteries that leverage behavioral economic insights might improve the effectiveness of workplace cessation support.

METHODS AND DESIGN

We examine in a cluster randomized trial if a workplace cessation group training paired with lottery deadlines will increase continuous abstinence rates over and above the cessation training alone. Organizations are randomized to either the control arm or lottery arm. The lotteries capitalize regret aversion by always informing winners at the deadline, but withholding prizes if they smoked. In the lottery-arm, winners are drawn out of all participants within a training group, regardless of their smoking status. In weeks 1-13 there are weekly lotteries. Winners are informed about their prize (€50), but can only claim it if they did not smoke that week, validated biochemically. After 26 weeks, there is a long-term lottery where the winners are informed about their prize (vacation voucher worth €400), but can only claim it if they were abstinent between weeks 13 and 26. The primary outcome is continuous abstinence 52 weeks after the quit date.

DISCUSSION

There is a quest for incentives to support smoking cessation that are considered fair, affordable and effective across different socioeconomic groups. Previous use of behavioral economics in the design of lotteries have shown promising results in changing health behavior. This cluster randomized trial aims to demonstrate if these lotteries are also effective for supporting smoking cessation. Therefore the study design and protocol are described in detail in this paper. Findings might contribute to the application and development of effective cessation support at the workplace.

TRIAL REGISTRATION

Netherlands Trial Register Identifier: NL8463 . Date of registration: 17-03-2020.

Behavioral Economics and Tobacco Control: Current Practices and Future Opportunities

Despite considerable progress, smoking remains the leading preventable cause of death in the United States. To address the considerable health and economic burden of tobacco use, the development of improved tobacco control and treatment interventions is critical. By combining elements of economics and psychology, behavioral economics provides a framework for novel solutions to treat smokers who have failed to quit with traditional smoking cessation interventions. The full range of behavioral economic principles, however, have not been widely utilized in the realm of tobacco control and treatment. Given the need for improved tobacco control and treatment, the limited use of other behavioral economic principles represents a substantial missed opportunity. For this reason, we sought to describe the principles of behavioral economics as they relate to tobacco control, highlight potential gaps in the behavioral economics tobacco research literature, and provide examples of potential interventions that use each principle.

Cohort profile for the Loma Linda University Health BREATHE programme: a model to study continuously incentivised employee smoking cessation

PURPOSE

The purpose of the Loma Linda University Health (LLUH) BREATHE cohort is to test the efficacy of a novel method of continuously incentivising participation in workplace smoking cessation on participation, long-term abstinence, health outcomes, healthcare costs and healthcare utilisation.

PARTICIPANTS

In 2014, LLUH-a US academic medical centre and university-incentivised participation in a workplace smoking cessation programme (LLUH BREATHE) by lowering health plan costs. Specifically, LLUH introduced a Wholeness Health Plan (WHP) option that, for the smokers, continuously incentivises participation in nicotine screening and the LLUH BREATHE smoking cessation programme by offering an 'opt-in wellness discount' that consisted of 50%-53% lower out of pocket health plan costs (ie, monthly employee premiums, copayments). This novel 'continuously incentivised' model lowers annual health plan costs for smokers who, on an annual basis, attempt or maintain cessation from tobacco use. The annual WHP cost savings for smokers far exceed the value of short-term incentives that have been tested in workplace cessation trials to date. This ongoing health plan option offered to over 16 000 employees has created an open, dynamic LLUH BREATHE cohort of current and former smokers (n=1092).

FINDINGS TO DATE

Our profile of the LLUH BREATHE cohort indicates that after 5 years of follow-up in a prospective cohort study (2014-2019), continuously incentivised smoking cessation produced a 74% participation (95% CI (71% to 77%)) in employer-sponsored smoking cessation attempts that were occurring less than a year after the incentive was offered. The cohort can be purposed to examine the effect of continuously incentivised cessation on cessation outcomes, health plan utilisation/costs, use of electronic nicotine delivery systems, and COVID-19 outcomes.

One-month alcohol abstinence national campaigns: a scoping review of the harm reduction benefits

Over the last decade, one-month alcohol abstinence campaigns (OMACs) have been implemented within the general population in an increasing number of countries. We identified the published studies reporting data on OMACs to explore the following aspects: profile of participants, rates and factors associated with the completion of the abstinence challenge, and outcomes and harm reduction benefits in participating in the challenges. We screened 322 records, including those found in the grey literature, and reviewed 6 studies and 7 Dry July Annual Reports. Compared to non-participating alcohol users, participants were more likely to be female, have a higher income, and a higher level of education. They were heavier drinkers and were more concerned by the consequences of alcohol on health and by their health in general. Participants who achieved the one-month abstinence challenge were lower drinkers and more likely to have registered on the campaign-related Internet communities. Both successful and unsuccessful participants frequently reported health benefits, including sleep improvement and weight loss. Successful participants were more likely to durably change their alcohol drinking habits. Overall, OMACs provide short- or mid-term harm reduction benefits for both successful and unsuccessful participants. Findings were limited by the paucity of studies, their observational nature, and heterogeneity in the features of the different national campaigns, which would probably gain in enhanced internationalization.

Can financial payments incentivize short-term smoking cessation in orthopaedic trauma patients? Evidence from a discrete choice experiment

BACKGROUND

Smoking increases the risk of complications and related costs after an orthopaedic fracture. Research in other populations suggests that a one-time payment may incentivize smoking cessation. However, little is known on fracture patients' willingness to accept financial incentives to stop smoking; and the level of incentive required to motivate smoking cessation in this population. This study aimed to estimate the financial threshold required to motivate fracture patients to stop smoking after injury.

METHODS

This cross-sectional study utilized a discrete choice experiment (DCE) to elicit patient preferences towards financial incentives and reduced complications associated with smoking cessation. We presented participants with 12 hypothetical options with several attributes with varying levels. The respondents' data was used to determine the utility of each attribute level and the relative importance associated with each attribute.

RESULTS

Of the 130 enrolled patients, 79% reported an interest in quitting smoking. We estimated the financial incentive to be of greater relative importance (ri) (45%) than any of the included clinical benefits of smoking cessations (deep infection (ri: 24%), bone healing complications (ri: 19%), and superficial infections (ri: 12%)). A one-time payment of $800 provided the greatest utility to the respondents (0.64, 95% CI: 0.36 to 0.93), surpassing the utility associated with a single $1000 financial incentive (0.36, 95% CI: 0.18 to 0.55).

CONCLUSIONS

Financial incentives may be an effective tool to promote smoking cessation in the orthopaedic trauma population. The findings of this study define optimal payment thresholds for smoking cessation programs.

Behavioural interventions for smoking cessation: an overview and network meta-analysis

BACKGROUND

Smoking is a leading cause of disease and death worldwide. In people who smoke, quitting smoking can reverse much of the damage. Many people use behavioural interventions to help them quit smoking; these interventions can vary substantially in their content and effectiveness.

OBJECTIVES

To summarise the evidence from Cochrane Reviews that assessed the effect of behavioural interventions designed to support smoking cessation attempts and to conduct a network meta-analysis to determine how modes of delivery; person delivering the intervention; and the nature, focus, and intensity of behavioural interventions for smoking cessation influence the likelihood of achieving abstinence six months after attempting to stop smoking; and whether the effects of behavioural interventions depend upon other characteristics, including population, setting, and the provision of pharmacotherapy. To summarise the availability and principal findings of economic evaluations of behavioural interventions for smoking cessation, in terms of comparative costs and cost-effectiveness, in the form of a brief economic commentary.

METHODS

This work comprises two main elements. 1. We conducted a Cochrane Overview of reviews following standard Cochrane methods. We identified Cochrane Reviews of behavioural interventions (including all non-pharmacological interventions, e.g. counselling, exercise, hypnotherapy, self-help materials) for smoking cessation by searching the Cochrane Library in July 2020. We evaluated the methodological quality of reviews using AMSTAR 2 and synthesised data from the reviews narratively. 2. We used the included reviews to identify randomised controlled trials of behavioural interventions for smoking cessation compared with other behavioural interventions or no intervention for smoking cessation. To be included, studies had to include adult smokers and measure smoking abstinence at six months or longer. Screening, data extraction, and risk of bias assessment followed standard Cochrane methods. We synthesised data using Bayesian component network meta-analysis (CNMA), examining the effects of 38 different components compared to minimal intervention. Components included behavioural and motivational elements, intervention providers, delivery modes, nature, focus, and intensity of the behavioural intervention. We used component network meta-regression (CNMR) to evaluate the influence of population characteristics, provision of pharmacotherapy, and intervention intensity on the component effects. We evaluated certainty of the evidence using GRADE domains. We assumed an additive effect for individual components.

MAIN RESULTS

We included 33 Cochrane Reviews, from which 312 randomised controlled trials, representing 250,563 participants and 845 distinct study arms, met the criteria for inclusion in our component network meta-analysis. This represented 437 different combinations of components. Of the 33 reviews, confidence in review findings was high in four reviews and moderate in nine reviews, as measured by the AMSTAR 2 critical appraisal tool. The remaining 20 reviews were low or critically low due to one or more critical weaknesses, most commonly inadequate investigation or discussion (or both) of the impact of publication bias. Of note, the critical weaknesses identified did not affect the searching, screening, or data extraction elements of the review process, which have direct bearing on our CNMA. Of the included studies, 125/312 were at low risk of bias overall, 50 were at high risk of bias, and the remainder were at unclear risk. Analyses from the contributing reviews and from our CNMA showed behavioural interventions for smoking cessation can increase quit rates, but effectiveness varies on characteristics of the support provided. There was high-certainty evidence of benefit for the provision of counselling (odds ratio (OR) 1.44, 95% credibility interval (CrI) 1.22 to 1.70, 194 studies, n = 72,273) and guaranteed financial incentives (OR 1.46, 95% CrI 1.15 to 1.85, 19 studies, n = 8877). Evidence of benefit remained when removing studies at high risk of bias. These findings were consistent with pair-wise meta-analyses from contributing reviews. There was moderate-certainty evidence of benefit for interventions delivered via text message (downgraded due to unexplained statistical heterogeneity in pair-wise comparison), and for the following components where point estimates suggested benefit but CrIs incorporated no clinically significant difference: individual tailoring; intervention content including motivational components; intervention content focused on how to quit. The remaining intervention components had low-to very low-certainty evidence, with the main issues being imprecision and risk of bias. There was no evidence to suggest an increase in harms in groups receiving behavioural support for smoking cessation. Intervention effects were not changed by adjusting for population characteristics, but data were limited. Increasing intensity of behavioural support, as measured through the number of contacts, duration of each contact, and programme length, had point estimates associated with modestly increased chances of quitting, but CrIs included no difference. The effect of behavioural support for smoking cessation appeared slightly less pronounced when people were already receiving smoking cessation pharmacotherapies.

AUTHORS' CONCLUSIONS

Behavioural support for smoking cessation can increase quit rates at six months or longer, with no evidence that support increases harms. This is the case whether or not smoking cessation pharmacotherapy is also provided, but the effect is slightly more pronounced in the absence of pharmacotherapy. Evidence of benefit is strongest for the provision of any form of counselling, and guaranteed financial incentives. Evidence suggested possible benefit but the need of further studies to evaluate: individual tailoring; delivery via text message, email, and audio recording; delivery by lay health advisor; and intervention content with motivational components and a focus on how to quit. We identified 23 economic evaluations; evidence did not consistently suggest one type of behavioural intervention for smoking cessation was more cost-effective than another. Future reviews should fully consider publication bias. Tools to investigate publication bias and to evaluate certainty in CNMA are needed.

Association between behavioral phenotypes and response to a physical activity intervention using gamification and social incentives: Secondary analysis of the STEP UP randomized clinical trial

Participants often vary in their response to behavioral interventions, but methods to identify groups of participants that are more likely to respond are lacking. In this secondary analysis of a randomized clinical trial, we used baseline characteristics to group participants into distinct behavioral phenotypes and evaluated differential responses to a physical activity intervention. Latent class analysis was used to segment participants based on baseline participant data including demographics, validated measures of psychosocial variables, and physical activity behavior. The trial included 602 adults from 40 U.S. states with body mass index ≥25 who were randomized to control or one of three gamification interventions (supportive, collaborative, or competitive) to increase physical activity. Daily step counts were monitored using a wearable device for a 24-week intervention with 12 weeks of follow-up. The model segmented participants into three classes named for key defining traits: Class 1, extroverted and motivated; Class 2, less active and less social; Class 3, less motivated and at-risk. Adjusted regression models were used to test for differences in intervention response relative to control within each behavioral phenotype. In Class 1, only participants in the competitive arm increased their mean daily steps during the intervention (adjusted difference, 945; 95% CI, 352-1537; P = .002), but it was not sustained during follow-up. In Class 2, participants in all three gamification arms significantly increased their mean daily steps compared to control during the intervention (supportive arm adjusted difference 1172; 95% CI, 363-1980; P = .005; collaborative arm adjusted difference 1119; 95% CI, 319-1919; P = .006; competitive arm adjusted difference 1179; 95% CI, 400-1957; P = .003) and all three had sustained impact during follow-up. In Class 3, none of the interventions had a significant effect on physical activity. Three behavioral phenotypes were identified, each with a different response to the interventions. This approach could be used to better target behavioral interventions to participants that are more likely to respond to them.

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.