Worksite-based incentives and competitions to reduce tobacco use. A systematic review

Evaluation of an organisational-level monetary incentive to promote the health and wellbeing of workers in small and medium-sized enterprises: A mixed-methods cluster randomised controlled trial

We conducted an independent evaluation on the effectiveness of an organisational-level monetary incentive to encourage small and medium-sized enterprises (SMEs) to improve employees' health and wellbeing. This was A mixed-methods cluster randomised trial with four arms: high monetary incentive, low monetary incentive, and two no monetary incentive controls (with or without baseline measurements to examine 'reactivity' The consequence of particpant awareness of being studied, and potential impact on participant behavior effects). SMEs with 10-250 staff based in West Midlands, England were eligible. We randomly selected up to 15 employees at baseline and 11 months post-intervention. We elicited employee perceptions of employers' actions to improve health and wellbeing; and employees' self-reported health behaviours and wellbeing. We also interviewed employers and obtained qualitative data. One hundred and fifty-two SMEs were recruited. Baseline assessments were conducted in 85 SMEs in three arms, and endline assessments in 100 SMEs across all four arms. The percentage of employees perceiving "positive action" by their employer increased after intervention (5 percentage points, pp [95% Credible Interval -3, 21] and 3pp [-9, 17], in models for high and low incentive groups). Across six secondary questions about specific issues the results were strongly and consistently positive, especially for the high incentive. This was consistent with qualitative data and quantitative employer interviews. However, there was no evidence of any impact on employee health behaviour or wellbeing outcomes, nor evidence of 'reactivity'. An organisational intervention (a monetary incentive) changed employee perceptions of employer behaviour but did not translate into changes in employees' self-reports of their own health behaviours or wellbeing. Trial registration: AEARCTR-0003420, registration date: 17.10.2018, retrospectively registered (delays in contracts and identfying a suitable trial registry). The authors confirm that there are no ongoing and related trials for this intervention.

The effectiveness of tobacco cessation programs for university students: A systematic review and meta-analysis

INTRODUCTION

This systematic review and meta-analysis aimed to explore the existing tobacco interventions and synthesize whether those interventions affected tobacco use among university students.

METHODS

We searched and found 1799 studies in PubMed, ClinicalKey for Nursing, Embase, and SCOPUS between 2009 and 2022. The risk of bias was assessed using similar criteria for RCT and non-randomized studies guided by the Cochrane Handbook for Systematic Reviews. The heterogeneity of studies was evaluated using Cochran's Q and I² index. The GRADE system was used to distinguish the quality of evidence, and Egger's linear regression test was performed to assess publication bias.

RESULTS

Eighteen studies used data extraction and analyses, and only eleven were meta-analyzed, which found that the estimate obtained via the fixed-effects model was statistically significant. Technology-based and motivational interview interventions found pooled ORs of statical significance, while reinforcer interventions showed the smallest effect size. The level of heterogeneity was considered substantial. The assessment for quality of evidence showed low overall certainty of evidence due to imprecision of outcome and suspicion of publication bias. Egger's test showed no publication bias among included studies (p=0.38).

CONCLUSIONS

There were numerous tobacco cessation interventions for university students, but the most effective intervention to change tobacco consumption behavior was still inconclusive and uncertain.

TRIAL REGISTRATION

This systematic review was registered with PROSPERO. The registration number is CRD42019142491.

Factors Associated With Postpartum Smoking Relapse Among Women Who Quit in Early Pregnancy: The Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study

BACKGROUND

While a wide range of predictors of postpartum smoking relapse have been suggested, population-based studies have rarely examined these factors exclusively among women who quit in early pregnancy. Furthermore, workplace secondhand smoke (SHS) exposure has never been examined.

METHODS

We analyzed data from 10,466 pregnant women who participated in the Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study. Age, education, parity, breastfeeding, postpartum depression, SHS exposure at home, and SHS exposure at work (not working, working without SHS exposure, working with SHS exposure) were evaluated as possible predictors. Multiple logistic regression analyses were conducted to examine the associations between these factors and smoking relapse by 1 year postpartum among women who quit in early pregnancy. Analyses stratified by SHS exposure at home were also conducted.

RESULTS

About one-fourth of early-pregnancy quitters had relapsed into smoking by 1 year postpartum. Lower education, multiparity, not breastfeeding, postpartum depression, and SHS exposure at home were associated with increased risks of smoking relapse. Working with SHS exposure was associated with an increased risk of smoking relapse; the multivariate-adjusted odds ratios of working without SHS exposure and working with SHS exposure compared with not working were 1.14 (95% confidence interval [CI], 0.82-1.59) and 2.18 (95% CI, 1.37-3.46), respectively. The significant association of workplace SHS exposure was observed only among women without SHS exposure at home.

CONCLUSION

SHS exposure at work, as well as education, multiparity, breastfeeding, postpartum depression, and SHS exposure at home were associated with postpartum smoking relapse among early-pregnancy quitters.

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.

Barriers to introduction of smoke-free workplaces in Central Europe: example of the Czech Republic

OBJECTIVES

Smoking at the workplace has a negative impact both on employers' economic interests and employees' health. The aim of this study is to describe the current situation, mainly barriers in implementation and resources in the Czech Republic as an example of a Central European country.

METHODS

We synthesised relevant review papers with our knowledge of the local situation based upon professional experience of both authors.

RESULTS

Despite smoke-free laws, some EU workers are still exposed to passive smoking during working hours. The main barriers towards smoke-free workplace implementation are the lack of resources, perception of smoking as a norm, and exceptions for leading personalities and their smoking. Social support increases smoking cessation effectiveness. Low availability of local smoking cessation services is an overall problem in Central Europe.

CONCLUSIONS

The working environment influences smoking habits. Smoking cessation support is cost-effective not only for the smoking employee but for employers as well. Smoking cessation resources should be available during the working day. No exceptions should be made as they serve as barriers to a smoke-free working environment.

Social predictors of continued and indoor smoking among partners of non-smoking pregnant women: the TMM BirThree Cohort Study

BACKGROUND

Secondhand smoke (SHS) from partners is a major source of exposure for non-smoking women. However, epidemiological studies have rarely examined social factors associated with continued and indoor smoking among pregnant women's partners.

METHODS

We analyzed data on 6091 partners of non-smoking pregnant women in the Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study. Partners' age, education, income, workplace SHS exposure (almost never or sometimes, almost every day), and pregnant women's smoking history (never, quit before pregnancy awareness, quit after pregnancy awareness) were used as social factors. Multivariate logistic regression analyses were conducted to examine the associations of social factors with partners' continued smoking and indoor smoking.

RESULTS

Among 2432 smoking partners, 2237 continued to smoke after pregnancy awareness. Workplace SHS exposure was associated with increased risk of partners' continued smoking: the odds ratio of workplace SHS exposure almost every day compared with almost never or sometimes was 2.08 (95% confidence interval, 1.52-2.83). Women's quitting smoking after-but not before-pregnancy awareness was associated with decreased risk of partners' continued smoking: the odds ratio of women's quitting after pregnancy awareness compared with never smoking was 0.57 (95% confidence interval, 0.40-0.80). About one-third of partners who continued to smoke did so indoors. Older age, lower education, workplace SHS exposure, and women's quitting smoking after pregnancy awareness were associated with increased risk of partners' indoor smoking.

CONCLUSIONS

Workplace SHS exposure and pregnant women's smoking history were associated with continued smoking and indoor smoking among partners of non-smoking pregnant women.

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.

Occupational health professionals' attitudes, knowledge, and motivation concerning smoking cessation-Cross-sectional survey

OBJECTIVES

Occupational health (OH) professionals could play a prominent role in smoking cessation treatment and support (SCTS) and help individuals and workplaces become smoke free. However, their role has not been evaluated. The aim of this study was to assess differences between OH professionals' perceptions of their role in SCTS by measuring three groups of OH professionals' attitudes, knowledge, and motivation concerning SCTS.

METHODS

We collected data through an online survey completed by a cross-sectional sample of OH professionals: OH physicians (n = 182), OH nurses (n = 296), and OH physiotherapists (n = 96), collected from national trade union registers. The differences between the OH professional groups were analyzed using ANOVA, the Kruskal-Wallis, and chi-square tests.

RESULTS

The OH professionals had a positive attitude toward offering SCTS and were highly motivated to enhance their knowledge of this topic and acquire further training. The OH physicians and OH nurses assessed their current knowledge as sufficient. Conversely, the OH physiotherapists' level of knowledge was seen as insufficient. Traditionally, OH physicians and OH nurses have been responsible for carrying out SCTS, but the majority of the OH physiotherapists thought that SCTS should also be included in their job description.

CONCLUSIONS

All the OH professionals were highly motivated to deepen their knowledge of SCTS. The barriers between different professionals need to be recognized in occupational health services (OHS). OHS should organize its SCTS more effectively, strengthen their contributions to smoking cessation programs, and recognize the potential of OH physiotherapists for providing SCTS and enable them to expand their training.

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.

Development and Validation of the Policies, Opportunities, Initiatives and Notable Topics (POINTS) Audit for Campuses and Worksites

Background: Workplace or campus wellness/obesity-prevention policies and initiatives can improve health. Research tools to assess worksite or campus policies/initiatives are scarce. Thus, the aim of this research is to develop and validate the policies, opportunities, initiatives, and notable topics (POINTS) audit. Methods: POINTS was developed and refined via expert review, pilot-testing, and field testing. Trained researchers completed a web-based review from a student-focus or employee-focus regarding 34 health-promoting topics for colleges. Each topic was evaluated on a 0⁻2 scale: 0 = no policy/initiative, 1 = initiatives, 2 = written policy. When a written policy was detected, additional policy support questions (administered, monitored, reviewed) were completed. Results: Cronbach's Alpha for the student-focused POINTS audit was α = 0.787 (34 items, possible points = 65), and for the employee-focused POINTS audit was α = 0.807 (26 items, possible points = 50). A total of 115 student-focused and 33 employee-focused audits were completed. Although there was little evidence of policy presence beyond stimulant standards (smoking and alcohol), there were extensive examples of health initiatives. The student-focused POINTS audit was validated using the Healthier Campus Initiative's survey. Conclusions: POINTS is a web-based audit tool that is valid and useful for pre-assessment, advocacy, benchmarking, and tracking policies for health and well-being for students (campus) and employees (worksite).

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.

Employee characteristics and health belief variables related to smoking cessation engagement attitudes

BACKGROUND

Workplace smoking cessation programs can effectively assist employees to quit smoking. However, little is known about employees' attitudes towards engagement in workplace smoking cessation programs.

OBJECTIVE

This study aimed to address the limited understanding of the interaction between employee characteristics and their health beliefs toward engaging in a workplace smoking cessation program.

METHODS

Self-report data was collected from 897 employees of a mining company operating in two remote towns in Australia. The majority of participants were male (73%), the mean age was 36.9 years (SD = 11.5). Chi square tests of independence were used to analyze relationships between employee characteristics and smoking cessation engagement attitudes. Engagement attitudes included: A desire to cease smoking; desire for assistance with the smoking cessation process; and intention to participate in a workplace smoking intervention.

RESULTS

The findings from this study indicated that attitudes towards engagement in smoking cessation programs varied for mining employees according to gender, age, perceived severity, perceived self-efficacy, and stage of readiness to change.

CONCLUSIONS

These findings provide insights that health promotion practitioners may apply to inform the design and marketing of effective workplace smoking cessation programs for similar employees.

Incentives and Patches for Medicaid Smokers: An RCT

INTRODUCTION

Most successful trials of financial incentives for smoking cessation have offered large rewards contingent on outcomes. This study examines whether more modest incentives to encourage engagement, non-contingent on outcomes, also increase cessation; whether sending medications directly to participants boosts quitting; and whether these strategies are effective in Medicaid.

STUDY DESIGN

Three-group RCT of usual care (UC); nicotine patch (NP); and NP and financial incentive (NP+FI).

SETTING/PARTICIPANTS

Medicaid beneficiaries calling the California Smokers' Helpline, 2012-2013 (N=3,816). Data were analyzed in 2017.

INTERVENTION

All participants enrolled in evidence-based, multisession telephone counseling. All received proof of enrollment with which they could obtain free quitting aids at their pharmacy. NP and NP+FI also received nicotine patches sent to their homes. NP+FI received up to $60 for completing counseling calls.

MAIN OUTCOME MEASURES

Quit attempt rate, 7-day and 30-day abstinence at 2 and 7 months, and 6-month prolonged abstinence (primary outcome).

RESULTS

In both complete-case and intention-to-treat analyses, outcomes trended upward from UC to NP to NP+FI. Differences between NP and UC were generally nonsignificant. By contrast, the NP+FI group significantly outperformed the other groups on all measures. In intention-to-treat analysis, compared with UC, NP+FI was more likely to make a quit attempt (68.4% vs 54.3%, p<0.001); be abstinent for 7 days at 2 months (36.1% vs 25.5%, p<0.001) and 7 months (21.2% vs 16.1%, p=0.002); be abstinent for 30 days at 2 months (30.0% vs 18.9%, p<0.001) and 7 months (21.5% vs 16.7%, p=0.004); and achieve 6-month prolonged abstinence (13.2% vs 9.0%, p=0.001).

CONCLUSIONS

Financial incentives increased treatment engagement and short- and long-term smoking cessation, despite being modest and non-contingent on outcomes. The study found that incentives can be effective in a Medicaid population, and can feasibly be integrated into existing quitline services.

TRIAL REGISTRATION

The trial is registered at www.clinicaltrials.gov NCT01502306.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Prevalence and characteristics of young adult smokers in the U.S. in the precontemplation stage of smoking cessation

INTRODUCTION

The precontemplation stage of smoking cessation refers to having no intention to quit smoking in the next six months. We aimed to estimate the prevalence of and characteristics associated with the precontemplation stage of smoking cessation among U.S. young adult smokers to inform the development of targeted interventions.

METHODS

We analyzed data in 2017 from the 2013-2014 National Adult Tobacco Survey. Young adult (18-29 years old) daily and non-daily smokers were included (n = 1809). We applied weighted multiple logistic regression models to examine the associations between demographics, tobacco use behaviors, exposure to pro- and anti-tobacco messages, and the precontemplation stage of smoking cessation.

RESULTS

59.0% of U.S. young adult smokers are in the precontemplation stage of smoking cessation. Unemployment was positively associated with being in the precontemplation stage of smoking cessation (AOR = 1.42 95% CI = 1.05, 1.91). Smoking every day (vs. some days), more cigarettes smoked per day, using roll-your-own cigarettes (vs. manufactured cigarettes only), currently smoking cigars, and signing up for promotional offers were positively associated with being in the precontemplation stage of smoking cessation (p < 0.05). Non-Hispanic Black was negatively associated with precontemplation stage (AOR = 0.40, 95% CI = 0.27, 0.59). Not smoking after viewing a health warning on a cigarette pack was negatively associated with the precontemplation stage of smoking cessation (AOR = 0.36, 95% CI = 0.25, 0.51).

CONCLUSIONS

Many U.S. young adult smokers classify as being in the precontemplation stage of smoking cessation. Interventions to motivate these smokers to quit smoking with considerations of their specific characteristics (e.g., being unemployed) are warranted.

Interventions to encourage smoke-free homes in remote indigenous Australian communities: a study protocol to evaluate the effects of a community-inspired awareness-raising and motivational enhancement strategy

INTRODUCTION

Rates of secondhand smoke exposure are currently significantly higher among remote indigenous communities in the top end of Australia. By implementing a 'smoke-free home' rule, secondhand smoke exposure can be reduced. Smoke-free homes encourage quit attempts and improve the health of children. The prevalence of indigenous smoking rates in remote, discrete communities in Australia is elevated compared with their non-indigenous counterparts. The primary aim of this project is to examine the feasibility of conducting a health-driven intervention to encourage community members to make their homes a smoke-free zone.

METHODS AND ANALYSIS

This study uses mixed-methods exploratory evaluation design to obtain data from key informants and community householders to assess their willingness to implement a 'smoke-free' rule in their homes. Initial focus groups will provide guidance on intervention content and deliver evaluation procedures and community requirements. A rapid survey will be conducted to ascertain interest from community members in having the project team visit to discuss study objectives further and to have a particle meter (with consent) placed in the house. Focus groups recordings will be transcribed and analysed thematically. Rapid surveys will be analysed using frequency distributions and tabulations of responses.

ETHICS AND DISSEMINATION

The National Health and Medical Research Council guidelines on ethical research approaches to indigenous studies will be adhered to. The James Cook University Human Research Ethics Committee has provided ethics approval.

A 30-month worksite-based lifestyle program to promote cardiovascular health in middle-aged bank employees: Design of the TANSNIP-PESA randomized controlled trial

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death worldwide. With atherosclerosis as the underlying cause for many CVD events, prevention or reduction of subclinical atherosclerotic plaque burden (SAPB) through a healthier lifestyle may have substantial public health benefits.

OBJECTIVE

The objective was to describe the protocol of a randomized controlled trial investigating the effectiveness of a 30-month worksite-based lifestyle program aimed to promote cardiovascular health in participants having a high or a low degree of SAPB compared with standard care.

METHODS

We will conduct a randomized controlled trial including middle-aged bank employees from the Progression of Early Subclinical Atherosclerosis cohort, stratified by SAPB (high SAPB n=260, low SAPB n=590). Within each stratum, participants will be randomized 1:1 to receive a lifestyle program or standard care. The program consists of 3 elements: (a) 12 personalized lifestyle counseling sessions using Motivational Interviewing over a 30-month period, (b) a wrist-worn physical activity tracker, and (c) a sit-stand workstation. Primary outcome measure is a composite score of blood pressure, physical activity, sedentary time, body weight, diet, and smoking (ie, adapted Fuster-BEWAT score) measured at baseline and at 1-, 2-, and 3-year follow-up.

CONCLUSIONS

The study will provide insights into the effectiveness of a 30-month worksite-based lifestyle program to promote cardiovascular health compared with standard care in participants with a high or low degree of SAPB.

Worksite Cancer Prevention Activities in the National Comprehensive Cancer Control Program

Workplaces are one setting for cancer control planners to reach adults at risk for cancer and other chronic diseases. However, the extent to which Centers for Disease Control and Prevention-funded National Comprehensive Cancer Control Programs (NCCCP) implement interventions in the workplace setting is not well characterized. We conducted a qualitative content analysis of program action plans submitted by NCCCP grantees from 2013 to 2015 to identify and describe cancer prevention objectives and interventions in the workplace setting. Nearly half of NCCCP action reports contained at least one cancer prevention objective or intervention in the workplace setting. Common interventions included education about secondhand smoke exposure in the workplace, and the importance of obtaining colorectal cancer screening. Workplace interventions were relatively common among NCCCP action plans, and serve as one way to address low percentages of CRC screening, and reduce risk for obesity- and tobacco-related cancers.

Feasibility of Workplace Health Promotion for Restaurant Workers, Seattle, 2012

Introduction

Restaurant workers are a large population at high risk for tobacco use, physical inactivity, and influenza. They are difficult to reach with health care interventions and may be more accessible through workplaces, yet few studies have explored the feasibility of workplace health promotion in this population. This study sought to identify barriers and facilitators to promotion of tobacco cessation, physical activity, and influenza vaccination in restaurants.

Methods

Moderators conducted 7 focus groups, 3 with restaurant owners and managers, 2 with English-speaking workers, and 2 with Spanish-speaking workers. All groups were recorded, and recordings were transcribed and uploaded to qualitative-analysis software. Two researchers coded each transcript independently and analyzed codes and quotations for common themes.

Results

Seventy people from the restaurant industry participated. Barriers to workplace health promotion included smoking-break customs, little interest in physical activity outside of work, and misinformation about influenza vaccinations. Facilitators included creating and enforcing equitable break policies and offering free, on-site influenza vaccinations. Spanish-speakers were particularly amenable to vaccination, despite their perceptions of low levels of management support for health promotion overall. Owners required a strong business case to consider investing in long-term prevention for their employees.

Conclusion

Tobacco cessation and influenza vaccinations are opportunities for health promotion among restaurant workers, whereas physical activity interventions face greater challenges. Promotion of equitable breaks, limited smoking-break policies, and free, on-site influenza vaccinations could improve health for restaurant workers, who often do not have health insurance. Workplace interventions may be particularly important for Hispanic workers who have additional access barriers.

Overview of systematic reviews on the health-related effects of government tobacco control policies

BACKGROUND

Government interventions are critical to addressing the global tobacco epidemic, a major public health problem that continues to deepen. We systematically synthesize research evidence on the effectiveness of government tobacco control policies promoted by the Framework Convention on Tobacco Control (FCTC), supporting the implementation of this international treaty on the tenth anniversary of it entering into force.

METHODS

An overview of systematic reviews was prepared through systematic searches of five electronic databases, published up to March 2014. Additional reviews were retrieved from monthly updates until August 2014, consultations with tobacco control experts and a targeted search for reviews on mass media interventions. Reviews were assessed according to predefined inclusion criteria, and ratings of methodological quality were either extracted from source databases or independently scored.

RESULTS

Of 612 reviews retrieved, 45 reviews met the inclusion criteria and 14 more were identified from monthly updates, expert consultations and a targeted search, resulting in 59 included reviews summarizing over 1150 primary studies. The 38 strong and moderate quality reviews published since 2000 were prioritized in the qualitative synthesis. Protecting people from tobacco smoke was the most strongly supported government intervention, with smoke-free policies associated with decreased smoking behaviour, secondhand smoke exposure and adverse health outcomes. Raising taxes on tobacco products also consistently demonstrated reductions in smoking behaviour. Tobacco product packaging interventions and anti-tobacco mass media campaigns may decrease smoking behaviour, with the latter likely an important part of larger multicomponent programs. Financial interventions for smoking cessation are most effective when targeted at smokers to reduce the cost of cessation products, but incentivizing quitting may be effective as well. Although the findings for bans on tobacco advertising were inconclusive, other evidence suggests they remain an important intervention.

CONCLUSION

When designing and implementing tobacco control programs, governments should prioritize smoking bans and price increases of tobacco products followed by other interventions. Additional studies are needed on the various factors that can influence a policy's effectiveness and feasibility such as cost, local context, political barriers and implementation strategies.

Impact of school staff health on work productivity in secondary schools in Massachusetts

BACKGROUND

Healthy, productive employees are an integral part of school health programs. There have been few assessments of work productivity among secondary school staff. This study describes the frequency of 3 common health risk factors--obesity, depressive symptoms, and smoking--and their impact on work productivity in secondary school employees.

METHODS

Employees of secondary schools in Massachusetts (N = 630) participated in a longitudinal weight gain prevention intervention study. Assessment completed at baseline, 1-year and 2-year follow-up included survey assessments of health risk factors as well as measurements for height, weight, and body mass index (BMI). The survey also included a depression inventory and Work Limitations Questionnaire. Data analysis included multivariate mixed effect models to identify productivity differences in relation to BMI, depressive symptoms, and smoking in this population stratified by position type (teacher and other school staff).

RESULTS

The sample included 361 teachers and 269 other school staff. Obesity, depressive symptoms, and smoking were significantly associated with work productivity, including workdays missed because of health concerns (absenteeism) and decreases in on-the-job productivity because of health concerns (presenteeism).

CONCLUSIONS

Three common health conditions, namely obesity, depressive symptoms, and smoking, adversely affect the productivity of high school employees.

Incentives for smoking cessation

BACKGROUND

Material or financial incentives are widely used in an attempt to precipitate or reinforce behaviour change, including smoking cessation. They operate in workplaces, in clinics and hospitals, and to a lesser extent within community programmes. In this third update of our review we now include trials conducted in pregnant women, to reflect the increasing activity and resources now targeting this high-risk group of smokers.

OBJECTIVES

To determine whether incentives and contingency management programmes lead to higher long-term quit rates.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, with additional searches of MEDLINE, EMBASE, CINAHL and PsycINFO. The most recent searches were in December 2014, although we also include two trials published in 2015.

SELECTION CRITERIA

We considered randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures. We include studies in a mixed-population setting (e.g. community-, work-, institution-based), and also, for this update, trials in pregnant smokers.

DATA COLLECTION AND ANALYSIS

One author (KC) extracted data and a second (JH-B) checked them. We contacted study authors for additional data where necessary. The main outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up, and at least six months from the start of the intervention. In the trials of pregnant smokers abstinence was measured at the longest follow-up, and at least to the end of the pregnancy.

MAIN RESULTS

Twenty-one mixed-population studies met our inclusion criteria, covering more than 8400 participants. Ten studies were set in clinics or health centres, one in Thai villages served by community health workers, two in academic institutions, and the rest in worksites. All but six of the trials were run in the USA. The incentives included lottery tickets or prize draws, cash payments, vouchers for goods and groceries, and in six trials the recovery of money deposited by those taking part. The odds ratio (OR) for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.42 (95% confidence interval (CI) 1.19 to 1.69; 17 trials, [20 comparisons], 7715 participants). Only three studies demonstrated significantly higher quit rates for the incentives group than for the control group at or beyond the six-month assessment: One five-arm USA trial compared rewards- and deposit-based interventions at individual and group level, with incentives available up to USD 800 per quitter, and demonstrated a quit rate in the rewards groups of 8.1% at 12 months, compared with 4.7% in the deposits groups. A direct comparison between the rewards-based and the deposit-based groups found a benefit for the rewards arms, with an OR at 12 months of 1.76 (95% CI 1.22 to 2.53; 2070 participants). Although more people in this trial accepted the rewards programmes than the deposit programmes, the proportion of quitters in each group favoured the deposit-refund programme. Another USA study rewarded both participation and quitting up to USD 750, and achieved sustained quit rates of 9.4% in the incentives group compared with 3.6% for the controls. A deposit-refund trial in Thailand also achieved significantly higher quit rates in the intervention group (44.2%) compared with the control group (18.8%), but uptake was relatively low, at 10.5%. In the remaining trials, there was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that contingent rewards enhanced success rates over fixed payment schedules. We rated the overall quality of the older studies as low, but with later trials (post-2000) more likely to meet current standards of methodology and reporting.Eight of nine trials with usable data in pregnant smokers (seven conducted in the USA and one in the UK) delivered an adjusted OR at longest follow-up (up to 24 weeks post-partum) of 3.60 (95% CI 2.39 to 5.43; 1295 participants, moderate-quality studies) in favour of incentives. Three of the trials demonstrated a clear benefit for contingent rewards; one delivered monthly vouchers to confirmed quitters and to their designated 'significant other supporter', achieving a quit rate in the intervention group of 21.4% at two months post-partum, compared with 5.9% among the controls. Another trial offered a scaled programme of rewards for the percentage of smoking reduction achieved over the course of the 12-week intervention, and achieved an intervention quit rate of 31% at six weeks post-partum, compared with no quitters in the control group. The largest (UK-based) trial provided intervention quitters with up to GBP 400-worth of vouchers, and achieved a quit rate of 15.4% at longest follow-up, compared to the control quit rate of 4%. Four trials confirmed that payments made to reward a successful quit attempt (i.e. contingent), compared to fixed payments for attending the antenatal appointment (non-contingent), resulted in higher quit rates. Front-loading of rewards to counteract early withdrawal symptoms made little difference to quit rates.

AUTHORS' CONCLUSIONS

Incentives appear to boost cessation rates while they are in place. The two trials recruiting from work sites that achieved sustained success rates beyond the reward schedule concentrated their resources into substantial cash payments for abstinence. Such an approach may only be feasible where independently-funded smoking cessation programmes are already available, and within a relatively affluent and educated population. Deposit-refund trials can suffer from relatively low rates of uptake, but those who do sign up and contribute their own money may achieve higher quit rates than reward-only participants. Incentive schemes conducted among pregnant smokers improved the cessation rates, both at the end-of-pregnancy and post-partum assessments. Current and future research might continue to explore the scale, loading and longevity of possible cash or voucher reward schedules, within a variety of smoking populations.

Behavioral Interventions to Enhance Smoking Cessation

In the United States, the rate of cigarette smoking has significantly declined over the past 2 decades, but much more work is needed, as almost 20% of adults still smoke and smoking continues to be the leading preventable cause of death. Furthermore, rates of smoking in certain subpopulations have remained relatively stable and have historically been neglected in smoking cessation research. Pharmacotherapy (both prescription and over-the-counter) and behavioral support are known to aid cessation, and their combination is more effective than either alone. There are significant barriers to access, use, and adherence, however, especially with pharmacotherapy. Therefore, the purpose of this review is to provide an update and overview of the numerous behavioral approaches that have been used to enhance smoking cessation. The research described can be classified into the type of approach used, the setting in which it is delivered, and the population targeted. Regardless of the classification, all the approaches attempt to provide smokers with the information, motivation, and behavioral skills thought to be necessary for achieving initial cessation and sustained abstinence. Recommendations for future research on behavioral smoking cessation are also included.

Efficacy of team-based financial incentives for smoking cessation in the workplace

Worksite smoking cessation programs offer accessibility of the target population, availability of occupational health support, and the potential for peer pressure and peer support. The purpose of this study was to identify the efficacy of the financial incentives given to various teams in the workplace. St. Paul's Hospital's employees were enrolled. Each team of employees consisted of smoking participants and non-smoking fellow workers from the same department. The financial incentive of 50000 won (about $45) was rewarded to the team for each successful participant-not to individual members-after the first week and then after one month. If the smokers in the team remained abstinent for a longer time period, the team was given an incentive of 100000 won for each successful participant after 3 and 6 months. A total 28 smoking participants and 6 teams were enrolled. Self-reported abstinence rates validated by urinary cotinine test at 3, 6, and 12 months after the initial cessation were 61%, 54%, and 50%, respectively. Smokers with high nicotine dependence scores or those who began participation 1 month after enrollment initiation had a lower abstinence rate at 3 months, but not at 6 and 12 months. Participants who succeeded at smoking cessation at 12 months were more likely to be older and have a longer smoking duration history. The financial incentives given to teams could be promising and effective to improve long-term rates of smoking cessation. This approach could use peer pressure and peer support in the workplace over a longer period.

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.

A systematic review of internet-based worksite wellness approaches for cardiovascular disease risk management: outcomes, challenges & opportunities

Context

The internet is gaining popularity as a means of delivering employee-based cardiovascular (CV) wellness interventions though little is known about the cardiovascular health outcomes of these programs. In this review, we examined the effectiveness of internet-based employee cardiovascular wellness and prevention programs.

Evidence Acquisition

We conducted a systematic review by searching PubMed, Web of Science and Cochrane library for all published studies on internet-based programs aimed at improving CV health among employees up to November 2012. We grouped the outcomes according to the American Heart Association (AHA) indicators of cardiovascular wellbeing – weight, BP, lipids, smoking, physical activity, diet, and blood glucose.

Evidence Synthesis

A total of 18 randomized trials and 11 follow-up studies met our inclusion/exclusion criteria. Follow-up duration ranged from 6 – 24 months. There were significant differences in intervention types and number of components in each intervention. Modest improvements were observed in more than half of the studies with weight related outcomes while no improvement was seen in virtually all the studies with physical activity outcome. In general, internet-based programs were more successful if the interventions also included some physical contact and environmental modification, and if they were targeted at specific disease entities such as hypertension. Only a few of the studies were conducted in persons at-risk for CVD, none in blue-collar workers or low-income earners.

Conclusion

Internet based programs hold promise for improving the cardiovascular wellness among employees however much work is required to fully understand its utility and long term impact especially in special/at-risk populations.

Health promotion in smaller workplaces in the United States

Most American workplaces are smaller, with fewer than 1,000 employees. Many of these employees are low-wage earners and at increased risk for chronic diseases. Owing to the challenges smaller workplaces face to offering health-promotion programs, their employees often lack access to health-promotion opportunities available at larger workplaces. Many smaller employers do not offer health insurance, which is currently the major funding vehicle for health-promotion services. They also have few health-promotion vendors to serve them and low internal capacity for, and commitment to, delivery of on-site programs. The programs they offer, whether aimed at health promotion alone or integrated with health protection, are rarely comprehensive and are understudied. Research priorities for health promotion in smaller workplaces include developing programs feasible for the smallest workplaces with fewer than 20 employees. Policy priorities include incentives for smaller workplaces to implement comprehensive programs and an ongoing system for monitoring and evaluation.

Implementation of a personalized workplace smoking cessation programme

BACKGROUND

Providing smoking cessation programmes through workplaces is an effective method of assisting employees to quit smoking; however, few employers provide such services, and achieving long-term success remains challenging.

AIMS

To evaluate the effectiveness of a workplace-based tailored smoking cessation programme that combined telephone-based counselling with group behaviour therapy sessions in helping employees to quit.

METHODS

A smoking cessation programme was offered to employees of a large corporation that is respons ible for the passenger rail network in New South Wales (NSW), Australia. Two hundred and thirty participants enrolled in the programme, which offered telephone-based coaching and group sessions designed around cognitive behavioural therapy principles. One hundred and eight participants (47%) completed the 6 month follow-up assessment.

RESULTS

Of the estimated 2850 smokers in the organization, 8% (230) registered for the smoking cessation programme, with 77% (176) participating in telephone-based coaching and/or group sessions. Intention-to-treat analysis indicated 22% of participants achieved 7 day point prevalence abstinence and 10% achieved 3 month prolonged abstinence at the 6 month follow-up. Over 75% of those still smoking at follow-up reported intentions to quit in the next 6 months. Psychological distress was also significantly lower at 6 month follow-up. Participants reported high levels of satisfaction with the programme.

CONCLUSIONS

The smoking cessation programme successfully assisted employees to quit smoking. Unique aspects of the programme such as continuity of care were valued by participants and may have contributed to the programme's success.

The use of financial incentives in promoting smoking cessation

OBJECTIVE

Cigarette smoking is the leading cause of preventable death in the United States and world. Despite the availability of numerous therapies for smoking cessation, additional efficacious interventions are greatly needed. We provide a narrative review of published studies evaluating financial incentives for smoking cessation and discuss the parameters important for ensuring the efficacy of incentive interventions for smoking cessation.

METHODS

Published studies that evaluated the impact of incentives to promote smoking cessation and included an appropriate control or comparison condition were identified and reviewed.

RESULTS

Incentives are efficacious for promoting smoking abstinence across the general population of smokers as well as substance abusers, adolescents, patients with pulmonary disease, patients with serious mental illness and other challenging subgroups. To develop and implement an effective incentive treatment for smoking, special attention should be paid to biochemical verification of smoking status, incentive magnitude and the schedule of incentive delivery.

CONCLUSION

Consistent with the extensive literature showing that incentives are effective in reducing illicit drug use, a large body of evidence supports their effectiveness in reducing smoking. Continued efforts are warranted to further develop and disseminate incentive-based treatments for smoking cessation across clinical settings and populations.

Population approaches to improve diet, physical activity, and smoking habits: a scientific statement from the American Heart Association

BACKGROUND

Poor lifestyle behaviors, including suboptimal diet, physical inactivity, and tobacco use, are leading causes of preventable diseases globally. Although even modest population shifts in risk substantially alter health outcomes, the optimal population-level approaches to improve lifestyle are not well established.

METHODS AND RESULTS

For this American Heart Association scientific statement, the writing group systematically reviewed and graded the current scientific evidence for effective population approaches to improve dietary habits, increase physical activity, and reduce tobacco use. Strategies were considered in 6 broad domains: (1) Media and educational campaigns; (2) labeling and consumer information; (3) taxation, subsidies, and other economic incentives; (4) school and workplace approaches; (5) local environmental changes; and (6) direct restrictions and mandates. The writing group also reviewed the potential contributions of healthcare systems and surveillance systems to behavior change efforts. Several specific population interventions that achieved a Class I or IIa recommendation with grade A or B evidence were identified, providing a set of specific evidence-based strategies that deserve close attention and prioritization for wider implementation. Effective interventions included specific approaches in all 6 domains evaluated for improving diet, increasing activity, and reducing tobacco use. The writing group also identified several specific interventions in each of these domains for which current evidence was less robust, as well as other inconsistencies and evidence gaps, informing the need for further rigorous and interdisciplinary approaches to evaluate population programs and policies.

CONCLUSIONS

This systematic review identified and graded the evidence for a range of population-based strategies to promote lifestyle change. The findings provide a framework for policy makers, advocacy groups, researchers, clinicians, communities, and other stakeholders to understand and implement the most effective approaches. New strategic initiatives and partnerships are needed to translate this evidence into action.

Implementation of workplace-based smoking cessation support activities and smoking cessation among employees: the Finnish Public Sector Study

OBJECTIVES

We investigated the relationship between implementation of workplace smoking cessation support activities and employee smoking cessation.

METHODS

In 2 cohort studies, participants were 6179 Finnish public-sector employees who self-reported as smokers at baseline in 2004 (study 1) or 2008 (study 2) and responded to follow-up surveys in 2008 (study 1; n=3298; response rate = 71%) or 2010 (study 2; n=2881; response rate=83%). Supervisors' reports were used to assess workplace smoking cessation support activities. We conducted multilevel logistic regression analyses to examine changes in smoking status.

RESULTS

After adjustment for sociodemographic characteristics, number of cigarettes smoked per day, work unit size, shift work, type of job contract, health status, and health behaviors, baseline smokers whose supervisors reported that the employing agency had offered pharmacological treatments or financial incentives were more likely than those in workplaces that did not offer such support to have quit smoking. In general, associations were stronger among moderate or heavy smokers (≥ 10 cigarettes/day) than among light smokers (<10 cigarettes/day).

CONCLUSIONS

Cessation activities offered by employers may encourage smokers, particularly moderate or heavy smokers, to quit smoking.

Strategies for strengthening the evidence base for employee health promotion programs

Employee health promotion programs have been a visible facet of the American workplace for more than 30 years. During that time, a substantial amount of research on best practices has been conducted, but because of a lack of significant public investment in research funding there is still much to be done. Most researchers and practitioners familiar with the literature recognize the need to strengthen the evidence base for the field. In this edition of The Art of Health Promotion we examine the primary recommendations emerging from a recent federally sponsored effort to identify strategies for strengthening the evidence base for employee health promotion.

Clinical management of smoking cessation: patient factors affecting a reward-based approach

Although the majority of current smokers indicate they would like to quit, only about half of smokers make a quit attempt each year. Of those who attempt to quit, only about 5% are successful. Many effective products and programs are available to assist in smoking cessation; however those interested in quitting often do not make use of these resources. To increase use of cessation products in order to improve successful cessation rates, the Consumer Demand Roundtable has argued that smokers need to be viewed as consumers of cessation products rather than as patients needing treatment. With this consumer-based approach in mind, the current review examines how participant characteristics, perceptions, and behavior influence, and are influenced by, contingency management (CM) paradigms in various settings. Findings suggest that participant factors associated with success in these programs include demographic characteristics (eg, gender, marital status), self-efficacy, motivation to quit, and impulsivity. Overall, participants perceive incentives for successful cessation as motivating. However, such programs may involve greater withdrawal symptoms (eg, craving for cigarettes) initially, but these symptoms tend to decrease at a greater rate over time compared with nonincentive group participants. CM programs have also been shown to be successful across a number of settings (eg, communities, schools), including settings in which smokers are often considered difficult to treat (eg, substance abuse treatment centers). Overall, CM programs are perceived positively by participants and can increase rates of successful cessation. Furthermore, CM interventions have the flexibility to adapt to individual preferences and needs, leading to greater participation and likelihood of successful cessation. Thus, CM provides an important framework for addressing the need for consumer-focused smoking cessation interventions.