The use of financial incentives in promoting smoking cessation

Financial Incentives and Treatment Outcomes in Adolescents With Severe Obesity: A Randomized Clinical Trial

Importance

Adolescent severe obesity is usually not effectively treated with traditional lifestyle modification therapy. Meal replacement therapy (MRT) shows short-term efficacy for body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) reduction in adolescents, and financial incentives (FIs) may be an appropriate adjunct intervention to enhance long-term efficacy.

Objective

To evaluate the effect of MRT plus FIs vs MRT alone on BMI, body fat, and cardiometabolic risk factors in adolescents with severe obesity.

Design, Setting, and Participants

This was a randomized clinical trial of MRT plus FIs vs MRT alone at a large academic health center in the Midwest conducted from 2018 to 2022. Participants were adolescents (ages 13-17 y) with severe obesity (≥120% of the 95th BMI percentile based on sex and age or ≥35 BMI, whichever was lower) who were unaware of the FI component of the trial until they were randomized to MRT plus FIs or until the end of the trial. Study staff members collecting clinical measures were blinded to treatment condition. Data were analyzed from March 2022 to February 2024.

Interventions

MRT included provision of preportioned, calorie-controlled meals (~1200 kcals/d). In the MRT plus FI group, incentives were provided based on reduction in body weight from baseline.

Main Outcomes and Measures

The primary end point was mean BMI percentage change from randomization to 52 weeks. Secondary end points included total body fat and cardiometabolic risk factors: blood pressure, triglyceride to high-density lipoprotein ratio, heart rate variability, and arterial stiffness. Cost-effectiveness was additionally evaluated. Safety was assessed through monthly adverse event monitoring and frequent assessment of unhealthy weight-control behaviors.

Results

Among 126 adolescents with severe obesity (73 female [57.9%]; mean [SD] age, 15.3 [1.2] years), 63 participants received MRT plus FIs and 63 participants received only MRT. At 52 weeks, the mean BMI reduction was greater by -5.9 percentage points (95% CI, -9.9 to -1.9 percentage points; P = .004) in the MRT plus FI compared with the MRT group. The MRT plus FI group had a greater reduction in mean total body fat mass by -4.8 kg (95% CI, -9.1 to -0.6 kg; P = .03) and was cost-effective (incremental cost-effectiveness ratio, $39 178 per quality-adjusted life year) compared with MRT alone. There were no significant differences in cardiometabolic risk factors or unhealthy weight-control behaviors between groups.

Conclusions and Relevance

In this study, adding FIs to MRT resulted in greater reductions in BMI and total body fat in adolescents with severe obesity without increased unhealthy weight-control behaviors. FIs were cost-effective and possibly promoted adherence to health behaviors.

Trial Registration

ClinicalTrials.gov Identifier: NCT03137433.

Effectiveness of Contingency Management in Tobacco Smokers with Depressive Symptoms: A Systematic Review

Background: Effective interventions are required to address tobacco smoking in people with depressive symptomatology. In this context, contingency management could be one useful therapeutic strategy. Objectives: This study is a systematic review of tobacco cessation interventions for smokers with depressive symptomatology including a contingency management component, evaluating their efficacy with regards to tobacco abstinence, depressive symptomatology, adherence to treatment and other variables related to tobacco use. For this purpose, a search was carried out in Pubmed, PsycINFO, Cochrane, Web of Science and ClinicalTrials.gov in September 2022. The quality of the studies was assessed using the Cochrane Risk of Bias tool. Results: Of the 208 articles identified, six were included in this review. Results: For the most part, the research included suggests that contingency management is an effective strategy for improving abstinence outcomes, adherence, and other smoking-related variables such as delay discounting and intensity of cigarette demand in smokers with depressive symptomatology. Conclusions: Although contingency management could be a promising intervention in tobacco smokers with depressive symptomatology, further research in this area is still required.

Using Non-Violent Discipline Tools: Evidence Suggesting the Importance of Attunement

Training in non-violent discipline is important to prevent violence against children and ensure that their caregivers remain a safe base for them. This paper aims to deepen understanding of non-violent discipline by exploring attunement as a mechanism in the effectiveness of non-violent discipline tools. Attunement describes the sensitive responsiveness of caregivers towards their children and has been found to be central to the formation of secure attachment bonds and development of self-regulation. It includes understanding or being "in tune with" the child's needs and signals, matching these with appropriate responses. The objective of this paper is to explore attunement in relation to non-violent discipline. Peer-reviewed systematic reviews previously included in a systematic overview of evidence on non-violent discipline options were screened for information relevant to attunement. All reviews were published in English between 1999 and 2018 and offered evidence on at least one non-violent discipline tool. Although no reviews explicitly addressed attunement, evidence was found suggesting its importance in the use and effectiveness of discipline methods. Research directly investigating attunement in discipline is needed.

Financial incentives for quitting smoking in pregnancy: Are they cost-effective?

AIMS

To evaluate whether adding financial incentives to usual care is cost-effective in encouraging pregnant women to quit tobacco smoking, compared with usual care alone.

DESIGN

Cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) from a health-care provider's perspective, embedded in the Smoking Cessation in Pregnancy Incentives Trial (CPIT III). Long-term analyses were conducted from the same perspective, using an existing Markov model over a life-time horizon.

SETTING

Seven maternity smoking cessation sites in Scotland, England and Northern Ireland in the United Kingdom.

PARTICIPANTS

In the short-term analysis, CPIT III participants were assessed: women 16 years or older, self-reporting as smokers, fewer than 24 weeks pregnant and English-speaking (n = 944). The same population was used for the life-time analysis, plus their infants.

MEASUREMENTS

Costs included financial incentive vouchers and postage, cessation support and nicotine replacement therapy and neonatal stays. The outcome measure was a biochemically verified quit rate for the CEA and quality-adjusted life-years (QALYs) for CUA. Costs are presented in 2020 GBP sterling (£). Data for the life-time analysis came from the trial and were combined with data from published literature embedded in the model, reporting incremental cost per quitter and QALY. A 3.5% discount rate was applied.

FINDINGS

The short-term incremental cost per quitter was £4400 and cost per QALY was £150 000. Results of sensitivity analyses confirmed these results. The long-term analysis combined costs and outcomes for mother and infants; results showed a cost saving of £37 [95% confidence interval (CI]) = £35-106] and increase in QALYs of 0.171 (95% CI = 0.124-0.229). These findings indicate that, over a life-time, financial incentives are cost-saving and improve health outcomes.

CONCLUSIONS

In the United Kingdom, offering up to £400 financial incentives, in addition to usual care, to support pregnant women to stop smoking appears to be highly cost-effective over a life-time for mother and infants.

The Impacts of Supervised Exercise Intervention on Tobacco Withdrawal Symptoms

This study examined a supervised moderate-intensity aerobic exercise programme's effectiveness in regulating the Tobacco Withdrawal Symptoms (TWS) during temporary abstinence. This was a single group, pre and post-quasi intervention study. Thirty daily smokers participated in an 8-week supervised moderate-intensity aerobic exercise programme. We assessed the TWS, smoking urge, mood and stress-pleasure related hormonal variables after the aerobic exercise intervention. The measurements were conducted after overnight abstinence at baseline, post-intervention (at week-8) and post-detraining (at week-10). TWS components, smoking urge and mood were found to improve. For hormonal variables, cortisol and beta-endorphin except adrenaline showed insignificant changes at post-intervention and de-training. The findings suggest moderate-intensity exercise might help in reducing withdrawal symptoms and its adverse effects. Thus, exercise is an effective adjunct treatment in a smoking cessation programme.

The acceptability of financial incentives to support service engagement of adults experiencing homelessness and mental illness: a qualitative study of key stakeholder perspectives Authorship

PURPOSE

Evidence suggests financial incentives may effectively support service engagement among people experiencing homelessness, but literature related to their acceptability in this population is limited. This study used qualitative methods to explore stakeholder perspectives on the acceptability of using financial incentives to promote service engagement among homeless adults with mental illness.

METHODS

As part of a larger mixed-methods pragmatic trial of a community-based brief case management program in Toronto, Canada, twenty-two trial participants were purposefully recruited to participate in semi-structured qualitative interviews, and five service providers and seven key informants were purposefully recruited to participate in a focus group and interviews, respectively. Topics included perspectives of acceptability and lived experiences of using financial incentives to support engagement, health and well-being. Data collection occurred between April 2019 and December 2020. Data was audio-recorded and transcribed. Coding and interpretation of data was informed by grounded theory and inductive thematic analysis.

RESULTS

Stakeholders held diverse views on the acceptability of financial incentives to promote service engagement in this population. Main themes across groups included moralizing recipient motivation; tensions in how best to define and respect autonomy; and consideration of potential unintended consequences for both individuals and the service system. Significant group differences within some themes emerged.

CONCLUSION

Results highlight ongoing debates over using financial incentives to facilitate service engagement among adults experiencing homelessness and mental illness. Differences in stakeholder perspectives suggest the need for person-centredness in health and research settings, and balancing theoretical risks and long-term goals with likely potential for immediate benefits.

If You Pay, Will They Come? Evaluating the Impact of Subsidies on Cessation Outcomes in the Walk or Run to Quit Program

Introduction

Exercise interventions may assist smoking cessation attempts. One such publicly available 10-week program, Walk or Run to Quit (WRTQ), demonstrated success in smoking cessation and physical activity (PA) outcomes. However, initial WRTQ participants (2016-2017) were fairly homogenous in their demographic profile. To increase diversity, subsidies for participation were offered in 2018. This study assessed how the subsidies affected participant demographics, running frequency, smoking cessation, intention to quit, and program attendance and completion.

Methods

The $70 registration fee was subsidized for 41% of participants in 2018. A pre-postdesign was used, with participants completing surveys on their demographics and smoking and physical activity behaviours. Descriptive statistics compared the year subsidies were available (2018) and unsubsidized years (2016-2017) and subsidized and unsubsidized participants' data from 2018.

Results

The 2018 participants had lower average attendance and program completion rates compared to 2016-2017 and no statistically significant differences in demographics or smoking cessation and PA outcomes. There were no differences in smoking cessation, run frequency, or demographic variables between the subsidized and unsubsidized participants in 2018.

Conclusions

Offering subsidies did not diversify the participant profile. Subsidies did not have a negative impact on attendance nor primary outcomes. Subsidies may not have addressed barriers that prevented a more diverse sample from participating in WRTQ, such as program location, timing, and design. Equitable access to smoking cessation programs remains essential. As subsidies may play a role in reducing financial barriers disproportionately faced by marginalized groups, the implementation of, and recruitment for, such subsidized programs requires further investigation.

HIV patients’ perceptions of a potential multi-component mindfulness-based smoking cessation smartphone application intervention

Objectives

Cigarette smoking rates among people living with HIV (PLWH) in the US is triple that of the general population. PLWH smokers are a high-risk group for smoking-related health disparities and should be a prime focus for smoking cessation efforts. Our team has developed a novel evidence-based Mindfulness Training (MT) smoking cessation smartphone application (app), “Craving-to-Quit.” Using qualitative focus groups among PLWH smokers, this study aims to tailor and optimize the app’s content and design to PLWH’s unique psychosocial profile and needs.

Methods

We conducted 8 focus groups among PLWH smokers (n = 59; 47.5% females; ≥18 years) to gain insight into participants’ perceptions about the app, MT, and the feasibility and acceptability of adding two additional strategies (CM: Contingency Management; self-monitoring of anti-retroviral therapies intake [ART]) to further optimize the app. Participants were asked to practice MTs and watch videos from the app presented on a screen in the conference room to discuss their experience. Sessions were audio-taped, transcribed verbatim, and analyzed thematically using NVivo.

Results

Most participants were non-Hispanic black (67.8%), on a federal health insurance program (61.0%). Participants considered it easy to learn the app and thought that MT is helpful in reducing stress and motivating quit attempts and were supportive of adding CM and recommended providing $20-$50 weekly cash incentives to help in quitting. Participants felt that adding self-monitoring of ART is helpful but were concerned about confidentiality in case they lost their phone. Participants recommended making the app cost-free and adding information about smoking cessation medications and the negative effects of smoking among PLWH.

Conclusions

Findings will guide the development of a novel multi-component smoking cessation intervention app integrating MT, CM, and ART self-monitoring strategies. This intervention has the potential to address several barriers to quitting in PLWH. Further clinical research is needed to test this intervention.

Do financial incentives increase mental health treatment engagement? A meta-analysis

OBJECTIVE

Engagement in mental health treatment is low, which can lead to poor outcomes. We evaluated the efficacy of offering patients financial incentives to increase their mental health treatment engagement, also referred to as contingency management.

METHOD

We meta-analyzed studies offering financial incentives for mental health treatment engagement, including increasing treatment attendance, medication adherence, and treatment goal completion. Analyses were run within a multilevel framework. All study designs were included, and sensitivity analyses were run including only randomized and high-quality studies.

RESULTS

About 80% of interventions incentivized treatment for substance use disorders. Financial incentives significantly increased treatment attendance (Hedges' g = 0.49, [0.33, 0.64], k = 30, I2 = 83.14), medication adherence (Hedges' g = 0.95, [0.47, 1.44], k = 6, I2 = 87.73), and treatment goal completion (Hedges' g = 0.61, [0.22, 0.99], k = 5, I2 = 60.55), including completing homework, signing treatment plans, and reducing problematic behavior.

CONCLUSIONS

Financial incentives increase treatment engagement with medium to large effect sizes. We provide strong evidence for their effectiveness in increasing substance use treatment engagement and preliminary evidence for their effectiveness in increasing treatment engagement for other mental health disorders. Future research should prioritize testing the efficacy of incentivizing treatment engagement for mental health disorders aside from substance use. Research must also identify ways to incentivize treatment engagement that improve functioning and long-term outcomes and address ethical and systemic barriers to implementing these interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Barriers and Enablers to Food Waste Recycling: A Mixed Methods Study amongst UK Citizens

We aim to identify influences on UK citizens’ household food waste recycling as a basis for designing strategies to increase household food waste collection rates via local services. Using a UK dataset (n = 1801) and the COM-B (Capability–Opportunity–Motivation–Behaviour) model as a theoretical framework, we conduct quantitative regression and supporting thematic analyses to investigate influences on citizens’ recycling of food waste. Results show that automatic motivation (e.g., emotions and habit) and psychological capability (e.g., knowledge) predict household food waste recycling. Physical opportunity (i.e., dealing with food waste in other ways such as home-composting or feeding pets/strays, time and financial costs) was the main barrier to recycling food waste identified in thematic analyses. Participants also reported automatic motivation-related barriers such as concerns over pests, odour, hygiene and local authorities’ food waste collection capabilities. Based on findings we recommend the development of clear, consistent communications aimed at creating positive social norms relating to recycling and increasing knowledge of what can and cannot be put in food waste bins. Improved functional design and free distribution of bins and compostable caddy liners developed according to user-centred needs for cleanliness, convenience and hygiene are also needed. These will not be sufficient without a nationally uniform, efficient and reliable system of household food waste collection.

OUP accepted manuscript

Introduction

Financial incentive programs promote smoking cessation. However, the incentive amount which should be provided—and how this may interact with other program characteristics—is unknown. The objective of this study was to evaluate the influence of the design of incentive programs for smoking cessation on current smokers’ perceptions of programs and willingness to enroll.

Method

An online discrete choice experiment was conducted amongst adult current smokers residing in the United Kingdom (N = 430). Hypothetical incentive programs were described using five attributes (incentive amount, incentive type, frequency of sessions, reward schedules, program location). Participants responded to a series of choice sets comprised of two hypothetical programs. For each set, participants selected their preferred program. They then specified whether they would enroll in their preferred program if it were available. Analyses also considered the effect of participant income on preferences.

Results

Overall, participants preferred higher amounts over lower amounts, cash over vouchers, healthcare settings over workplaces, and consistent amounts over an escalating schedule. One session per week was the most preferred session frequency. Willingness to enroll increased quadratically with the incentive amount, although this increase slowed for higher amounts. Although middle- and high-income smokers preferred slightly higher amounts (cf. low-income participants), enrollment choices did not differ by income.

Conclusion

The characteristics of incentive programs influence smokers’ perceptions of programs and willingness to enroll. Higher amounts may encourage greater enrollment rates, but there will likely be a ceiling point beyond which increasing the incentive amount does not meaningfully increase enrollments.

Implications

There is increasing evidence incentive programs aid smoking cessation. Yet, the variety in previous program designs means how to best structure programs, including optimal incentive amount and the impact of the design on potential enrollment rates, remains unclear. This study suggests enrollments may be highest when incentive amounts are higher, rewards of a consistent amount in cash are provided, and sessions occur once per week in a healthcare setting. Although higher-income participants may desire higher incentive amounts compared to lower-income participants, this may not translate into differences in willingness to enroll.

Engagement in Digital Mental Health Interventions: Can Monetary Incentives Help?

Digital mental health interventions (DMHI) are scalable and cost-effective strategies for increasing access to mental health care; however, dropout rates associated with digital interventions are high, particularly for open-access digital interventions. While some studies have focused on predictors of dropout from digital mental health programs, few studies have focused on engagement features that might improve engagement. In this perspective article, we discuss whether monetary incentives (MI) are one avenue to increasing user engagement in DMHI. We begin by reviewing the literature on the effects of MI for behavior change in health domains (e.g., dietary behaviors, substance use, and medication adherence). Then, drawing on a pilot study we conducted to test the effects of different levels of MI on usage and improvement in subjective well-being among users of a DMHI (Happify), we discuss the potential applications of MI for DMHI, the potential drawbacks of financial incentives in this context, and open questions for future research.

Cost-effectiveness of stop smoking incentives for medicaid-enrolled pregnant women

Maternal smoking increases mortality and morbidity risks for both mother and infant. The First Breath Wisconsin study examined the cost-effectiveness of providing incentives to pregnant women who smoked to engage in stop smoking treatment. Participants (N = 1014) were Medicaid-enrolled pregnant women recruited from September 2012 to April 2015 through public health departments, private, and community health clinics in Wisconsin. The incentive group (n = 505) could receive $460 for completing pre-birth visits ($25 each), post-birth home visits ($40, $25, $25, $40 for 1-week, 2-month, 4-month and 6-month visits), monthly smoking cessation phone calls post-birth ($20 each), and biochemically-verified tobacco abstinence at 1-week ($40) and 6-months ($40) post-birth. The control group (n = 509) received up to $80 for 1-week ($40) and 6-month ($40) post-birth assessments. Intervention costs included incentive payments to participants, counselor and administrative staff time, and smoking cessation medications. Cost-effectiveness analysis calculated the incremental cost-effectiveness ratio (ICER) per one additional smoker who quit. The incentive group had higher 6-month post-birth biochemically-confirmed tobacco abstinence than the control group (14.7% vs. 9.2%). Incremental costs averaged $184 per participant for the incentive group compared to controls ($317 vs $133). The ICER of financial incentives was $3399 (95% CI $2228 to $8509) per additional woman who was tobacco abstinent at 6 months post-birth. The ICER was lower ($2518 vs $4760) for women who did not live with another smoker. This study shows use of financial incentives for stop smoking treatment is a cost-effective option for low-income pregnant women who smoke.

Smokers' Perceptions of Incentivized Smoking Cessation Programs: Examining How Payment Thresholds Change With Income

INTRODUCTION

Studies demonstrate that financial incentive programs increase smoking cessation. However, there is little guidance on which incentive magnitudes will ensure optimal enrollment and motivation levels. This study investigates current smokers' perceptions of varying incentive magnitudes to identify whether there is evidence for optimal amount(s) and whether perceptions differ by income group.

METHODS

Studies 1 (N = 56) and 2 (N = 147) were conducted online via Prolific.co. Current smokers were randomly shown multiple hypothetical incentive programs that differed only in the incentive amount offered. For each program, smokers rated its appeal and their likelihood of enrolling and predicted their motivation to quit if enrolled. Growth models were used to investigate the relationship between perspectives and the incentive amount.

RESULTS

An increasing quadratic trend in smokers' perceptions of programs as the incentive amount increased was identified. Incentive amounts beyond approximately £50-75 per week (£500-£750 total) did not significantly alter perceptions of programs. In Study 2, high-income smokers found programs significantly less appealing and motivating than low-income smokers, although no significant between-group differences were observed in the likelihood of enrollment. No significant differences were observed between low- and middle-income smokers.

CONCLUSIONS

Increasing the incentive amount increased smoker's perceptions of programs. This relationship was curvilinear, meaning there may be a point beyond which further increasing the amount will not improve enrollment or motivation levels. Incentives appear equally appealing to low- and middle-income smokers; the population among whom smoking is most prevalent. Future research could explore other elements of program design and whether findings hold under real-world conditions.

IMPLICATIONS

While acknowledging that they work, policymakers frequently request information about the monetary amount needed for incentive programs to be effective, and if this differs by income level. We investigated these questions using smokers' perceptions of hypothetical cessation programs that differed in the amount offered. An increasing quadratic trend in perceptions of programs by the amount and potential cut points was observed, suggesting a point may exist beyond which increasing the incentive will not improve perceptions of programs or enrollment levels. High-income smokers may not perceive incentives to be as appealing as other income groups, but appear equally willing to enroll.

Factors motivating smoking cessation: a cross-sectional study in a lower-middle-income country

INTRODUCTION

Only one-quarter of smokers in Pakistan attempt to quit smoking, and less than 3% are successful. In the absence of any literature from the country, this study aimed to explore factors motivating and strategies employed in successful smoking cessation attempts in Pakistan, a lower-middle-income country.

METHODS

A survey was carried out in Karachi, Pakistan, amongst adult (≥ 18 years) former smokers (individuals who had smoked ≥100 cigarettes in their lifetime but who had successfully quit smoking for > 1 month at the time of survey). Multivariable logistic regression, with number of quit attempts (single vs. multiple) as the dependent variable, was performed while adjusting for age, sex, monthly family income, years smoked, cigarettes/day before quitting, and having suffered from a smoking-related health problem.

RESULTS

Out of 330 former smokers, 50.3% quit successfully on their first attempt with 62.1% quitting "cold turkey". Only 10.9% used a cessation aid (most commonly nicotine replacement therapy: 8.2%). Motivations for quitting included self-health (74.5%), promptings by one's family (43%), and family's health (14.8%). Other social pressures included peer-pressure to quit smoking (31.2%) and social avoidance by non-smokers (22.7%). Successful smoking cessation on one's first attempt was associated with being married (OR: 4.47 [95% CI: 2.32-8.61]), employing an abrupt cessation mode of quitting (4.12 [2.48-6.84]), and telling oneself that one has the willpower to quit (1.68 [1.04-2.71]).

CONCLUSION

In Pakistan, smoking cessation is motivated by concern for self-health and family's health, family's support, and social pressures. Our results lay a comprehensive foundation for the development of smoking-cessation interventions tailored to the population of the country.

IMPLICATIONS

Little is known about the patterns and strategies employed by smokers who are attempting to quit smoking, especially in lower-middle-income countries like Pakistan. Likewise, there are very few smoking cessation programs designed to assist in quitting. Our study will allow for a better understanding of the culture-specific motivating factors and strategies that most contributed to successful quit attempts. Based on these results, evidence based smoking cessation interventions can be developed tailored to the socioeconomic demographic of our country and region, including smoking cessation clinics and public outreach and media campaigns highlighting key elements of successful smoking cessation.

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.

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

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

Iowa's Medicaid Healthy Behaviors Program Associated With Reduced Hospital-Based Care But Higher Spending, 2012-17

Health behavior incentive programs are increasingly common in Medicaid programs nationwide. Iowa's Healthy Behaviors Program (HBP) requires Medicaid expansion enrollees to complete an annual wellness exam and health risk assessment or pay monthly premiums to avoid disenrollment. The extent to which the program reduces the use of hospital-based care and lowers health care spending is unknown. Using data for 2012-17 from Medicaid and for 2014-17 from HBP, we evaluated changes in use and spending associated with HBP participation. Compared to nonparticipants, HBP participants were less likely to have an emergency department visit or be hospitalized (by 9.6 percentage points and 2.8 percentage points, respectively) but had higher total health care spending ($1,594). Meanwhile, Iowa's Medicaid expansion was associated with increased use and spending independent of HBP participation-that is, applying to both participants and nonparticipants. Overall, our findings suggest that the HBP was associated with substantial reductions in hospital-based care but increased health care spending.

Financial incentives and proactive calling for reducing barriers to tobacco treatment among socioeconomically disadvantaged women: A factorial randomized trial

Improved strategies and scalable interventions to engage low-socioeconomic status (SES) smokers in tobacco treatment are needed. We tested an intervention designed to connect low-SES smokers to treatment services, implemented through Minnesota's National Breast and Cervical Cancer Early Detection Program (Sage) in 2017; the trial was designed to last 3 months (July through October). Participants were female smokers who were 250% below the federal poverty level (randomized N = 3723; analyzed N = 3365). Using a factorial design, participants were randomized to six intervention groups consisting of a proactive call (no call vs call) and/or a financial incentive offered for being connected to treatment services ($0 vs $10 vs $20). Simple randomization was conducted using Stata v.13. All individuals received direct mail. Participants and staff were blinded to allocation. The outcome was connection via phone to QUITPLAN Services®, Minnesota's population-based cessation services. Groups that received $10 or $20 incentives had higher odds of treatment engagement compared to the no incentive group [respectively, OR = 1.94; 95% CI (1.19-3.14); OR = 2.18; 95% CI (1.36-3.51)]. Individuals that received proactive calls had higher odds of treatment engagement compared to individuals not called [OR = 1.59; 95% CI (1.11-2.29)]. Economic evaluation revealed that the $10 incentive, no call group had the best cost-benefit ratio compared to the no incentive, no call group. Direct mail with moderate incentives or proactive calling can successfully encourage connections to population-based tobacco treatment services among low-SES smokers. The intervention could be disseminated to similar programs serving low-SES populations. This trial is registered at ClinicalTrials.gov (NCT03760107).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Technology-based contingency management and e-cigarettes during the initial weeks of a smoking quit attempt

Contingency management (CM) interventions are among the most effective behavioral interventions for smoking. This study assessed the effects of CM and electronic cigarettes (ECs) on smoking reductions and abstinence for durations of 30-36 days. Twelve participants were exposed to Baseline, EC alone, and EC + CM conditions. An internet-based platform was used to monitor smoking via breath carbon monoxide (CO) and deliver CM for smoking abstinence (CO ≤4 ppm). A Bluetooth-enabled EC monitored daily EC puffs. Abstinence rates were equivalent between EC (34.4%) and EC + CM (30.4%) conditions. Both conditions promoted smoking reductions. We observed an inverse correlation between smoking and EC puffs (r = -.62, p < .05). Results suggest the use of electronic cigarettes can promote smoking reductions and abstinence, and CM did not improve these outcomes. Larger magnitude consequences or tailoring EC characteristics (e.g., flavor) may have improved outcomes. Technology-based methods to collect intensive, longitudinal measures of smoking and electronic cigarette use may be useful to characterize their environmental determinants.

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.

Smoke-Free Moms: Financial Rewards for Smoking Cessation by Low-Income Rural Pregnant Women

INTRODUCTION

Maternal smoking places the child at risk during pregnancy and postpartum. Most women who quit smoking do so early when they first learn of pregnancy. Few low-income women quit once they enter prenatal care. The purpose of this study is to test in a clinical prenatal care setting the effectiveness of the Smoke-Free Moms intervention, which provides pregnant women a series of financial incentives for smoking cessation.

STUDY DESIGN

A prospective nonrandomized controlled trial that collected control population data of smoking-cessation rates at each clincal visit during pregnancy and postpartum with usual smoking counseling in 2013-2014. In 2015-2016, the same data were collected during the implementation of the Smoke-Free Moms intervention of financial incentives. Data analysis occurred in 2017.

SETTING/PARTICIPANTS

Women who were smoking at the first prenatal visit at four federally qualified health centers in rural New Hampshire.

INTERVENTION

All women received 5A's smoking counseling from clinic staff. At each clinic visit, with point-of-care confirmed negative urinary cotinine, intervention women received gift cards.

MAIN OUTCOME MEASURES

Cotinine confirmed smoking cessation without relapse: (1) during pregnancy and (2) smoking cessation in both pregnancy and postpartum.

RESULTS

Of 175 eligible pregnant women enrolled, 134 women were followed to the postpartum visit (Intervention n=66, Control n=68). The quit rates during pregnancy did not differ between groups (Intervention 36.4%, Control 29.4%, p=0.46). However, significantly more intervention mothers quit and continued as nonsmokers postpartum (Intervention 31.8%, Control 16.2%, p=0.04). In a logistic regression model including baseline sociodemographic, depressed mood, stress, and readiness to quit items, confidence in being able to quit predicted both cessation outcomes. The financial incentive intervention was an independent predictor of cessation in pregnancy through postpartum.

CONCLUSIONS

Financial incentives with existing smoking-cessation counseling by staff in low-income clinical prenatal programs led to cessation that continued during the postpartum period. Further study in larger populations is indicated.

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.

Paying Low-Income Smokers to Quit? The Cost-Effectiveness of Incentivizing Tobacco Quit Line Engagement for Medicaid Recipients Who Smoke

OBJECTIVES

To determine the cost-effectiveness of an incentive-based stop-smoking intervention that paid Medicaid recipients who smoke to take calls from a tobacco quit line.

METHODS

A cost-effectiveness analysis was conducted alongside a randomized controlled trial. The analysis was conducted from a health care systems perspective on the basis of costs and effectiveness over a 6-month follow-up. Participants (n = 1900) were recruited from May 2013 to June 2015 through quit line (n = 980), clinic-based (n = 444), or community-based (n = 476) referrals. Incentive group participants (n = 948) received $30 a call for taking up to five tobacco quit line calls and $40 for biochemically verified tobacco abstinence at 6 months. Control group participants (n = 952) did not receive financial incentives for taking quit line calls. Intervention resource costs included incentive payments to participants, counselor and administrative staff time, and smoking cessation medications. Smoking status at baseline and 6 months was determined for all study participants via carbon monoxide (CO) breath tests (abstinence: CO < 7 ppm). Cost-effectiveness analysis calculated the incremental cost-effectiveness ratio (ICER).

RESULTS

Incentive treatment produced higher 6-month CO-confirmed 7-day point-prevalence abstinence than did the control treatment (21.6 vs. 13.8%; P < 0.001). The ICER of the financial incentives intervention was $2316 (95% confidence interval $1582-$4270) per additional person who quit. The study ICER compares favorably with other smoking treatments, such as varenicline combined with proactive telephone counseling, whose ICER has been estimated at $2600 per additional smoker who quits.

CONCLUSIONS

Use of financial incentives to engage with tobacco quit line treatment is a cost-effective option to enhance smoking cessation rates for low-income smokers.

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.

Impact of Financial Incentives on Service Use, Spending, and Health in Medicaid

INTRODUCTION

The Centers for Medicare and Medicaid Services provided grants to Medicaid programs through the Medicaid Incentives for Prevention of Chronic Diseases program to test whether financial incentives changed the use of healthcare services, Medicaid spending, and health outcomes. Six states implemented programs related to diabetes prevention, weight management, diabetes management, and hypertension management. The purpose of this study is to examine whether receipt of financial incentives increased use of services incentivized by the program; reduced expenditures, inpatient admissions, emergency department visits; and improved health outcomes.

METHODS

State data on program participation and incentives (between 2011 and 2015) and 2 years of Medicaid claims data pre-Medicaid Incentives for Prevention of Chronic Diseases enrollment and >2 years of claims data after enrollment were analyzed using covariate-adjusted regression analyses. Negative binomial, logistic, and linear regressions were used, depending on the outcome variable of interest (services, inpatient admissions and emergency department visits, and total expenditures). Analyses were conducted in 2015 and 2016.

RESULTS

Incentive recipients attended, on average, one to two more diabetes prevention classes than control participants, but incentives did not significantly improve uptake of other types of services, such as meetings with a health coach or doctor, gym visits, or attendance at Weight Watchers meetings. Modest improvements in health outcomes, such as weight loss, were observed, yet there were very few significant changes in inpatient admissions, emergency department visits, and Medicaid expenditures.

CONCLUSIONS

Financial incentives are useful for engaging Medicaid enrollees in disease prevention programs, but program engagement may not necessarily lead to changing patterns of healthcare utilization and expenditures in the short run.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Participant Satisfaction and Perceptions About Program Impact in the Medicaid Incentives for Prevention of Chronic Disease Pilot Program

PURPOSE

Evaluate the Centers for Medicare & Medicaid Incentives for Prevention of Chronic Diseases (MIPCD) program in terms of participant satisfaction and self-reported program impact.

DESIGN

Participant survey (mail/telephone follow-up), English and Spanish (N = 2274).

SETTINGS

Ten states in MIPCD program.

PARTICIPANTS

Medicaid beneficiaries.

INTERVENTION

Incentive-based health promotion programs targeting diabetes prevention and management, smoking cessation, and weight, hypertension, and cholesterol management.

MEASURES

Dependent measures are (1) overall program satisfaction and (2) self-reported program impact, operationalized as whether program helped with understanding health issues, learning ways to take care of health, and encouraging healthy lifestyle changes.

ANALYSIS

Multilevel multivariable ordinal logistic regression models to identify predictors of overall program satisfaction and program impact.

RESULTS

Sixty-seven percent were very satisfied with the program, and 76% strongly agreed the program encouraged healthy lifestyle changes. Age (59+ vs <45 years) and being female predicted overall program satisfaction. Satisfaction with specific aspects of the program including communication with staff, accessibility, and incentives predicted higher overall satisfaction. Age (45-52 vs <45 years) and being black or Hispanic predicted higher program impact. Points redeemable for rewards performed worse than money-valued incentives in terms of encouraging lifestyle changes (odds ratio [OR], 0.30; 95% confidence interval [CI], 0.11-0.82). Participants receiving incentives valued at $25 to <$100 were more likely to report higher agreement that the program helped them learn ways to care for their health (OR, 1.72; 95% CI, 1.21-2.44) and encouraged lifestyle changes (OR, 1.46; 95% CI, 1.02-2.10), compared to participants receiving incentives valued at $0 to <$25. Incentives valued at $100 to <$400 predicted higher agreement that the program helped with understanding of health issues (OR, 1.62; 95% CI, 1.13-2.33), compared to incentives valued at $0 to <$25.

CONCLUSION

Effective chronic disease prevention programs are needed for Medicaid populations. Study findings highlight important considerations for incentive-based programs.

Promoting smoking abstinence among patients with chronic obstructive pulmonary disease: Initial feasibility

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the U.S., with the majority of COPD deaths attributable to cigarette smoking. Despite this, individuals with COPD have a higher prevalence of smoking, poorer quit rates, and higher relapse rates compared to smokers without a COPD diagnosis. We examined the feasibility of an incentives-based intervention for producing an initial period of biochemically-verified smoking abstinence among daily smokers with COPD. Participants were randomly assigned to a Contingent (n = 13) or Noncontingent (n = 16) incentives condition and visited the clinic for 14 consecutive days. Contingent participants earned vouchers with monetary value contingent on breath carbon monoxide (CO) levels during Study Days 1–5 and urinary cotinine during Days 6–14. Voucher earnings began at $9.00 and increased by $1.50 with each subsequent negative sample for maximum possible of $362.50. Noncontingent participants received vouchers of comparable value independent of smoking status. Differences between conditions varied across study days for daily smoking abstinence (X² = 45.27, p < 0.0001), CO (F(13, 280) = 1.95, p = 0.025), and cotinine (F(13, 279) = 2.20, p = 0.010), with generally higher rates of abstinence and lower CO and cotinine levels observed in the Contingent vs. Noncontingent conditions. Results from this randomized pilot study support the potential efficacy of an incentives-based intervention for reducing cigarette smoking among individuals with COPD. Further research efforts should seek to promote and evaluate longer-term abstinence and associated changes in respiratory function.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY DESIGN

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

DATA EXTRACTION

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

PRINCIPAL FINDINGS

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

CONCLUSIONS

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

Behavioural incentive interventions for health behaviour change in young people (5-18 years old): A systematic review and meta-analysis

Physical inactivity, an unhealthy diet, smoking, and alcohol consumption are key determinants of morbidity and mortality. These health behaviours often begin at a young age and track into adulthood, emphasising a need for interventions in children and young people. Previous research has demonstrated the potential effectiveness of behavioural incentive (BI) interventions in adults. However, little is known about their effectiveness in children and adolescents. Eight bibliographic databases were searched. Eligibility criteria included controlled trials using behavioural incentives (rewards provided contingent on successful performance of the target behaviour) as an intervention component for health behaviour change in children and adolescents. Intervention effects (standardised mean differences or odds ratios) were calculated and pooled by health behaviour, using a random effects model. Twenty-two studies were included (of n = 8392 identified), 19 of which were eligible for meta-analysis: physical activity (n = 8); healthier eating (n = 3); and smoking (n = 8). There was strong evidence that behavioural incentives may encourage healthier eating behaviours, some evidence that behavioural incentives were effective for encouraging physical activity behaviour, and limited evidence to support the use of behavioural incentives for smoking cessation and prevention in adolescents. Findings suggest that behavioural incentives may encourage uptake and initiation of healthy eating and physical activity in young people. However, this is a limited evidence base and a wide range of incentive designs have yet to be explored. Future research should further investigate the acceptability of these intervention approaches for young people.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Rationale, design and pilot feasibility results of a smartphone-assisted, mindfulness-based intervention for smokers with mood disorders: Project mSMART MIND

BACKGROUND

Although individuals with psychiatric disorders are disproportionately affected by cigarette smoking, few outpatient mental health treatment facilities offer smoking cessation services. In this paper, we describe the development of a smartphone-assisted mindfulness smoking cessation intervention with contingency management (SMI-CM), as well as the design and methods of an ongoing pilot randomized controlled trial (RCT) targeting smokers receiving outpatient psychiatric treatment. We also report the results of an open-label pilot feasibility study.

METHODS

In phase 1, we developed and pilot-tested SMI-CM, which includes a smartphone intervention app that prompts participants to practice mindfulness, complete ecological momentary assessment (EMA) reports 5 times per day, and submit carbon monoxide (CO) videos twice per day. Participants earned incentives if submitted videos showed CO≤6ppm. In phase 2, smokers receiving outpatient treatment for mood disorders are randomized to receive SMI-CM or enhanced standard treatment plus non-contingent CM (EST).

RESULTS

The results from the pilot feasibility study (N=8) showed that participants practiced mindfulness an average of 3.4times/day (≥3min), completed 72.3% of prompted EMA reports, and submitted 68.0% of requested CO videos. Participants reported that the program was helpful overall (M=4.85/5) and that daily mindfulness practice was helpful for both managing mood and quitting smoking (Ms=4.50/5).

CONCLUSIONS

The results from the feasibility study indicated high levels of acceptability and satisfaction with SMI-CM. The ongoing RCT will allow evaluation of the efficacy and mechanisms of action underlying SMI-CM for improving cessation rates among smokers with mood disorders.

Interpersonal Communication in Response to an Intervention and Its Impact on Smoking Cessation Within a Low-Income Population

BACKGROUND

It is a priority to develop population-based strategies for reducing barriers to smoking cessation among low-income populations. Harnessing secondary transmission such as interpersonal communication (IC) has helped to reduce tobacco use, but there is a dearth of quasi-experimental research that examines IC and the full spectrum of smoking cessation behaviors, particularly in the context of population-level programs.

AIMS

Using quasi-experimental methods, we examined IC in response to a population-level intervention and its impact on the full spectrum of smoking cessation outcomes among low-income smokers.

METHOD

We used propensity score matching; three different propensity score matching procedures were used to estimate and approximate experimental effects. We assessed four cessation outcomes: utilization of a free tobacco quitline (QL), making a quit attempt, and being smoke-free for 7 and 30 days at follow-up. We also examined predictors of IC.

RESULTS

IC was significantly related to QL utilization (effect sizes ranging from 0.135 to 0.166), making a quit attempt (effect sizes ranging from 0.115 to 0.147), being smoke-free for 7 days (effect sizes ranging from 0.080 to 0.121), and being smoke-free for 30 days at follow-up (effect sizes ranging from 0.058 to 0.082). Program-related and participant characteristics predicted IC, such as receiving emotional direct mail materials and living with a fellow smoker.

DISCUSSION

IC in response to a population-based program affected the cessation process, and IC had a marked impact on sustained cessation.

CONCLUSION

Population-based programs should aim to harness psychosocial dynamics such as IC to promote sustained cessation among low-income populations.

Psychological, pharmacological, and combined smoking cessation interventions for smokers with current depression: A systematic review and meta-analysis

We conducted a systematic literature review and meta-analysis (ID: CRD42016051017) of smoking cessation interventions for patients with current depression. We examined the effectiveness of smoking cessation treatments in improving abstinence rates and depressive symptoms. The following electronic databases were used for potentially eligible studies: PUBMED, PSYCINFO, DIALNET and WEB OF KNOWLEDGE. The search terms used were: smoking cessation, depressive disorder, depression, mood, depressive, depressed, smoking, smokers, nicotine, nicotine dependence, and tobacco cigarette smoking. The methodological quality of included studies was assessed using the Effective Public Health Practice Project Quality assessment tool (EPHPP). Of the 6,584 studies identified, 20 were eligible and included in the review. Trial designs of studies were 16 randomized controlled trials and 4 secondary studies. Studies included three types of intervention: psychological (6/30%), pharmacological (6/30%) or combined (8/40%). Four trials comprised special populations of smokers. Four studies received a strong methodological quality, 7 were scored as moderate and 9 studies received a weak methodological rating. Analyses of effectiveness showed that smoking cessation interventions appear to increase short-term and long-term smoking abstinence in individuals with current depression. Subgroup analyses revealed stronger effects among studies that provided pharmacological treatments than in studies using psychological treatments. However, the evidence is weak due to the small number of studies. Smoking abstinence appears to be associated with an improvement in depressive symptoms. Heterogeneity in protocols in similar types of treatment also prevent firm conclusions being drawn on the effectiveness of any particular treatment model to optimally manage abstinence among depressed smokers. Further research is required to strengthen the evidence base.

A Randomized Trial of Incentives for Smoking Treatment in Medicaid Members

INTRODUCTION

Low-income populations are especially likely to smoke and have difficulty quitting. This study evaluated a monetary incentive intended to increase smoking treatment engagement and abstinence among Medicaid recipients who smoke.

STUDY DESIGN

Two-group randomized clinical trial of Incentive (n=948) and Control interventions (n=952) for smoking.

SETTING/PARTICIPANTS

Medicaid recipients recruited from primary care patients (n=920) and callers to the Wisconsin Tobacco Quit Line (n=980).

INTERVENTION

Participants were offered five quitline cessation calls and were encouraged to obtain cessation medication (covered by Medicaid). All participants received payment for completing a baseline assessment and a 6-month smoking test. Only Incentive condition participants received compensation for taking counseling calls ($30 per call) and for biochemically verified abstinence at the 6-month visit ($40).

MAIN OUTCOME MEASURES

Seven-day point-prevalence smoking abstinence 6-months post study entry and cost/quit.

RESULTS

Incentive condition participants had significantly higher biochemically determined 7-day point-prevalence smoking abstinence rates 6 months after study induction than did Controls (21.6% vs 13.8%, respectively, p<0.0001). A positive treatment effect of incentives was present across other abstinence indices, but the size of effects and levels of abstinence varied considerably across indices. Incentive condition participants were also significantly more likely than non-incentivized Control participants to accept Wisconsin Tobacco Quit Line treatment calls and their acceptance of calls mediated their attainment of higher abstinence rates at 6-month follow-up. The cost/quit/participant averaged $4,268.26 for the Control participants and $3,601.37 for the Incentive participants.

CONCLUSIONS

This study shows that fairly moderate levels of incentive payments for treatment engagement and abstinence (a total possible payment of $190) increased very low-income smokers' engagement and success in smoking cessation treatment.

CLINICAL REGISTRATION

This study is registered at www.clinicaltrials.gov: NCT02713594.

Income Levels and Response to Contingency Management for Smoking Cessation

BACKGROUND

Contingency management (CM) has demonstrated its efficacy in treating many drug addictions, including nicotine. However, one of the most commonly perceived limitations with regard to its dissemination into community settings is whether this protocol could be equally effective for treating patients across different income levels.

OBJECTIVE

This study aimed to examine whether individuals' income levels affect treatment success in a cognitive behavioral treatment (CBT) that included a voucher-based CM protocol for smoking cessation.

METHODS

A total of 92 treatment-seeking smokers in a community setting were randomly assigned to a CBT group (N = 49) or to a CBT plus CM group (N = 43). The CM procedure included a voucher program through which smoking abstinence was reinforced on a schedule of escalating magnitude of reinforcement with a reset contingency. We analyzed the impact of self-reported monthly income, alone and in combination with treatment condition, on short-term (treatment retention) and long-term (self-reported number of days of continuous smoking abstinence at 6-month follow-up) results.

RESULTS

Income had no effect on treatment retention and continuous abstinence outcomes at 6-month follow-up in either treatment condition. Treatment modality emerged as the only significant predictor of treatment success.

CONCLUSIONS

Our findings suggest that treatment-seeking smokers from the general population respond equally well to CM regardless of their income levels. The results of this randomized controlled trial support the generalizability of this evidenced-based program into community settings.

Internet-based self-tailored deposit contracts to promote smoking reduction and abstinence

Deposit contracting may reduce costs and increase efficacy in contingency management interventions. We evaluated two Internet-based deposit contract arrangements for smoking. In Experiment 1, nine participants deposited self-selected amounts that could be earned back for meeting goals. During treatment, participants were reimbursed for breath samples with less than or equal to 6 parts per million carbon monoxide and met the criterion for 47% of samples compared to 1% during baseline. In Experiment 2, 10 participants' deposits were matched up to $50. No samples met the criterion during baseline but 41.5% met it during treatment. The average deposit was $82 in Experiment 1 and $49 in Experiment 2. Participants rated the intervention favorably and sample submission rates were high. These experiments suggest that Internet-based self-tailored deposits are acceptable, feasible, and can promote brief reduction and abstinence in some smokers. Future research should investigate individual and intervention factors that affect long-term cessation and uptake of deposit contracts.

Treating Smokers in Substance Treatment With Contingent Vouchers, Nicotine Replacement and Brief Advice Adapted for Sobriety Settings

Treatment for substance use disorders (SUD) provides an opportunity to use voucher-based treatment for smoking. Nicotine replacement (NRT) could improve outcomes previously observed with vouchers without NRT.

METHODS

A randomized controlled trial compared contingent vouchers (CV) for smoking abstinence to noncontingent vouchers (NV), when all received counseling and NRT. Smokers who had not sought smoking treatment (n=340) in residential SUD treatment were provided 14days of vouchers for complete smoking abstinence per exhaled carbon monoxide (CO) after a 5-day smoking reduction period, or vouchers only for breath samples, plus brief advice (four sessions) and 8weeks of NRT.

RESULTS

Within treatment, 20% had complete abstinence with CV, 5% with NV (p<.001), and participants showed 50% of days abstinent in CV compared to 22% in NV (p<.001). Across 1, 3, 6 and 12months after randomization, CV resulted in significantly fewer cigarettes per day (p<.01) and fewer days smoking (p<.01), but with small effects. Point-prevalence abstinence differences across follow-up (e.g., 4% CV, 2% in NV at 6 and 12months) were not significant. No differences in substance use were seen.

CONCLUSIONS

Within-treatment effects on abstinence are stronger than in a prior study of the same CV with BA but without NRT, but NRT does not improve abstinence after vouchers end. Implications for voucher-based treatment include investigating effects when combined with stronger smoking medications and using motivational interviewing. Smoking treatment does not harm SUD recovery.

Prioritizing the mHealth Design Space: A Mixed-Methods Analysis of Smokers' Perspectives

Background

Smoking remains the leading cause of preventable disease and death in the United States. Therefore, researchers are constantly exploring new ways to promote smoking cessation. Mobile health (mHealth) technologies could be effective cessation tools. Despite the availability of commercial quit-smoking apps, little research to date has examined smokers’ preferred treatment intervention components (ie, design features). Honoring these preferences is important for designing programs that are appealing to smokers and may be more likely to be adopted and used.

Objective

The aim of this study was to understand smokers’ preferred design features of mHealth quit-smoking tools.

Methods

We used a mixed-methods approach consisting of focus groups and written surveys to understand the design preferences of adult smokers who were interested in quitting smoking (N=40). Focus groups were stratified by age to allow differing perspectives to emerge between older (>40 years) and younger (<40 years) participants. Focus group discussion included a “blue-sky” brainstorming exercise followed by participant reactions to contrasting design options for communicating with smokers, providing social support, and incentivizing program use. Participants rated the importance of preselected design features on an exit survey. Qualitative analyses examined emergent discussion themes and quantitative analyses compared feature ratings to determine which were perceived as most important.

Results

Participants preferred a highly personalized and adaptive mHealth experience. Their ideal mHealth quit-smoking tool would allow personalized tracking of their progress, adaptively tailored feedback, and real-time peer support to help manage smoking cravings. Based on qualitative analysis of focus group discussion, participants preferred pull messages (ie, delivered upon request) over push messages (ie, sent automatically) and preferred interaction with other smokers through closed social networks. Preferences for entertaining games or other rewarding incentives to encourage program use differed by age group. Based on quantitative analysis of surveys, participants rated the importance of select design features significantly differently (P<.001). Design features rated as most important included personalized content, the ability to track one’s progress, and features designed to help manage nicotine withdrawal and medication side effects. Design features rated least important were quit-smoking videos and posting on social media. Communicating with stop-smoking experts was rated more important than communicating with family and friends about quitting (P=.03). Perceived importance of various design features varied by age, experience with technology, and frequency of smoking.

Conclusions

Future mHealth cessation aids should be designed with an understanding of smokers’ needs and preferences for these tools. Doing so does not guarantee treatment effectiveness, but balancing user preferences with best-practice treatment considerations could enhance program adoption and improve treatment outcomes. Grounded in the perspectives of smokers, we identify several design considerations, which should be prioritized when designing future mHealth cessation tools and which warrant additional empirical validation.

Evidence Suggests That The ACA's Tobacco Surcharges Reduced Insurance Take-Up And Did Not Increase Smoking Cessation

To account for tobacco users' excess health care costs and encourage cessation, the Affordable Care Act (ACA) allowed insurers to impose a surcharge on tobacco users' premiums for plans offered on the health insurance exchanges, or Marketplaces. Low-income tax credits for Marketplace coverage were based on premiums for non-tobacco users, which means that these credits did not offset any surcharge costs. Thus, this policy greatly increased out-of-pocket premiums for many tobacco users. Using data for 2011-14 from the Behavioral Risk Factor Surveillance System, we examined the effect of tobacco surcharges on insurance status and smoking cessation in the first year of the exchanges' implementation, among adults most likely to purchase insurance from them. Relative to smokers who faced no surcharges, smokers facing medium or high surcharges had significantly reduced coverage (reductions of 4.3 percentage points and 11.6 percentage points, respectively), but no significant differences in smoking cessation. In contrast, those facing low surcharges showed significantly less smoking cessation. Taken together, these findings suggest that tobacco surcharges conflicted with a major goal of the ACA-increased financial protection-without increasing smoking cessation. States should consider these potential effects when deciding whether to limit surcharges to less than the federal maximum.

Financial incentives to promote extended smoking abstinence in opioid-maintained patients: a randomized trial

BACKGROUND AND AIMS

Prior studies by our group demonstrated the efficacy of a brief but intensive behavioral intervention for producing initial smoking abstinence among opioid-dependent patients. In the present study, our aim was to promote longer-duration abstinence in this population. Following an initial 2-week incentive intervention for smoking abstinence, we examined whether a 10-week maintenance arm involving continuation of contingent reinforcement will produce greater smoking abstinence than a similar duration of noncontingent reinforcement.

DESIGN

Randomized, 12-week, parallel-group study.

SETTING

Out-patient research clinic in Burlington, Vermont, USA.

PARTICIPANTS

Opioid-maintained smokers (n = 88) who provided breath carbon monoxide and urinary cotinine specimens and received contingent reinforcement for smoking abstinence during weeks 1-2 (phase 1), with 63 randomized on day 14 to an extended contingent (EC; n = 31) or extended noncontingent (EN; n = 32) experimental condition for weeks 3-12 (phase 2).

INTERVENTION AND CONTROL

The EC condition consisted of voucher values that escalated across consecutive negative samples until they reached $30, after which they remained at $30 per negative sample. A positive or a missing sample resulted in no vouchers for that day and reset the value of the next negative same to $9. Two consecutive negatives returned the schedule to the pre-reset value. The EN control condition consisted of vouchers delivered for providing scheduled samples, but independent of smoking status.

MEASUREMENTS

The primary outcome was percentage of biochemically abstinent samples during phase 2. Secondary measures included abstinence status at final study visit, complete abstinence, participants' longest duration of continuous abstinence, cotinine and carbon monoxide (CO) levels and self-reported cigarettes per day.

FINDINGS

EC participants achieved greater smoking abstinence during phase 2 than EN participants [46.7 versus 23.5% negative samples, respectively; odds ratio (OR) = 2.98, 95% confidence interval (CI) = 1.16-7.65, χ(2) 1  (=)  5.0, P = 0.02]. When longest duration of continuous abstinence was compared between experimental groups, EC participants achieved twice the mean duration of continuous abstinence compared with EN participants (3.31 versus 1.68 weeks; t61  = 1.83, P = 0.07). An effect of experimental condition was also seen on mean cotinine levels (42.5 versus 210.6 ng/ml, respectively; F1,61 =5.9, P = 0.02).

CONCLUSIONS

Among opioid-maintained smokers receiving an initial period of daily contingent incentives, a contingent reinforcement intervention appears to be more effective at extending smoking abstinence than noncontingent reinforcement over 10 weeks.

Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design

BACKGROUND

Smoking in pregnancy and/or not breastfeeding have considerable negative health outcomes for mother and baby.

AIM

To understand incentive mechanisms of action for smoking cessation in pregnancy and breastfeeding, develop a taxonomy and identify promising, acceptable and feasible interventions to inform trial design.

DESIGN

Evidence syntheses, primary qualitative survey, and discrete choice experiment (DCE) research using multidisciplinary, mixed methods. Two mother-and-baby groups in disadvantaged areas collaborated throughout.

SETTING

UK.

PARTICIPANTS

The qualitative study included 88 pregnant women/recent mothers/partners, 53 service providers, 24 experts/decision-makers and 63 conference attendees. The surveys included 1144 members of the general public and 497 health professionals. The DCE study included 320 women with a history of smoking.

METHODS

(1) Evidence syntheses: incentive effectiveness (including meta-analysis and effect size estimates), delivery processes, barriers to and facilitators of smoking cessation in pregnancy and/or breastfeeding, scoping review of incentives for lifestyle behaviours; (2) qualitative research: grounded theory to understand incentive mechanisms of action and a framework approach for trial design; (3) survey: multivariable ordered logit models; (4) DCE: conditional logit regression and the log-likelihood ratio test.

RESULTS

Out of 1469 smoking cessation and 5408 breastfeeding multicomponent studies identified, 23 smoking cessation and 19 breastfeeding studies were included in the review. Vouchers contingent on biochemically proven smoking cessation in pregnancy were effective, with a relative risk of 2.58 (95% confidence interval 1.63 to 4.07) compared with non-contingent incentives for participation (four studies, 344 participants). Effects continued until 3 months post partum. Inconclusive effects were found for breastfeeding incentives compared with no/smaller incentives (13 studies) but provider commitment contracts for breastfeeding show promise. Intervention intensity is a possible confounder. The acceptability of seven promising incentives was mixed. Women (for vouchers) and those with a lower level of education (except for breastfeeding incentives) were more likely to disagree. Those aged ≤ 44 years and ethnic minority groups were more likely to agree. Agreement was greatest for a free breast pump and least for vouchers for breastfeeding. Universal incentives were preferred to those targeting low-income women. Initial daily text/telephone support, a quitting pal, vouchers for > £20.00 per month and values up to £80.00 increase the likelihood of smoking cessation. Doctors disagreed with provider incentives. A 'ladder' logic model emerged through data synthesis and had face validity with service users. It combined an incentive typology and behaviour change taxonomy. Autonomy and well-being matter. Personal difficulties, emotions, socialising and attitudes of others are challenges to climbing a metaphorical 'ladder' towards smoking cessation and breastfeeding. Incentive interventions provide opportunity 'rungs' to help, including regular skilled flexible support, a pal, setting goals, monitoring and outcome verification. Individually tailored and non-judgemental continuity of care can bolster women's capabilities to succeed. Rigid, prescriptive interventions placing the onus on women to behave 'healthily' risk them feeling pressurised and failing. To avoid 'losing face', women may disengage.

LIMITATIONS

Included studies were heterogeneous and of variable quality, limiting the assessment of incentive effectiveness. No cost-effectiveness data were reported. In surveys, selection bias and confounding are possible. The validity and utility of the ladder logic model requires evaluation with more diverse samples of the target population.

CONCLUSIONS

Incentives provided with other tailored components show promise but reach is a concern. Formal evaluation is recommended. Collaborative service-user involvement is important.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012001980.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Voucher-based contingency management and in-treatment behaviors in smoking cessation treatment

A high percentage of patients relapse within months following an attempt to quit smoking. For this reason, greater understanding of the determinants of successful smoking cessation is needed. The present study assessed the effect of Contingency Management (CM) combined with Cognitive-Behavioral Treatment (CBT) on certain in-treatment behaviors (treatment retention, in-treatment smoking abstinence, and weekly decrease of cotinine levels) and examined the effects of these in-treatment behaviors on smoking status at a 6-month follow-up. A total of 154 treatment-seeking patients in a community setting were randomly assigned to a CBT, CBT plus CM for Abstinence (CMA) or to a CBT plus CM for Shaping cessation (CMS) group. Both CBT + CM procedures improved the in-treatment behaviors compared to CBT alone. These in-treatment behaviors (particularly in-treatment smoking abstinence) were associated with long-term abstinence. The effect of CM on in-treatment behaviors may partially explain the positive long-term outcomes of this procedure. Our findings extend previous knowledge about the effect of CM on smoking behavior.

Connecting low-income smokers to tobacco treatment services

The Affordable Care Act calls for using population-level incentive-based interventions, and cigarette smoking is one of the most significant health behaviors driving costs and adverse health in low-income populations. Telehealth offers an opportunity to facilitate delivery of evidence-based smoking cessation services as well as incentive-based interventions to low-income populations. However, research is needed on effective strategies for linking smokers to services, how to couple financial incentives with telehealth, and on how to scale this to population-level practice. The current paper evaluates primary implementation and follow-up results of two strategies for connecting low-income, predominantly female smokers to a telephone tobacco quitline (QL). The population-based program consisted of participant-initiated phone contact and two recruitment strategies: (1) direct mail (DM) and (2) opportunistic telephone referrals with connection (ORC). Both strategies offered financial incentives for being connected to the QL, and all QL connections were made by trained patient navigators through a central call center. QL connections occurred for 97% of DM callers (N=870) and 33% of ORC callers (N=4550). Self-reported continuous smoking abstinence (i.e., 30 smoke-free days at seven-month follow-up) was 20% for the DM group and 16% for ORC. These differences between intervention groups remained in ordered logistic regressions adjusting for smoking history and demographic characteristics. Each recruitment strategy had distinct advantages; both successfully connected low-income smokers to cessation services and encouraged quit attempts and continuous smoking abstinence. Future research and population-based programs can utilize financial incentives and both recruitment strategies, building on their relative strengths.

Tobacco use among low-income housing residents: does hardship motivate quit attempts?

PURPOSE

The purpose of this study was to examine material hardship among smokers to determine whether such hardship was positively associated with current attempts to quit tobacco use.

METHODS

We analyzed cross-sectional data from the Health in Common (HIC) study, an observational study to investigate social and physical determinants of cancer risk-related behaviors among residents of low-income housing in three cities in the Boston metropolitan area. In this study, three indicators of hardship were used: food hardship, financial hardship, and material hardship (food and financial hardship combined). Logistic regression models were used to obtain the odds of currently trying to quit among current smokers in the HIC (n = 170) across hardship types experienced, adjusting for sociodemographic and psychosocial factors.

RESULTS

Fully adjusted models revealed no statistically significant association between trying to quit tobacco use and indicators of material hardship: food hardship and financial hardship present (OR 1.33 (0.42-4.2); food hardship and no financial hardship OR 3.83 (0.97-15.13); and financial hardship but no food hardship OR 0.5 (0.1-2.39).

CONCLUSIONS

These findings suggest that even in the presence of material hardship, low-income housing resident tobacco users are not more likely to quit tobacco use; therefore, cessation efforts focused on the financial benefits of quitting may be insufficient to motivate quit attempts among low-income smokers.

Predictive Validity of a Cigarette Purchase Task in a Randomized Controlled Trial of Contingent Vouchers for Smoking in Individuals With Substance Use Disorders

INTRODUCTION

A cigarette purchase task (CPT) is a behavioral economic measure of the reinforcing value of smoking in monetary terms (ie, cigarette demand). This study investigated whether cigarette demand predicted response to contingent monetary rewards for abstinence among individuals with substance use disorders. It also sought to replicate evidence for greater price sensitivity at whole-dollar pack price transitions (ie, left-digit effects).

METHODS

Participants (N = 338) were individuals in residential substance use disorder treatment who participated in a randomized controlled trial that compared contingent vouchers to noncontingent vouchers for smoking abstinence. Baseline demand indices were used to predict number of abstinent days during the 14-day voucher period (after the reduction lead-in) and at 1 and 3 months afterward.

RESULTS

Demand indices correlated with measures of smoking and nicotine dependence. As measured by elasticity, intensity and O max, higher demand significantly predicted fewer abstinent exhaled carbon monoxide readings during voucher period for individuals in the noncontingent vouchers condition. Breakpoint exhibited a trend-level association with abstinent exhaled carbon monoxide readings. Demand indices did not predict abstinence in the contingent vouchers group, and did not predict abstinence at 1- and 3-month follow-ups. Left-digit price transitions were associated with significantly greater reductions in consumption.

CONCLUSIONS

The association of cigarette demand with smoking behavior only in the group for whom abstinence was not incentivized indicates that CPT assesses the value of smoking more than the value of money per se and that vouchers counteract the effects of the intrinsic reinforcing value of cigarettes. Results provide initial short-term evidence of predictive validity for the CPT indices.

IMPLICATIONS

This study provides the first evidence of the validity of the CPT for predicting early response to brief advice for smoking cessation plus nicotine replacement in smokers with substance dependence. However, demand for cigarettes did not predict voucher-based treatment response, indicating that incentives serve as a powerful motivator not to smoke that acts in opposition to the intrinsic reinforcing value of cigarettes and that the indices reflect the value of smoking more than the value of money per se.

Cost-effectiveness of a voucher-based intervention for smoking cessation

BACKGROUND

Contingency management (CM) has been shown to be effective in reducing smoking consumption, but has traditionally been criticized for its costs.

OBJECTIVES

This study assessed the cost-effectiveness of using a voucher-based CM protocol added to a cognitive behavioral treatment (CBT) for smoking cessation among treatment-seeking patients from the general population.

METHODS

A total of 92 patients were randomly assigned to CBT or CBT plus CM for abstinence. Incremental cost-effectiveness ratios (ICERs) were calculated by dividing the increase in costs by the increase in effects (continuous abstinence, longest duration of abstinence at 6-month follow-up and cotinine results during the treatment). An acceptability curve illustrated the statistical uncertainty surrounding the cost-effectiveness estimate. We also determined the optimum cost per participant for predicting the smoking status at 6-month follow-up.

RESULTS

The average cost per participant in the CBT condition was €138.73 (US$ 150.23) as opposed to €411.61 (US$ 445.73) in the CBT plus CM condition (p < 0.01). The incremental cost of using voucher-based CM to increase the number of participants that maintained abstinence at 6-month follow-up by one extra participant was €68.22 (US$ 73.88), and to lengthen the longest duration of abstinence by 1 week was €53.92 (US$ 58.39). The incremental cost to obtain an extra cotinine-negative result was €181.90 (US$ 196.98).

CONCLUSION

Compared with CBT alone, the voucher-based protocol required additional costs but achieved significantly better outcomes. These results will allow stakeholders to make policy decisions about CM implementation for smoking cessation in the broader community.

Interpersonal Communication and Smoking Cessation in the Context of an Incentive-Based Program: Survey Evidence From a Telehealth Intervention in a Low-Income Population

The tobacco epidemic disproportionately affects low-income populations, and telehealth is an evidence-based strategy for extending tobacco cessation services to underserved populations. A public health priority is to establish incentive-based interventions at the population level in order to promote long-term smoking cessation in low-income populations. Yet randomized clinical trials show that financial incentives tend to encourage only short-term steps of cessation, not continuous smoking abstinence. One potential mechanism for increasing long-term cessation is interpersonal communication (IPC) in response to population-level interventions. However, more research is needed on IPC and its influence on health behavior change, particularly in the context of incentive-based, population-level programs. This study used survey data gathered after a population-level telehealth intervention that offered $20 incentives to low-income smokers for being connected to Minnesota's free quitline in order to examine how perceived incentive importance and IPC about the incentive-based program relate to both short-term and long-term health behavior change. Results showed that IPC was strongly associated with initial quitline utilization and continuous smoking abstinence as measured by 30-day point prevalence rates at 7-month follow-up. Perceived incentive importance had weak associations with both measures of cessation, and all associations were nonsignificant in models adjusting for IPC. These results were found in descriptive analyses, logistic regression models, and Heckman probit models that adjusted for participant recruitment. In sum, a behavioral telehealth intervention targeting low-income smokers that offered a financial incentive inspired IPC, and this social response was strongly related to utilization of intervention services as well as continuous smoking abstinence.