Public opinion about financial incentives for smoking cessation

Perceptions of Financial Incentives for Smoking Cessation: A Survey of Smokers in a Country With an Endgame Goal

Introduction

Financial incentives can support smoking cessation, yet low acceptability may limit the wider implementation of such schemes. Few studies have examined how smokers view financial-incentive interventions aimed at reducing smoking prevalence.

Methods

We recruited a sample of 623 smokers from an internet panel to a survey assessing support for, and perceived effectiveness of, financial incentives for smoking cessation. We used descriptive statistics, plus logistic regression, to test associations between demographics and smoking, and support. We used qualitative content analysis to analyze open-ended responses to a question that invited respondents to comment on financial incentives.

Results

Financial incentives were supported by 38.4% of smokers; 42.2% did not support and 19.4% had no opinion. Support was higher among heavy (OR = 3.96, 95% CI = 2.39 to 6.58) and moderate smokers (OR = 1.68, 95% CI = 1.13 to 2.49), and those with a recent quit attempt (OR = 1.47, 95% CI = 1.04 to 2.07). Support was strongly associated with perceived effectiveness. A Government-funded reward-only scheme was seen as the most acceptable option (preferred by 26.6% of participants), followed by a Government-funded deposit-based scheme (20.6%); few respondents supported employer-funded schemes. Open-ended responses (n = 301) indicated three overarching themes expressing opposition to financial incentives: smokers' individual responsibility for quitting, concerns about abuse of an incentive scheme, and concerns about unfairness.

Conclusion

Even amongst those who would benefit from schemes designed to reward smokers for quitting, support for such schemes is muted, despite the evidence of their effectiveness. Media advocacy and health education could be used to increase the understanding of, and support for, financial incentives for smoking cessation.

Implications

Given the absolute effectiveness and cost effectiveness of financial-incentive schemes for smoking cessation amongst pregnant smokers and in workplaces, implementing such schemes at a national-level could help reduce overall smoking prevalence and contribute to endgame goals. Our study found that similar proportions of smokers supported and opposed financial-incentive schemes and suggests that much of the opposition was underpinned by information gaps, which could be addressed using education and media advocacy.

Goal-directed versus outcome-based financial incentives for weight loss among low-income patients with obesity: rationale and design of the Financial Incentives foR Weight Reduction (FIReWoRk) randomised controlled trial

INTRODUCTION

Obesity is a major public health challenge and exacerbates economic disparities through employment discrimination and increased personal health expenditures. Financial incentives for weight management may intensify individuals' utilisation of evidence-based behavioural strategies while addressing obesity-related economic disparities in low-income populations. Trials have focused on testing incentives contingent on achieving weight loss outcomes. However, based on social cognitive and self-determination theories, providing incentives for achieving intermediate behavioural goals may be more sustainable than incentivising outcomes if they enhance an individual's skills and self-efficacy for maintaining long-term weight loss. The objective of this paper is to describe the rationale and design of the Financial Incentives foR Weight Reduction study, a randomised controlled trial to test the comparative effectiveness and cost-effectiveness of two financial incentive strategies for weight loss (goal directed vs outcome based) among low-income adults with obesity, as well as compared with the provision of health behaviour change resources alone.

METHODS AND ANALYSIS

We are recruiting 795 adults, aged 18-70 years with a body mass index ≥30 kg/m2, from three primary care clinics serving residents of socioeconomically disadvantaged neighbourhoods in New York City and Los Angeles. All participants receive a 1-year commercial weight loss programme membership, self-monitoring tools (bathroom scale, food journal and Fitbit Alta HR), health education and monthly check-in visits. In addition to these resources, those in the two intervention groups can earn up to $750 over 6 months for: (1) participating in an intensive weight management programme, self-monitoring weight and diet and meeting physical activity guidelines (goal-directed arm); or (2) a ≥1.5% to ≥5% reduction in baseline weight (outcome-based arm). To maximise incentive efficacy, we incorporate concepts from behavioural economics, including immediacy of payments and framing feedback to elicit regret aversion. We will use generalised mixed effect models for repeated measures to examine intervention effects on weight at 6, 9 and 12 months.

ETHICS AND DISSEMINATION

Human research protection committees at New York University School of Medicine, University of California Los Angeles (UCLA) David Geffen School of Medicine and Olive-View-UCLA Medical Center granted ethics approval. We will disseminate the results of this research via peer-reviewed publications, conference presentations and meetings with stakeholders.

TRIAL REGISTRATION NUMBER

NCT03157713.

Uptake of an Incentive-Based mHealth App: Process Evaluation of the Carrot Rewards App

BACKGROUND

Behavioral economics has stimulated renewed interest in financial health incentives worldwide. The Carrot Rewards app was developed as part of a public-private partnership to reward Canadians with loyalty points (eg, movies and groceries) for downloading the app, referring friends, and completing an average of 1 to 2 educational health quizzes per week ("micro-learning"), with long-term objectives of increasing health knowledge and encouraging healthy behaviors.

OBJECTIVE

The main objective of this study was to evaluate uptake of a loyalty points-based mHealth app during the exclusive 3-month launch period in British Columbia (BC), Canada. The secondary aims were to describe the health and sociodemographic characteristics of users, as well as participation levels (eg, proportion of quizzes completed and friends referred).

METHODS

The app was promoted via loyalty program email campaigns (1.64 million emails). Number of downloads and registrations (users enter age, gender, and valid BC postal code to register) were collected. Additional sociodemographics were inferred by linking postal codes with census data at the local health area (LHA) level. Health risk assessments were also deployed. Participation levels were collected over 3 months and descriptive data were presented.

RESULTS

In 3 months, 67,464 individuals downloaded the app; in its first week, Carrot Rewards was the most downloaded health app in Canada. Among valid users (n=57,885; at least one quiz completed), the majority were female (62.96%; 36,446/57,885) and aged 18 to 34 years (54.34%; 31,459/57,885). More than half of the users (52.40%; 30,332/57,885) resided in LHAs where the median personal income was below the provincial average (Can $28,765). Furthermore, 64.42% (37,291/57,885) of users lived in metropolitan (ie, urban) LHAs, compared with 56.17% of the general BC population. The most prevalent risk factors were "not" meeting physical activity guidelines (72.70%; 31,765/43,692) and "not" getting the flu shot last year (67.69%; 30,286/44,739). Regarding participation, 60.05% (34,761/57,885) of users were classified as "very high" engagers (>75% quiz completion rate).

CONCLUSIONS

Early results suggest that loyalty points may promote mHealth app uptake. The app was downloaded by younger females especially, and BC residents from higher and lower income regions were equally represented. Loyalty points appear to have driven participation throughout the inaugural 3-month period (ie, quiz completion).

Treatment Satisfaction in a Randomized Clinical Trial of mHealth Smoking Abstinence Reinforcement

The importance of patient satisfaction in modern healthcare is widely recognized, but research on satisfaction in the context of smoking cessation has not kept pace. The purpose of this study was to explore treatment satisfaction in a sample of smokers (N=84) randomized to one of two smoking cessation treatment interventions (mHealth reinforcement and mHealth monitoring) that used cell phone-based procedures to monitor smoking status in individuals' natural environments for 4 weeks. Starting on the target quit date, participants received usual care smoking cessation treatment consisting of 8 weeks of transdermal nicotine and 4 weeks of twice-weekly telephone counseling were also prompted 1 to 3 times daily (with exact number and timing not disclosed beforehand) to use a study cell phone and CO monitor to complete a CO self-test, video-record the process, and submit videos using multimedia messaging within 2 hours. mHealth reinforcement participants could earn prizes for smoking-negative on-time CO tests. A treatment satisfaction survey was completed at the end of the 4-week monitoring/reinforcement phase. Results indicate that participants overwhelmingly endorsed high levels of overall satisfaction in both conditions. Treatment adherence did not differ between conditions, but was positively associated with endorsing the highest satisfaction with help quitting with the intervention (p<.01 to .03). mHealth reinforcement was associated with increased longest duration of abstinence (p<.01). Controlling for relevant participant characteristics and treatment adherence, longest duration of abstinence robustly predicted highest satisfaction with help quitting and mediated the effect of treatment condition on that satisfaction. Further research on treatment satisfaction may aid the development of effective abstinence reinforcement and other smoking cessation interventions.

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.

Development of the Health Incentive Program Questionnaire (HIP-Q) in a cardiac rehabilitation population

The purpose of this study was to develop a questionnaire to facilitate the design of acceptable financial health incentive programs. A multiphase psychometric questionnaire development method was used. Theoretical and literature reviews and three focus groups generated a pool of content areas and items. New items were developed to ensure adequate content coverage. Field testing was conducted with a convenience sample of cardiac rehabilitation (CR) patients (n = 59) to establish face and construct validity (p = 0.021) and reliability (intraclass coefficients = 0.42–0.87). The final questionnaire is comprised of 23 items. This questionnaire builds on previous attempts to explore acceptability by sampling a wider range of instrumental and affective attitudes and by measuring the effect of program features on the likelihood of incentive program participation. Future research is now needed to examine whether tailoring incentives to preferences assessed by the questionnaire improves uptake and effectiveness.

Acceptability of financial incentives for breastfeeding: thematic analysis of readers' comments to UK online news reports

BACKGROUND

Whilst it is recommended that babies are breastfed exclusively for the first six months, many mothers do not maintain breastfeeding for this length of time. Previous research confirms that women and midwives value financial incentives for breastfeeding, but limited research has explored the wider acceptability of these interventions to the general public. This paper examines opinion towards financial incentives for breastfeeding using reader responses to UK on-line media coverage of a study undertaken in this area.

METHODS

This study used netnography to undertake a thematic analysis of 3,373 reader comments posted in response to thirteen articles, published in November 2013, which reported findings from a feasibility study of financial incentives for breastfeeding. All articles were published on one of six UK news websites that achieved a monthly audience of at least five million viewers across laptop and desktop computers and mobile devices during April-May 2013.

RESULTS

Nine analytical themes were identified, with a majority view that financial incentives for breastfeeding are unacceptable. These themes cover a range of opinions: from negligent parents unable to take responsibility for their own actions; through to psychologically vulnerable members of society who should be protected from coercion and manipulation; to capable and responsible women who can, and should be allowed to, make their own decisions. Many views focused on the immediate costs of the intervention, concluding that this was something that was currently unaffordable to fund (e.g. by the NHS). Others contrasted the value of the incentive against other 'costs' of breastfeeding. There was some consideration of the issue of cost-effectiveness and cost-saving, where the potential future benefit from initial investment was identified. Many commenters identified that financial incentives do not address the many structural and cultural barriers to breastfeeding.

CONCLUSIONS

Overall, those commenting on the on-line UK news articles viewed financial incentives for breastfeeding as unacceptable and that alternative, structural, interventions were likely to be more effective. Further consideration of how best to conduct internet-based qualitative research to elicit opinion towards public health issues is required.

Acceptability of financial incentives for encouraging uptake of healthy behaviours: A critical review using systematic methods

OBJECTIVE

Financial incentives are effective in encouraging healthy behaviours, yet concerns about acceptability remain. We conducted a systematic review exploring acceptability of financial incentives for encouraging healthy behaviours.

METHODS

Database, reference, and citation searches were conducted from the earliest available date to October 2014, to identify empirical studies and scholarly writing that: had an English language title, were published in a peer-reviewed journal, and explored acceptability of financial incentives for healthy behaviours in members of the public, potential recipients, potential practitioners or policy makers. Data was analysed using thematic analysis.

RESULTS

Eighty one papers were included: 59 pieces of scholarly writing and 22 empirical studies, primarily exploring acceptability to the public. Five themes were identified: fair exchange, design and delivery, effectiveness and cost-effectiveness, recipients, and impact on individuals and wider society. Although there was consensus that if financial incentives are effective and cost effective they are likely to be considered acceptable, a number of other factors also influenced acceptability.

CONCLUSIONS

Financial incentives tend to be acceptable to the public when they are effective and cost-effective. Programmes that benefit recipients and wider society; are considered fair; and are delivered to individuals deemed appropriate are likely to be considered more acceptable.

Unintended consequences of incentive provision for behaviour change and maintenance around childbirth

Financial (positive or negative) and non-financial incentives or rewards are increasingly used in attempts to influence health behaviours. While unintended consequences of incentive provision are discussed in the literature, evidence syntheses did not identify any primary research with the aim of investigating unintended consequences of incentive interventions for lifestyle behaviour change. Our objective was to investigate perceived positive and negative unintended consequences of incentive provision for a shortlist of seven promising incentive strategies for smoking cessation in pregnancy and breastfeeding. A multi-disciplinary, mixed-methods approach included involving two service-user mother and baby groups from disadvantaged areas with experience of the target behaviours as study co-investigators. Systematic reviews informed the shortlist of incentive strategies. Qualitative semi-structured interviews and a web-based survey of health professionals asked open questions on positive and negative consequences of incentives. The participants from three UK regions were a diverse sample with and without direct experience of incentive interventions: 88 pregnant women/recent mothers/partners/family members; 53 service providers; 24 experts/decision makers and interactive discussions with 63 conference attendees. Maternity and early years health professionals (n = 497) including doctors, midwives, health visitors, public health and related staff participated in the survey. Qualitative analysis identified ethical, political, cultural, social and psychological implications of incentive delivery at population and individual levels. Four key themes emerged: how incentives can address or create inequalities; enhance or diminish intrinsic motivation and wellbeing; have a positive or negative effect on relationships with others within personal networks or health providers; and can impact on health systems and resources by raising awareness and directing service delivery, but may be detrimental to other health care areas. Financial incentives are controversial and generated emotive and oppositional responses. The planning, design and delivery of future incentive interventions should evaluate unexpected consequences to inform the evidence for effectiveness, cost-effectiveness and future implementation.

Public acceptability of financial incentives for smoking cessation in pregnancy and breast feeding: a survey of the British public

OBJECTIVE

To survey public attitudes about incentives for smoking cessation in pregnancy and for breast feeding to inform trial design.

DESIGN

Cross-sectional survey.

SETTING AND PARTICIPANTS

British general public.

METHODS

Seven promising incentive strategies had been identified from evidence syntheses and qualitative interview data from service users and providers. These were shopping vouchers for: (1) validated smoking cessation in pregnancy and (2) after birth; (3) for a smoke-free home; (4) for proven breast feeding; (5) a free breast pump; (6) payments to health services for reaching smoking cessation in pregnancy targets and (7) breastfeeding targets. Ipsos MORI used area quota sampling and home-administered computer-assisted questionnaires, with randomised question order to assess agreement with different incentives (measured on a five-point scale). Demographic data and target behaviour experience were recorded. Analysis used multivariable ordered logit models.

RESULTS

Agreement with incentives was mixed (ranging from 34% to 46%) among a representative sample of 1144 British adults. Mean agreement score was highest for a free breast pump, and lowest for incentives for smoking abstinence after birth. More women disagreed with shopping vouchers than men. Those with lower levels of education disagreed more with smoking cessation incentives and a breast pump. Those aged 44 or under agreed more with all incentive strategies compared with those aged 65 and over, particularly provider targets for smoking cessation. Non-white ethnic groups agreed particularly with breastfeeding incentives. Current smokers with previous stop attempts and respondents who had breast fed children agreed with providing vouchers for the respective behaviours. Up to £40/month vouchers for behaviour change were acceptable (>85%).

CONCLUSIONS

Women and the less educated were more likely to disagree, but men and women of childbearing age to agree, with incentives designed for their benefit. Trials evaluating reach, impact on health inequalities and ethnic groups are required prior to implementing incentive interventions.

TRIAL REGISTRATION NUMBER

CRD42012001980.

'Will walk for groceries': Acceptability of financial health incentives among Canadian cardiac rehabilitation patients

Financial health incentives, such as paying people to exercise, remain controversial despite widespread implementation. This focus group study explored the acceptability of incentives among a sample of Canadian cardiac rehabilitation (CR) patients (n = 15). Focus groups were conducted between March and April 2013 until further sampling ceased to produce new analytical concepts. A thematic analysis approach was adopted in analysing the data. Three broad themes emerged from the focus groups. First, ethical concerns were prominent. Half of participants disagreed with the incentive approach believing that it was unfair, unnecessary or a waste of limited resources. Second, ethical concerns were mitigated in considering a range of incentive features including type, size and source. Specifically, privately sponsored (not government funded) health-promoting voucher-based incentives (e.g., grocery or gym vouchers) were perceived to be highly acceptable. Third, if designed like this, then financial incentives were considered potentially effective in motivating behaviour change and in reducing economic barriers to exercise participation. Overall, the majority of participants welcomed incentives if ethical concerns were addressed through thoughtful incentive programme design. The results of this focus group study will inform the design of a financial health incentive feasibility RCT to promote post-CR programme exercise compliance in this population.

Acceptability of an Internet-based contingency management intervention for smoking cessation: views of smokers, nonsmokers, and healthcare professionals

The acceptability of an Internet-based contingency management (CM) intervention for cigarette smoking was evaluated in two experiments. In Experiment 1, 67 participants (46% female) completed an Internet-based CM intervention and then answered questions about the intervention. Experiment 2 assessed the acceptability of the intervention among potential treatment users who had never used the intervention, (smokers, n = 164, 52% female), nonsmokers (n = 166, 73% female), and health-care providers (n = 139, 63% female). Participants in Experiment 2 were randomly assigned to either watch a video describing the standard CM intervention (no-deposit group) or to watch a video about the standard intervention plus a deposit incentive (deposit group). Overall, results of both experiments indicated high acceptability across all dimensions of the intervention. In Experiment 1, 74% (n = 26 of participants in the treatment group) of participants said they would use it if they needed to quit, as well as 92% (n = 150 among smokers) of those in Experiment 2. Of the health-care providers, 81% (n = 113) reported that they would be very likely to recommend the intervention to patients. Participants in both experiments reported that monitoring their progress and earning vouchers were strengths of the intervention. The no-deposit group rated voucher earnings, cash earnings, and cost-effectiveness of the intervention higher than the deposit group. Health-care professionals did not differ in their ratings across video conditions. Overall, the results suggest that Internet-based CM is acceptable as a method to help people quit smoking.