How and why do financial incentives contribute to helping people stop smoking? A realist review

BACKGROUND

Tobacco smoking remains a key cause of preventable illness and death globally. In response, many countries provide extensive services to help people to stop smoking by offering a variety of effective behavioural and pharmacological therapies. However, many people who wish to stop smoking do not have access to or use stop smoking supports, and new modes of support, including the use of financial incentives, are needed to address this issue. A realist review of published international literature was undertaken to understand how, why, for whom, and in which circumstances financial incentives contribute to success in stopping smoking for general population groups and among pregnant women.

METHODS

Systematic searches were undertaken from inception to February 2022 of five academic databases: MEDLINE (ovid), Embase.com, CIHAHL, Scopus and PsycINFO. Study selection was inclusive of all study designs. Twenty-two studies were included. Using Pawson and Tilley's iterative realist review approach, data collected were screened, selected, coded, analysed, and synthesised into a set of explanatory theoretical findings.

RESULTS

Data were synthesised into six Context-Mechanism-Outcome Configurations and one overarching programme theory after iterative rounds of analysis, team discussion, and expert panel feedback. Our programme theory shows that financial incentives are particularly useful to help people stop smoking if they have a financial need, are pregnant or recently post-partum, have a high threshold for behaviour change, and/or respond well to external rewards. The incentives work through a number of mechanisms including the role their direct monetary value can play in a person's life and through a process of reinforcement where they can help build confidence and self-esteem.

CONCLUSION

This is the first realist review to synthesise how, why, and for whom financial incentives work among those attempting to stop smoking, adding to the existing evidence demonstrating their efficacy. The findings will support the implementation of current knowledge into effective programmes which can enhance the impact of stop smoking care.

PROSPERO REGISTRATION NUMBER

CRD42022298941.

How Financial Incentives Increase Smoking Cessation: A Two-Level Path Analysis

Introduction

Financial incentives effectively increase smoking cessation rates, but it is unclear via which psychological mechanisms incentives influence quit behavior. The current study examines how receiving financial incentives for smoking cessation leads to quitting smoking and investigates several mediators and moderators of that relationship.

Aims and Methods

The study sample consisted of 604 tobacco-smoking employees from 61 companies in the Netherlands who completed a baseline and follow-up questionnaire. The current study is a secondary analysis from a cluster randomized trial where employees received smoking cessation group counseling at the workplace. Participants in the intervention group additionally received financial incentives of €350 in total for 12-month continuous smoking abstinence. We used a two-level path analysis to test a model that assesses the effects of financial incentives through smoking cessation program evaluation, medication use, nicotine replacement use, attitudes, self-efficacy, and social influences on quit success. We additionally tested whether an individual’s reward responsiveness moderated the influence of incentives on quit success.

Results

The effect of financial incentives on quit success was mediated by a higher self-efficacy. Financial incentives were also associated with a higher use of cessation medication. A more positive program evaluation was related to higher self-efficacy, more social influence to quit, and more positive attitudes about quitting. The results did not differ significantly by individual reward responsiveness.

Conclusions

The results of the current study suggest that financial incentives may be used to increase medication use and self-efficacy for quitting smoking, which offers an indirect way to increase successful smoking cessation.

Implications

(1) This is the first study investigating via which psychological pathways financial incentives for quitting smoking can lead to long-term quit success. (2) The results showed a path between financial incentives and a higher likelihood of medication use. Incentives may encourage smokers to use medication in order to increase their chance of quitting smoking and receive the reward. (3) There was a path from financial incentives to quit success via a higher self-efficacy. (4) The effects of financial incentives did not depend on individual reward responsiveness.

Smoking Behaviors of General Educational Development (GED) Recipients

OBJECTIVE

Cigarette smoking is inversely associated with education, and despite this gradient effect, individuals with a General Educational Development (GED) diploma, obtained through a high school equivalency test, have the highest smoking prevalence. Considered the high school equivalency credential, it is unclear why individuals with a GED have a substantially higher smoking prevalence compared to high school graduates and dropouts. We conducted a qualitative study to understand life experiences, tobacco use patterns, and perceptions of tobacco among GED smokers and attitudes and behaviors around smoking cessation.

METHODS

We recruited 40 GED smokers aged 18 to 35 years and conducted surveys and semi-structured individual interviews. Transcripts were independently coded, then coding differences were resolved and reviewed by a third team member. We independently determined themes within and between codes and met to determine final themes.

RESULTS

GED recipients had many early life experiences and characteristics that made them highly vulnerable to tobacco dependence. With perceived high cognitive abilities, GED smokers were knowledgeable of many evidence-based smoking cessation strategies and were aware of health risks. Health risks and the financial burden of smoking were motivation to quit. The majority were uninterested or lacked confidence that nicotine replacement therapy, medications, counseling, or the quitline could help them quit. Nearly all were enthusiastic and confident that financial incentives had the potential to help them quit.

CONCLUSIONS

Research is needed to determine whether financial incentives could improve smoking cessation outcomes in this unique population with an unequal burden of smoking.

Treatment Outcomes of a Multi-Component Mobile Health Smoking Cessation Pilot Intervention for People with Schizophrenia

The objective of this study was to investigate the feasibility and acceptability of a multi-component mobile contingency management (CM) pilot intervention for smoking cessation for people with schizophrenia. Methods: This intervention included mobile CM (i.e., monetary compensation for bioverification of abstinence through using a phone app), cognitive behavioral therapy (CBT), and pharmacotherapy for smoking cessation. This intervention was compared to an intensive treatment comparison (ITC), which contained all components except the CM. Participants were bioverified with carbon monoxide and saliva cotinine at a 6-month follow-up session. Results: In this pilot, the treatment group did not differ from the ITC at any time point. However, measures of treatment feasibility and acceptability indicated that smokers with schizophrenia were able to navigate the CM phone application and adhere to the protocol, demonstrating the potential utility of mobile interventions in this population. Conclusions: Despite lack of long-term abstinence for participants, adherence to the mobile application intervention indicates the potential for future investigation of mobile smoking cessation treatments for people with schizophrenia.

An Information Theoretic Approach to Model Selection: A Tutorial with Monte Carlo Confirmation

A reliance on null hypothesis significance testing (NHST) and misinterpretations of its results are thought to contribute to the replication crisis while impeding the development of a cumulative science. One solution is a data-analytic approach called Information-Theoretic (I-T) Model Selection, which builds upon Maximum Likelihood estimates. In the I-T approach, the scientist examines a set of candidate models and determines for each one the probability that it is the closer to the truth than all others in the set. Although the theoretical development is subtle, the implementation of I-T analysis is straightforward. Models are sorted according to the probability that they are the best in light of the data collected. It encourages the examination of multiple models, something investigators desire and that NHST discourages. This article is structured to address two objectives. The first is to illustrate the application of I-T data analysis to data from a virtual experiment. A noisy delay-discounting data set is generated and seven quantitative models are examined. In the illustration, it is demonstrated that it is not necessary to know the "truth" is to identify the one that is closest to it and that the most likely models conform to the model that generated the data. Second, we examine claims made by advocates of the I-T approach using Monte Carlo simulations in which 10,000 different data sets are generated and analyzed. The simulations showed that 1) the probabilities associated with each model returned by the single virtual experiment approximated those that resulted from the simulations, 2) models that were deemed close to the truth produced the most precise parameter estimates, and 3) adding a single replicate sharpens the ability to identify the most probable model.

Patient-Informed Treatment Development of Behavioral Smoking Cessation for People With Schizophrenia

The objective of this study was to use qualitative methodology to tailor and refine an existing smoking cessation intervention for the population of people who use cigarettes and are diagnosed with schizophrenia, schizoaffective, or psychotic disorder. Successive cohort design methodology was used to iteratively modify the treatment in response to qualitative participant, therapist, and consultant feedback on the intervention. Qualitative methodology for participant feedback included analysis of semistructured interviews with participants, visualization of app utilization data, and stakeholder feedback from study therapists and consultants. Using the successive cohort design, a tailored multicomponent mobile health smoking cessation intervention was developed. The intervention included mobile contingency management (i.e., financial compensation for confirmed abstinence from smoking), pharmacotherapy for smoking cessation, cognitive-behavioral counseling sessions, and the Stay Quit app for relapse prevention. Two cohorts (N = 13) were completed in the study; after each cohort, the treatment protocol was revised. The intervention is described, as well as the qualitative findings from each cohort and subsequent changes made to the intervention based upon patient and provider feedback. Metrics of patient engagement included treatment adherence (40% in Cohort 1 and 63% in Cohort 2). Both participants and therapists reported that the intervention was helpful. Over one third of participants self-reported abstinence at posttreatment. Since qualitative methodology is often underutilized in mental health treatment development, this study demonstrates the utility of the successive cohort design for treatment development of behavior change interventions for at-risk, vulnerable populations.