Effectiveness of financial incentives for longer-term smoking cessation: evidence of absence or absence of evidence?

Goal-directed versus outcome-based financial incentives for smoking cessation among low-income, hospitalised patients: rationale and design of the Financial Incentives for Smoking Treatment II (FIESTA II) randomised controlled trial

INTRODUCTION

Smoking remains the leading preventable cause of death in the USA. Low utilisation of treatments for smoking cessation remains a major barrier for reducing smoking rates. Financial incentives represent an innovative approach to increasing use of therapies for smoking cessation. This paper will describe the rationale and design of the Financial Incentives for Smoking Treatment II (FIESTA II) study, a randomised controlled trial to evaluate the effectiveness and feasibility of goal-directed and outcome-based financial incentives to promote smoking cessation among hospitalised smokers.

METHODS AND ANALYSIS

We are recruiting adult participants who smoked tobacco in the 30 days prior to initial interview and are contemplating quitting smoking. These participants will come from two hospitals in underserved communities in New York City and Los Angeles. They will be randomised into one of three arms. The first arm consists of goal-directed financial incentives plus enhanced usual care, which includes hospital-directed information about quitting smoking, nicotine replacement therapy and referral to a Quitline. The second arm involves outcome-based financial incentives plus enhanced usual care. The third arm consists of enhanced usual care alone. Multiple phone interviews with the participants will be completed after randomisation to assess smoking cessation. Participants will earn $20 for each follow-up interview completed and $30 for each smoking cessation test completed. Those who are randomised to the financial incentive groups can earn an additional $700. The participants in the outcome-based group will receive payments solely for exhibiting cessation, whereas the participants in the goal-based group are also eligible for receiving payments after meeting milestones such as speaking with a helpline coach.

ETHICS

Human research protection committees at New York University School of Medicine and the University of California Los Angeles (UCLA) David Geffen School of Medicine granted ethics approval.Protocol number: IRB#19-000 084.

TRIAL REGISTRATION NUMBER

NCT03979885.

[Financial incentives to achieve health-related behavioral goals: State of play and unresolved questions]

Programs providing monetary rewards to individuals who achieve a health-related goal (quitting smoking, losing weight, etc.) aim at promoting healthy behaviors. While these programs seem to achieve their objective in the short run, their ability to provoke lasting changes remains to be demonstrated. The identification of granting mechanisms likely to maximize the incentive effect of these rewards should be based on knowledge about individual attitudes evidenced by behavioral economics. As the latter has shown that preferences toward risk vary from one individual to another, these incentive mechanisms should be tailor-made according to individual preferences.

Incentive programmes for smoking cessation: cluster randomized trial in workplaces in Thailand

OBJECTIVE

To compare several monetary incentive programmes for promoting smoking abstinence among employees who smoke at workplaces in a middle income country.

DESIGN

Parallel group, open label, assessor blinded, cluster randomized controlled trial.

SETTING

Large industrial workplaces in metropolitan Bangkok, Thailand.

PARTICIPANTS

Employees who smoked cigarettes and planned to quit within six months recruited from 101 worksite clusters (84 different companies).

INTERVENTIONS

Worksites were digitally cluster randomized by an independent investigator to usual care or usual care plus one of eight types of incentive programmes. Usual care consisted of one time group counseling and cessation support through a 28 day text messaging programme. The incentive programmes depended on abstinence at three months and varied on three intervention components: refundable deposits, assignment to a teammate, and bonus size ($20 (£15; €17) or $40).

MAIN OUTCOME MEASURES

The primary outcome was biochemically verified seven day point prevalence smoking abstinence at 12 months. Secondary outcomes were programme acceptance at enrollment and smoking abstinence at three months (end of intervention) and at six months. All randomized participants who had complete baseline information were included in intention-to-treat analyses; participants with missing outcomes were coded as continuing smokers.

RESULTS

Between April 2015 and August 2016, the trial enrolled 4190 participants. Eighteen were omitted because of missing baseline covariates and death before the primary endpoint, therefore 4172 participants were included in the intention-to-treat analyses. Programme acceptance was relatively high across all groups: 58.7% (2451/4172) overall and 61.3% (271/442) in the usual care group. Abstinence rates at 12 months did not differ among deposit programmes (336/2253, 14.9%) and non-deposit programmes (280/1919, 14.6%; adjusted difference 0.8 points, 95% confidence interval -2.7 to 4.3, P=0.65), but were somewhat lower for team based programmes (176/1348, 13.1%) than individual based programmes (440/2824, 15.6%; -3.2 points, -6.6 to -0.2, P=0.07), and higher for $40 bonus programmes (322/1954, 16.5%) than programmes with no bonus (148/1198, 12.4%; 5.9 points, 2.1 to 9.7, P=0.002). The $40 individual bonus was the most efficacious randomization group at all endpoints. Intervention components did not strongly interact with each other.

CONCLUSIONS

Acceptance of monetary incentive programmes for promoting smoking abstinence was high across all groups. The $40 individual bonus programmes increased long term smoking abstinence compared with usual care, although several other incentive designs did not, such as team based programmes and deposit programmes. Incentive design in workplace wellness programmes might influence their effectiveness at reducing smoking rates in low resource settings.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02421224).

A randomized controlled trial to compare group motivational interviewing to very brief advice for the effectiveness of a workplace smoking cessation counseling intervention

BACKGROUND

Studies show that smokers have a lower work performance due to time spent smoking, increased fatigue perception and are more absent from work due to smoking-related diseases. The workplace could represent an important location to promote smoking cessation.

METHODS

This study is a multi-center, controlled trial for smoking cessation counseling at the participants' workplace, where 656 randomized participants received four sessions of group motivational interviewing or four sessions of very brief advice and were followed up for 52 weeks.

RESULTS

The Continuous Quit Rate (CQR) was higher for the smoking cessation counseling group than for the very brief advice group during weeks 9 to 12 (17.5% vs. 3.6%) weeks 9 to 24 (13.4% vs. 3.4%) and weeks 9 to 52 (10.3% vs. 3.1%).

CONCLUSIONS

This study demonstrated that motivational interviewing is an efficacious smoking cessation approach for smokers at their workplace. The short-term and long-term cessation rate of the intervention of the smoking cessation counseling group exceeded that of very brief advice.

Microrandomized trials for promoting engagement in mobile health data collection: Adolescent/young adult oral chemotherapy adherence as an example

Long-term engagement with mobile health (mHealth) apps can provide critical data for improving empirical models for real-time health behaviors. To learn how to improve and maintain mHealth engagement, micro-randomized trials (MRTs) can be used to optimize different engagement strategies. In MRTs, participants are sequentially randomized, often hundreds or thousands of times, to different engagement strategies or treatments. The data gathered are then used to decide which treatment is optimal in which context. In this paper, we discuss an example MRT for youth with cancer, where we randomize different engagement strategies to improve self-reports on factors related to medication adherence. MRTs, moreover, can go beyond improving engagement, and we reference other MRTs to address substance abuse, sedentary behavior, and so on.

Delayed gratification and adherence to exercise among patients with claudication

Few studies have explicitly identified factors that explain an individual's willingness to engage in community-based exercise for claudication. Identifying the unique characteristics of those inclined toward physical activity would inform interventions that encourage walking. We examined the utility of behavioral economics-related concepts in understanding walking among Veterans with claudication. Patients who received care at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, were surveyed on symptom severity, behavioral economics, stress, and depression. The primary outcome was a binary variable measuring current walking for exercise and defined as walking for at least 30 minutes every day. Multivariable logistic regression models were used to identify variables, both clinically and statistically significant, at a p-value < 0.05. Between April 2017 and March 2018, we received 148 (30%) responses. A total of 35% (n = 51) of respondents indicated that they walked recreationally for exercise compared to 65% (n = 94) who did not. Characteristics that were significantly associated with walking included regularly saving money (adjusted odds ratio (aOR) = 10.7, p = 0.001), seeking complex problem-solving (aOR = 0.12, p = 0.002), and severe symptoms (aOR = 0.24, p = 0.017). Individuals describing a preference for the future rather than immediate benefit also reported currently walking for exercise. Defining the characteristics of those who exercise may help inform strategies designed to increase walking among those who do not adhere to recommendations.

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.

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.

Understanding Participants' Perceptions of Access to and Satisfaction With Chronic Disease Prevention Programs

Despite the promise of incentive-based chronic disease prevention programs, comprehensive evidence on their accessibility among low-income populations remains limited. We adapted Aday and Andersen's framework to examine accessibility and consumer satisfaction within the Medicaid Incentives for the Prevention of Chronic Disease (MIPCD) cross-site demonstration. MIPCD provided 10 states with 5-year grants to implement incentivized chronic disease prevention and management programs for low-income and/or disabled-Medicaid enrolled-Americans. We conducted 36 focus group discussions between July 2014 and December 2015 with Medicaid enrollees participating in the MIPCD programs. We assessed participants' satisfaction by program type (i.e., diabetes prevention, diabetes management, hypertension reduction, smoking cessation, and weight management) related to three components: program enrollment and participation, staff courtesy, and program convenience. Based on Aday and Andersen's framework, we conducted thematic analysis to determine similarities and differences across MIPCD programs by type. Participant feedback confirmed the importance of several features of the Aday and Andersen framework, particularly programs with easy enrollment and participation procedures, courteous and helpful staff, and those that are convenient and flexible for participants. Participants valued programming around the clock via telephone and flexible, in-person hours of operation as well as proximity of the program to reliable transportation. We observed that most participants, despite enrollment and participation barriers, perceived programs as accessible and were willing to engage and continue to participate. This finding may reflect behavior change theory's perspective on personal readiness to change. Individuals in the preparation stage of change can effectively change health habits despite barriers they may encounter. In some cases, personal readiness to change was more impactful than consumer satisfaction at encouraging ongoing participation and perceived access to the programs. Thus, program developers may want to consider individual participant readiness to change and its impact on consumer satisfaction when designing, implementing, and evaluating behavior change initiatives.

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.

Characterizing Employees’ Preferences for Incentives for Healthy Behaviors: Examples to Improve Interest in Wellness Programs

Background. Many employers now incentivize employees to engage in wellness programs, yet few studies have examined differences in preferences for incentivizing participation in healthy behaviors and wellness programs. Method. We surveyed 2,436 employees of a large university about their preferences for incentivizing participation in different types of healthy behaviors and then used multivariable logistic regression to estimate associations between employees’ socioeconomic and demographic characteristics and their preferences for incentives for engaging in healthy behaviors. Results. Compared with nonunion members, union members had higher odds of wanting an incentive for eating healthily (adjusted odds ratio [AOR] = 1.60, 95% [CI; 1.21, 2.12]), managing weight (AOR = 1.53, 95% CI [1.14, 2.06]), avoiding drinking too much alcohol (AOR = 1.41, 95% CI [1.11, 1.78]), quitting tobacco (AOR = 1.37, 95% CI [1.06, 1.77]), managing stress (AOR = 1.37, 95% CI [1.08, 1.75]), and managing back pain (AOR = 1.64, 95% CI [1.28, 2.10]). Compared with staff, faculty employees reported higher odds for wanting an incentive for reducing alcohol intake (AOR = 1.34, 95% CI [1.00, 1.78]) and quitting tobacco (AOR = 1.43, 95% CI [1.04, 1.96]). Women had lower odds than men (AOR = 0.80, 95% CI [0.64, 0.99]) of wanting an incentive for managing back pain. Conclusions. Preferences for incentives to engage in different types of healthy behaviors differed by employees’ socioeconomic and demographic characteristics. Organizations may consider using survey data on employee preferences for incentives to more effectively engage higher risk populations in wellness programs.

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.

Are Financial Incentives for Lifestyle Behavior Change Informed or Inspired by Behavioral Economics? A Mapping Review

OBJECTIVE

To identify the behavioral economics (BE) conceptual underpinnings of lifestyle financial incentive (FI) interventions.

DATA SOURCE

A mapping review of peer-reviewed literature was conducted by searching electronic databases.

STUDY INCLUSION AND EXCLUSION CRITERIA

Inclusion criteria were real-world FI interventions explicitly mentioning BE, targeting individuals, or populations with lifestyle-related behavioral outcomes. Exclusion criteria were hypothetical studies, health professional focus, clinically oriented interventions.

DATA EXTRACTION

Study characteristics were tabulated according to purpose, categorization of BE concepts and FI types, design, outcome measures, study quality, and findings.

DATA SYNTHESIS AND ANALYSIS

Financial incentives were categorized according to type and payment structure. Behavioral economics concepts explicitly used in the intervention design were grouped based on common patterns of thinking. The interplay between FI types, BE concepts, and outcome was assessed.

RESULTS

Seventeen studies were identified from 1452 unique records. Analysis showed 76.5% (n = 13) of studies explicitly incorporated BE concepts. Six studies provided clear theoretical justification for the inclusion of BE. No pattern in the type of FI and BE concepts used was apparent.

CONCLUSIONS

Not all FI interventions claiming BE inclusion did so. For interventions that explicitly included BE, the degree to which this was portrayed and woven into the design varied. This review identified BE concepts common to FI interventions, a first step in providing emergent and pragmatic information to public health and health promotion program planners.

Variability and Limits of US State Laws Regulating Workplace Wellness Programs

We examined variability in state laws related to workplace wellness programs for public and private employers. We conducted legal research using LexisNexis and Westlaw to create a master list of US state laws that existed in 2014 dedicated to workplace wellness programs. The master list was then divided into laws focusing on public employers and private employers. We created 2 codebooks to describe the variables used to examine the laws. Coders used LawAtlas(SM) Workbench to code the laws related to workplace wellness programs. Thirty-two states and the District of Columbia had laws related to workplace wellness programs in 2014. Sixteen states and the District of Columbia had laws dedicated to public employers, and 16 states had laws dedicated to private employers. Nine states and the District of Columbia had laws that did not specify employer type. State laws varied greatly in their methods of encouraging or shaping wellness program requirements. Few states have comprehensive requirements or incentives to support evidence-based workplace wellness programs.

A Randomized, Controlled Trial of a Shared Panel Management Program for Small Practices

OBJECTIVES

To determine whether a shared panel management program was effective at improving quality of care for patients with uncontrolled chronic disease.

DATA SOURCES

Data were extracted from electronic health records.

STUDY DESIGN

Randomized controlled trial of a panel management program initiated by New York City Department of Health and Mental Hygiene. Patients from 20 practices with an uncontrolled chronic disease and a lapse in care were assigned to the intervention (a phone call requesting that the patient schedule a physician appointment) or usual care. Outcomes were visits to physician practices, body mass index measurement, blood pressure measurement and control, use of antithrombotics, and low-density lipoprotein measurement and control.

PRINCIPAL FINDINGS

Panel managers were able to successfully speak with 1,676 patients (14.7 percent of the intervention group). There were no significant differences in outcomes between the intervention and usual care groups. Successfully contacted patients were more likely to have an office visit within 1 year of randomization (45.6 percent [95 percent CI: 22.8, 26.9] vs. 38.1 percent [95 percent CI: 36.8, 39.3]) and more likely to be on antithrombotics (24.4 percent [95 percent CI: 17.7, 31.0]) versus those in the usual care group (17.0 percent [95 percent CI: 13.9, 20.0]) but had no other difference in quality.

CONCLUSIONS

A shared, low-intensity panel management program run by a city health department did not improve quality of care for patients with chronic illnesses and lapses in care.

Personal financial incentives for changing habitual health-related behaviors: A systematic review and meta-analysis

OBJECTIVES

Uncertainty remains about whether personal financial incentives could achieve sustained changes in health-related behaviors that would reduce the fast-growing global non-communicable disease burden. This review aims to estimate whether: i. financial incentives achieve sustained changes in smoking, eating, alcohol consumption and physical activity; ii. effectiveness is modified by (a) the target behavior, (b) incentive value and attainment certainty, (c) recipients' deprivation level.

METHODS

Multiple sources were searched for trials offering adults financial incentives and assessing outcomes relating to pre-specified behaviors at a minimum of six months from baseline. Analyses included random-effects meta-analyses and meta-regressions grouped by timed endpoints.

RESULTS

Of 24,265 unique identified articles, 34 were included in the analysis. Financial incentives increased behavior-change, with effects sustained until 18months from baseline (OR: 1.53, 95% CI 1.05-2.23) and three months post-incentive removal (OR: 2.11, 95% CI 1.21-3.67). High deprivation increased incentive effects (OR: 2.17; 95% CI 1.22-3.85), but only at >6-12months from baseline. Other assessed variables did not independently modify effects at any time-point.

CONCLUSIONS

Personal financial incentives can change habitual health-related behaviors and help reduce health inequalities. However, their role in reducing disease burden is potentially limited given current evidence that effects dissipate beyond three months post-incentive removal.

Incentives for smoking cessation

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Four lenses through which to develop wellness incentive policies

Employers had to scramble to develop policies for their Wellness Incentives in time for their Fall, 2013 Open Enrollment deadlines, and are already refining policies for the 2014 Open Enrollment period. Employers are encouraged to consider six policy elements and to view all of them through four lenses. The policy elements are: (1) Number and Types of Behaviors and Outcomes to Target. (2) Cost-Positive, Neutral, or Savings Approach. (3) Maximum Incentive Value and Allocation of Incentives. (4) Ratio of Types of Incentive Structure for Reasonable Alternative Standards. (5) Numbers of Cycles of RASs. (6) Access and Allocations for Family Members. The lenses are: (1) What drives healthy behavior? (2) What is equitable? (3) What is sustainable? and (4) What enhances employee morale?