Smoked Out: Financial Incentives Prove Effective in Weaning People Off Cigarettes

The results of a provocative new study suggest that paying individuals to quit smoking has a sustained impact on rates of smoking cessation, even after the money has stopped flowing.

In a study of low-income smokers motivated to quit, researchers randomized participants to a short-term intervention where they received internet-based smoking cessation support and up to $1,650 in supermarket vouchers for biochemically confirmed abstinence, or to cessation support but no financial incentive. Those randomized to the financial rewards were more than twice as likely to abstain from smoking over the follow-up period, even when payments stopped.

“In absolute terms, it’s not very large figures,” lead study author Jean-François Etter, PhD (University of Geneva, Switzerland) told TCTMD. “But if you look at the efficacy of smoking cessation drugs or even intensive physician counselling, the difference is about the same, five or six percentage points. So it’s about the same effect.”

Published August 15, 2016 in the Journal of the American College of Cardiology, the study points to bigger societal issues that relate to prevention and health economics. Paying people to stop smoking is “a bit provocative, but people in society already pay a lot of money when people are sick from smoking. It’s hugely costly to the healthcare system,” said Etter. “So if paying people works—and it appears that it works—then why not pay them?”

In all, 805 smokers were randomized to 6 months of vouchers and support, or to support only. Etter et al then tracked abstinence between 6 and 18 months—out to one full year after payments had ceased. At follow-up, the rate of continued abstinence between 6 and 18 months—the study’s primary endpoint—was higher among individuals randomized to financial compensation than to support alone (9.5% vs 3.7%; P=0.001).

The cost-effectiveness of the compensation approach is the next research question to answer, Etter said, surmising that paying people to quit smoking could potentially be a lot cheaper than paying for long-term health care costs, especially for conditions like lung cancer and heart disease. What could also be tested in future studies is whether combining financial incentives with counseling and medical interventions could have even greater results, Etter suggested.

Money Talks

“The three biggest motivators in the world are money, love, and sex,” Morton Kern, MD (University of California, Irvine), who was not involved in the study, told TCTMD. “Money will get people to do almost anything. So if you give money to people who need money to change their behavior, they will, until the money runs out. And that’s exactly what this study shows.”

While many parties benefit when one person stops smoking—the individual, insurance payers, and society as a whole—Kern questioned whether we are “ready to pay for everyone’s behavioral changes.”

In an accompanying editorial, Joseph Ladapo, MD, PhD (New York University School of Medicine and University of California, Los Angeles), and Judith Prochaska, PhD (Stanford University, CA), also address the financial elephant in the room. By their calculation, the estimated number needed to treat is 17, meaning the cost would be $28,050 to result in one additional long-term quitter. “One has to wonder who will be willing to pay for this initiative,” they write. “Even in the worksite setting, where the return on investment may be realized, adoption of financial incentives has been limited.”  

Etter believes the money should come from cigarette taxes, which he estimated make up between 60-80% of the cost of a pack of cigarettes in Switzerland.

For Ladapo and Prochaska, there are other unknowns, such as how large the financial incentives need to be to change behavior, whether individuals should be paid cash or given certificates (which were given in this study to a grocery store that does not sell tobacco products), and what level of behavior change deserves to be rewarded. It is also unknown if this approach would work for smokers unmotivated to quit.

“Future work should aim to bridge critical knowledge gaps concerning incentive design and delivery, and ultimately, inform the comparative effectiveness of financial incentives relative to other clinical and behavioral approaches to treating nicotine addiction,” they conclude.

Compensating for Lost Value

There are a multitude of other patient behaviors that cardiologists would typically like to modify, including medication adherence, making and keeping appointments with primary care physicians, diet, and exercise, Kern said. The possibility that financial incentives could be used to change these habits for the better is a question worth asking, he suggested.

It would have to be a compelling sum, however, Kern believes. “They are not going to change their behavior like smoking or exercise or diet for $50 or $100. It’s just not enough,” he said. “You need to compensate for the loss of a valued activity like eating or smoking, and the compensation needs to be at a level of what they lose, because they value this activity even if it’s unhealthy.”

For now, findings like this are simply “food for thought,” Kern said. “Cardiologists will look at it and say, ‘How interesting. Human behavior is influenced by money.’” But this should come as no surprise because physician behavior is influenced by reimbursement, he continued. “You pay us to do something, we do it. [If] you don’t pay us to do something, we’d have to think about it.”

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