The question of an incentive proved to be popular with employees asked to give up smoking for a reward of $800. Nearly everyone who was made the offer in a scientific trial accepted the challenge, but it was less effective than a program offering potential winnings only after an up-front deposit of $150 – which proved the less popular but better bet.

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A reward of $800 was effective – but not as much as the program that also had quitters depositing $150 in a bet on cessation chances.

The randomized controlled trial compared the effects of four different financial incentive programs – all worth around $800 over 6 months – added to a standard level of help for smoking cessation.

The quit rates achieved by employees at 6 and 12 months have been published in the New England Journal of Medicine.

All of the 2,538 study participants were offered usual care for smoking cessation – information about local resources, guides from the American Cancer Society, and, for 41% receiving health benefits, free access to a behavioral-modification program and nicotine-replacement therapy.

The results for the group of participants randomly assigned to this usual care alone were compared with results for groups assigned to an additional offer of financial incentive paid at different stages for biochemically confirmed abstinence:

  1. Individual reward – $200 paid at each point for abstinence maintained 14 days, 30 days and 6 months after the target quit date, with a $200 bonus also paid at the end
  2. Individual deposit – the same incentive structure as for intervention 1 but with an element of penalty for failed abstinence, losing the $150 deposit otherwise refundable with achievement of the 6-month bonus
  3. Collaborative reward – groups of six quitters worked together toward the same abstinence dates but were paid $100 each per time point if just one person succeeded, going up by that amount for every additional success in the group per time point, to a maximum of $600 each when all six achieved the abstinence
  4. Competitive reward – each of the six quitters had paid in $150, and this would be lost and redistributed along with $450 incentives spread out among only the successful quitters in the group, again for each time point of sustained smoking cessation.

All four financial programs improved quitters’ chances of giving up tobacco than usual care alone – with cessation rates being higher at both 6 and 12 months.

One of the study’s authors Dr. Troyen Brennan says:

“As we think about novel approaches to smoking cessation, these findings provide evidence that financial incentives can be a powerful motivator.”

Rates of sustained smoking abstinence at 6 months ranged from 9.4% to 16% in the cash programs, compared with 6% in the group offered usual care.

The reward-based cash programs were associated with higher abstinence rates than the deposit-based ones (15.7% versus 10.2% at 6 months) – but this was skewed by the much greater acceptance of people onto the programs.

After accounting for the lower popularity of the offer requiring payment of a $150 deposit, while a smaller proportion of people in these groups actually took up the challenge, they produced a higher success rate.

Therefore, the larger numbers of people going for the pure incentives without gambling any up-front payment were less likely to have success at 6 months. But the 13.2% higher level of success in the deposit groups was drawn from a proportion of only about 1 in 7 people who had taken up the challenge.

By comparison, the participation figures were 85.3% and 94.8% of the people assigned the options without any up-front payment, respectively, for the group-based and the individual reward.

Lead study author Dr. Scott Halpern, an assistant professor of medicine at the Perelman School of Medicine of the University of Pennsylvania in Philadelphia, says:

“This study is one of the first to compare incentive programs that first require deposits and programs that entail pure rewards to promote healthy behaviors.

The results are fully consistent with the behavioral theory that people are typically more motivated to avoid losses than to seek gains.”

“Although the need to make monetary deposits deters some people from participating,” Dr. Halpern adds, “deposit-requiring incentive programs can produce robust, long-term results in helping to change complex health behaviors.”

While motivations driven in part by loss may be stronger for individuals than those by pure incentive, the overall workforce and public health benefit would be higher with programs based on the latter, as discussed in the paper:

“Perhaps the most important finding is that incentive programs that required people to deposit $150 of their own money were less effective overall than reward-based programs of similar value because few people accepted such deposit programs.”

This fact was true, the authors continue, “despite the $650 reward offered to deposit arm participants in addition to the return of their original $150 deposits.”

In other smoking cessation news this week, a study in Neuropsychopharmacology suggests that a percentage of people who relapse into smoking after trying to give up may be driven by hard-wired connections in particular parts of their brains.