Smoking Cessation Program Tactics

Behavior change is hard and research on what wellness program designs are most effective at engaging health behavior change is in its infancy.  Research carried in the New England Journal of Medicine advances that state of the art in regard to smoking cessation, a particularly difficult bit of unhealthy health habits to change.   (NEJM Article)   Over 6000 smokers from 54 company-sponsored health plans who had engaged Vitality for a tobacco cessation program were included in the trial.  They were randomized to one of five arms of the study: usual care (education and inspirational text messages); free e-cigarettes; free cessation aids (like drugs); free cessation aids plus a $600 reward package for sustained abstinence; or free cessation aids plus $600 in redeemable funds in an account, but it would be lost if there wasn’t sustained abstinence.  Blood and urine testing was used to test for tobacco use.  The financial rewards were parceled out at one, three and six month intervals.  Among other things, the researchers were interested in ascertaining whether a perceived financial loss would be more effective in maintaining non-smoking behavior that a mere financial reward.

The primary outcome was remaining smoke free for six months after the assigned quit date.  This was determined by a self-reported survey and the lab tests.  Other outcomes included one month of abstinence and continued smoking cessation at one year, or six months after the official end of the intervention.  There was a website which provided support to all of the smokers in the trial and the subset of participants who actually used the website at least once were referred to as “engaged”.   Only about 20% of the participants ended up in this category.  This engaged group was more likely to be highly educated, female, to have used e-cigarettes in the past and to report being motivated to quit.  In one sense the trial was disappointing, as less than 10% of participants reported quitting smoking at any point during the intervention.  Only 80 participants, or a little over 1%, were smoke free after 6 months.  Almost no one in the usual care group quit.  Each of the interventions showed an improvement in quit rates, with the redeemable deposits group showing the highest rate at 2.9%.   While this was higher than the reward arm of the trial, it did not reach statistical significance compared to that arm, but did compared to the free cessation aids and free e-cigarette arms.  The engaged cohort showed much better results, with 9.5% in the financial reward groups and 12.7% in the redeemable deposit arm having a sustained cessation.  Only about half the people who had remained smoke-free through six months were still abstinent at 12 months.

The most striking lesson is just how hard smoking cessation is and what a difference it makes if people want to quit.  Creating some perception of financial loss appears to have some minor additive effect over a financial reward.  What would really make a difference is to create a meaningful connection between smoking and the financial consequences by making smokers pay a lot more for health care coverage and health care.  Until we are willing to make people bear the consequences of their actions, instead of being bailed out by others, it is hard to imagine that behavior will change significantly.