Financial Incentives for Quitting Smoking: A Mixed Bag

The jury is still out on financial incentives for quitting smoking among socioeconomically disadvantaged adults following mixed results from a trial plagued by missing data.

Among 320 longtime smokers who were uninsured or on Medicaid, offering upwards of $500 in potential gift cards along with usual care of counseling and pharmacotherapy was not associated with a significantly greater likelihood of biochemically verified smoking abstinence at 26 weeks compared with usual care alone (13.8% vs 8.7%, respectively; adjusted odds ratio [aOR] 1.79, 95% CI 0.85-3.80).

However, that result was based on a conservative analysis that counted all participants with incomplete smoking status as still smoking — and the trial only had complete smoking status data available for 65.3% of participants at 26 weeks, reported Darla Kendzor, PhD, of the University of Oklahoma Health Sciences Center in Oklahoma City, and coauthors of the Prevail II trial.

Investigators eked out a signal of smoking cessation benefit associated with financial incentives through 12 weeks (19.7% vs 11.2%; aOR 3.18, 95% CI 1.70-5.95) and at 26 weeks when they utilized multiple imputation to handle the problem of missing data (23.5% vs 12.1%; aOR 2.29, 95% CI 1.14-4.63), according to the findings in JAMA Network Open.

E. Neil Schachter, MD, of the Icahn School of Medicine at Mount Sinai in New York City, told MedPage Today that the data for financial incentives were not “totally convincing,” but that they are a step in the right direction. In the current study, he noted, incentives could be linked to smoking abstinence as early as 4 weeks.

Schachter, who was not involved in the trial, stressed that “every person is a different story” when it comes to quitting smoking, and factors like socioeconomic status can play a part in their journey. He added that the pandemic and its associated stressors may have made it more difficult for anyone looking to quit smoking.

Indeed, Kendzor’s team reported that rates of follow-up were significantly lower if they were scheduled during the COVID-19 pandemic (the trial was conducted from January 2017 to February 2022).

Based on the previous literature, patients who are socioeconomically disadvantaged are less likely to quit smoking, often due to “stress and/or adversity and smoking-conducive environments,” said Kendzor and co-authors. A recent review found that cessation-related incentives, even offered temporarily, can help improve abstinence rates, while a smaller study out of Texas indicated that adults with low socioeconomic status had increased short-term quit rates with incentives.

“The bottom line is that it’s very hard to get people to stop smoking,” commented Schachter. “Even a 1%, 2%, or 3% improvement in the smoking cessation rate — I mean, there are millions of smokers still out there — would be a great benefit. And financially, it could be a win-win situation because of the health costs involved in people who continue to smoke.”

Prevail II trial randomized 320 participants referred to a tobacco cessation clinic in Oklahoma City to usual care alone or with additional financial incentives. Eligible volunteers needed to have greater than 6th grade English literacy, be willing to attempt quitting smoking, smoke five or more cigarettes per day, and have an expired carbon monoxide (CO) level of at least 8 ppm.

The total cohort averaged 49 years and 63% were women. The patient population was 63% white, 26% Black, 8% multiracial or of another race, 5% Hispanic, and 4% American Indian or Alaska Native. Nearly 55% had an annual household income below $11,000. At baseline, participants had been smoking 19 cigarettes a day for 29 years on average, and had an average expired CO of 22.5 ppm.

Individuals in the financial incentive group were compensated through department store gift cards and were offered $50 for completing a baseline assessment, $30 for each weekly assessment from their quit day through 4 weeks, and $40 for follow-up assessments at 8, 12, and 26 weeks.

They were also able to earn up to $250 from abstinence demonstrated by self-reports and breath samples. Ultimately they earned an average of $72 in abstinence-contingent incentives throughout the first 12 weeks following their quit day, with an average cost per quit between about $310 to $521, depending on how missing data were categorized.

Usual care comprised a pre-quit counseling session with a tobacco treatment specialist and participants were offered five more weekly counseling sessions starting on their quit day. Most people (78%) also got complimentary combination nicotine replacement therapy (NRT), such as nicotine patches and gum or lozenges, until 12 weeks after their quit day. Those who did not use NRT were prescribed other complementary pharmacotherapies free of charge when appropriate.

The trial’s primary smoking cessation endpoint was defined as self-reported smoking abstinence over the past 7 days and a CO reading of no more than 6 ppm, or CO 6 ppm or less alone if self-reported information was missing.

Participants were asked to attend in-person study appointments at the clinic, until the onset of the COVID pandemic, after which they were asked to complete virtual assessments, attend sessions via phone or video call, and submit their CO breath samples remotely via breath monitor.

One potential limitation to the trial was its recruitment from a single state, which may limit generalizability to other populations. Additionally, Kendzor’s team noted, Black people had been disproportionately screened out of the trial due to their smoking fewer than five cigarettes per day.

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