Financial incentives can improve smoking cessation among socioeconomically disadvantaged adults

University of OklahomaJul 2 2024

A study published today by a University of Oklahoma researcher shows that financial incentives can make a big difference in helping smokers quit. The study found that when people with low socioeconomic status are offered small financial incentives to stop smoking (in addition to receiving counseling and pharmacotherapy, primarily nicotine replacement therapy), they achieve higher quit rates, with some measures doubling the quit rates, when compared to study participants who received the same treatments without incentives. This finding is particularly important because adults with socioeconomic challenges are more likely to smoke, experience more difficulty quitting, and suffer from more tobacco-related health problems and deaths than the general population.

The study, published in JAMA Network Open, a journal of the American Medical Association, was led by Darla Kendzor, Ph.D., co-director of the TSET Health Promotion Center at OU Health Stephenson Cancer Center and a professor of family medicine in the OU College of Medicine.

It's an amazing finding that smoking quit rates were doubled at final follow-up simply by offering small incentive payments for quitting. This is especially important for the counties in Oklahoma that have high levels of poverty and where many people don't have health insurance and face other socioeconomic challenges. Smoking rates are as high as 30% in some Oklahoma counties, which is much higher than national estimates."

Darla Kendzor, Ph.D., co-director of the TSET Health Promotion Center at OU Health Stephenson Cancer Center and a professor of family medicine in the OU College of Medicine

The study's findings come from a clinical trial in which adults were randomly assigned to one of two groups: those who received pharmacotherapy and counseling with a tobacco treatment specialist, and those who received the same treatments in addition to financial incentives for smoking abstinence.

Participants could earn up to $150 through weekly incentives if they were not smoking during the first several weeks after a quit attempt. The incentives started at $20 and increased by $5 each week, and there were additional $50 booster payments for smoking cessation at eight- and 12-week follow-ups. To verify that they had quit smoking, participants were required to blow into a carbon monoxide monitor. Twenty-six weeks after the start of the trial, an estimated 23.5% of participants receiving financial incentives were smoke-free, compared to 12.1% of those who did not receive incentives.

"People may be motivated to quit smoking because of the financial incentive, which can also increase their motivation to complete their counseling sessions and take their medication as directed," she said. "Incentivizing early success can potentially increase people's self-efficacy for quitting. People may be ambivalent about quitting smoking, or they may not be sure they will be able to quit. But when there's an incentive on the line and people have some initial success, that success can build from week to week. Incentives can also help people get back on track. When people lapse and restart smoking, they might be more likely to try to quit again because an incentive is available the next week."

Although the clinical trial began in 2017 before the arrival of COVID-19, it continued until 2022, two years into the pandemic. Study results reflect the upheaval caused by the pandemic: People in the incentivized group who participated in the trial before COVID-19 arrived had much higher cessation rates than those in the same group whose participation began after COVID-19.

"It was much harder for people to quit smoking during the worst time of the pandemic, and we had more attrition during that time as well," Kendzor said. "If this study had finished before COVID-19, we might have had even higher rates of cessation."

Efforts are underway to translate the study's findings to cessation strategies available to the public at large. Kendzor is collaborating with the Oklahoma Tobacco Settlement Endowment Trust (TSET), which funds the Oklahoma Tobacco Helpline (1-800-QUIT NOW), to evaluate and implement financial incentives for people calling the helpline. TSET is the state grantmaking trust established by voters in 1998 with payments from the Master Settlement Agreement with tobacco companies. In 2000, Oklahoma became the first state where residents voted to constitutionally protect the funds for the prevention of cancer and cardiovascular disease.

Kendzor is also enrolling participants in a new study to compare the same treatments with and without financial incentives, but, this time, delivered through a smartphone app. Participants will complete counseling by phone and receive nicotine replacement therapy in the mail. A portable carbon monoxide monitoring device will be connected to their phones to verify smoking cessation, and facial recognition will confirm their identity. Incentives will be added to participants' credit cards.

"In our newly published study, we worked with Oklahomans who could come into the clinic, but that is a huge barrier for some people," she said. "We can reach a much broader range of people in the new study that uses smartphone-delivered treatment. Because the majority of people have smartphones, we believe that approach, combined with incentives, can bypass some of the obstacles that people face and help them reach their goals of tobacco cessation."