More than 50 years after the release of the first Surgeon General’s report on the harmful effects of smoking, national policies, behavioral programs, and pharmacologic approaches have helped reduce smoking rates in the United States. However, the need for new approaches is clear because smoking remains the leading cause of preventable illness and death.

So begins a big paper from The New England Journal with a simple aim: getting people to butt out. It raises two important questions: If we are serious about promoting smoking cessation, are we willing to put ‘our money where our mouth is’ – literally? And how could we do this?

“Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation” by Dr. Scott D. Halpern et al. is this week’s Reading; it has just been published.

Though other papers have been written on this topic, the Halpern et al. paper is clever and interesting – and the results are surprising.

And, don’t tell the editors of The New England Journal of Medicine: the results are also disappointing.

Dr. Scott D. Halpern

This isn’t the first Reading in 2015 considering tobacco use. Back in February, we looked at the British Journal of Psychiatry paper where pregnant women were offered financial incentives to stop smoking.

Why two Readings on this topic in a handful of months?

First, despite the incredible progress of the past five decades, as The New England Journal of Medicine paper notes, smoking rates remain unacceptably high. Despite the education campaigns, the taxes and the regulations, nearly one in six Canadians still smoke. Smoking remains a public health disaster.

Second, behavioural economics is all the rage. Back in 2008, Richard Thaler and Cass Sunstein caused a stir with their book, Nudge: Improving Decisions about Health, Wealth and Happiness. In it, they argue that people could be “nudged” into better decisions with simple incentives. President Barack Obama appointed Sunstein to his administration; British Prime Minister David Cameron urged his staff to read Nudge. But if Tahler and Sunstein caused a stir, there is the larger question: is behavioural economics, well, relevant with real issues, like smoking?

Cass Sunstein

What makes this paper particularly interesting is that Halpern et al. try out different behavioural economic approaches to smoking cessation – four different programs designed to incentivize (and penalize) decisions.

What they did:

· 2,538 people were randomly assigned to one of five groups.

· Some were assigned to the usual care (smoking cessation resources and, for those with company health benefits, behavioural-modification and nicotine-replacement therapy).

· The rest were assigned to one of four programs, all offering up to $800 for cessation. But the organization of the programs was fundamentally different.

· Reward programs. There were two types. Individual-reward: people received $200 at several time points, 14 day, 30 day and 6 months, with a bonus of $200 at 6 months. Collaborative-reward: groups of six were given $100 at each time point for each member that quit (and a web-chat room encouraged communication among group members).

· Deposit programs. Individual-deposit: $800 would be given out including a $150 deposit (but that deposit was lost if smoking started again). Competitive-deposit: $150 deposit for each of the six group members plus $450 per member was distributed at each time point but rewards could be stopped depending on group behaviour (like several members smoking) – think Survivor means cessation.

· Saliva samples were used to confirm smoking status, except for people on nicotine-replacement, who took urine tests.

What they found:

· Compared to the reward programs, many fewer people enrolled in the deposit programs. Actually, the acceptance rate was so low that the protocol had to be reworked. (!)

· Overall, just over 51% accepted the intervention (that is, joined a program) – but the two reward-based incentive programs had high acceptance (90%) compared to the deposit-based programs (13.7%).

Acceptance Rates of Financial-Incentive Structures


· All four programs yielded higher abstinence rates than the usual care.

· Interestingly, while people hesitated about the deposit programs, those who enrolled did better at cessation than those who chose the incentives programs.

Rates of Sustained Abstinence from Smoking at 7 and 12 Months after Quit Target Time


The authors open the discussion with these comments:

In this large randomized trial across the United States, we found that four different incentive programs with expected values of $800 were each effective in promoting sustained abstinence from smoking. 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.

What would Sunstein think about Halpern et al.’s paper?

In fact, Sunstein pens an accompanying editorial, “Nudging Smokers.” He writes:

In the past 40 years, we have seen a revolution in thinking about thinking. The central idea is that human beings depart, in systematic ways, from standard economic approaches to rationality. Because the departures are systematic and predictable, they can be taken into account by researchers, clinicians, and others who want to improve health and reduce premature mortality.

Behavioral scientists have shown, for example, that people are “loss averse”; they tend to dislike losses more than they like corresponding gains. A 5-cent tax on the use of a grocery bag is likely to have a much greater effect than a 5-cent bonus for bringing one’s own bag.

This study demonstrates that point. After all, the deposit programs were much less attractive to people – but much more effective.

Sunstein observes:

Halpern et al. ended up demonstrating the importance of loss aversion in two different ways. The more obvious is that smokers are far more likely to quit if they stand to lose money if they fail. The more subtle is that the very prospect of incurring losses makes people far less willing to enter a smoking-cessation program. Despite the greater comparative effectiveness of the deposit program, the reward program is likely to be more successful, because far more people will sign up for it.

A few thoughts:

1. This is a very cool study, comparing different incentive/penalty programs directly.

2. There are clear policy implications here – for large employers, yes, but also for governments.

3. There is good news here: with proper incentives, smoking cessation rates are triple the usual care.

4. There is bad news here: the results are also disappointing. Despite the money spent, at 12 months, nearly half of smokers who quit at 6 months lapsed back into smoking.

Picking up on that last point, Sunstein wonders about a more elaborate system of incentives, perhaps stretching for 12 months. In the end, I wonder though if we have simply reached the limits of behavioural economics.

Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.