To make smokers healthy, it helps to make them wealthy, study finds

Would the promise of an $800 payout motivate you to quit smoking? And if so, what’s the most effective way to dangle that reward?

Researchers from the University of Pennsylvania sought to answer those questions, with help from more than 2,500 smokers who either worked for CVS Caremark or were their family members or friends.

They found that financial incentives greatly improved the odds of kicking the habit. Compared with a control group that was offered “usual care” – including smoking cessation guides from the American Cancer Society and referrals to local anti-smoking resources – those who also were offered the prospect of a payday were far more likely to be smoke-free six months after their quit dates. The researchers also discovered that the type of incentive offered could make a big difference in a smoker’s chances of success, according to their report published Wednesday by the New England Journal of Medicine.

Altogether, the researchers tried four types of incentive programs, which tested different combinations of features.

One of their goals was to see whether smokers did better on their own or if they were more motivated to quit when they were part of a group. After all, people on a team might encourage one another to succeed (or at least work extra hard to make sure they’re not holding the others back).

The other aim was to compare simple rewards with more sophisticated programs that required would-be quitters to put some of their own money on the line. Researchers in the field of behavioral economics have shown that people care more about avoiding losses than they do about receiving a windfall-style gain.

The researchers mixed and matched these features to create their four incentive systems. Smokers in the individual reward programs were able to earn $200 if they were smoke-free two weeks after their quit date. They could earn another $200 for remaining smoke-free for 30 days and $400 for staying off cigarettes for six months. Those who were testing the value of putting their own money on the line had to contribute $150 of this reward money.

The people in the group reward programs were divided into six-member teams. Some of those teams tested a “collaborative-reward” design, with payments made at the same time intervals. However, the more team members that were smoke-free at each milestone, the greater the payment to each of them.

The last incentive system was the “competitive-deposit” design. In this scenario, each smoker contributed $150 from their own pockets, which was pooled with reward money provided by the researchers. At each of the three milestones, those who had refrained from smoking split a $1,200 take. In addition, those who were still smoke-free at six months got a $200 bonus.

All of the rewards programs worked — but some of them worked better than others.

People who had their own skin in the game had the greatest odds of success. Among those who were willing to make a $150 deposit that they could earn back by remaining smoke-free, the quit rate at six months was 52%. That blew away the 17% quit rate for those didn’t put up any of their own cash. It also bested the 6% quit rate for those in the control group who only got usual care.

But the researchers said it’s not clear that the skin-in-the-game approach was the best way to go. Though the results were much better, smokers were far less likely to give it a try. Only 14% of the study participants assigned to a deposit-based program were willing to fork over their money. In comparison, 90% of those who didn’t have to shell out agreed to participate in their part of the experiment.

When the researchers took this into account, the success rate for the simple reward systems beat out the success rate for the deposit systems by margin of 16% to 10%. That was a statistically significant difference, the study authors wrote.

On the other hand, the researchers found no significant difference between the reward systems designed for individuals (which had a 12% success rate) and for groups (which had a 14% success rate).

The Penn researchers concluded that simply paying smokers to quit was the most “effective” way to go because people were so much more willing to give it a try. But it’s possible that a buy-in program could work better if the price tag were lower than $150. Finding an ideal amount that’s not too steep to scare people off but still high enough to motivate smokers to earn it back should be the subject of future studies, they wrote.

In the meantime, if companies like CVS Caremark — which made headlines for its decision to remove tobacco products from its stores — wish to encourage their employees quit smoking, any of these programs would be worth implementing. Although they cost $800 per successful quitter, that’s cheap compared with the $5,816 in additional healthcare costs that employers pay for each smoker on their payroll, according to the study.

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