Financial incentive programmes for the promotion of smoking cessation

Smoking remains the largest preventable contributor to morbidity and mortality, resulting in over 8 million deaths globally per year. While effective cessation supports including counselling and pharmacotherapies are available, quit rates are stagnating and approximately one third of people who currently smoke do not desire to ever quit. Financial incentive (FI) programmes have been increasingly investigated as a method of promoting health behaviour change and motivating engagement with services or supports. When applied to behaviours including smoking cessation, current literature suggests incentives are efficacious. Yet key questions about these programmes remain. These questions include which real-world settings programmes could be implemented in, and clarification of the impact of programme design – including the incentive amount – on effectiveness and uptake.
I herein describe a series of studies investigating questions important for a more complete understanding of incentive programmes. Two chapters explore novel settings wherein FI programmes may be feasible, first by integrating a FI programme into regional and rural community pharmacies, and second through combining the offer of free pharmacotherapy with Quitline support. The three further chapters discuss research which investigated the impact of the programme design, particularly the incentive amount, on effectiveness and potential uptake. This first involved a review of previous FI programmes, and subsequently incorporated experimental work with hypothetical decision-making tasks and modelling of programme uptake across FI amounts.
The first study in this series suggests implementing an FI programme within regional and rural community pharmacies could encourage quit attempts and point-prevalence abstinence (Chapter 3). Feasibility information suggested good interest in, and potential uptake of, the programme, although some retention issues were identified. Qualitatively, participants found the programme beneficial, were motivated by the offer of incentives, and valued the support and accountability to abstain from smoking engendered by pharmacy staff. Overall, findings indicate a novel setting wherein implementation may be beneficial and feasible.
Within the second study, free nicotine replacement therapy (NRT) was offered in conjunction with Quitline support (Chapter 4). Although this study was intended to have an active control group, recruitment issues were encountered. The treatment arm was therefore compared to a historical control group comprised of Quitline callers who received standard Quitline support within the previous year. The offer of free NRT with Quitline support resulted in a greater number of quit attempts being made and a greater proportion of participants using NRT than was observed when offering Quitline support alone.
Chapters 3 and 4 focused on embedding incentives programmes into existing settings. This work highlighted that more information on how to best design programmes is necessary, particularly regarding how much incentives should be for when financial rewards are used. Therefore, studies in Chapters 5 to 7 relate to the impact of the design of programmes including the FI amount, whether higher monetary amounts are superior at producing outcomes, and if the influence of the programme designs differs by recipient income.
The idea higher FI amounts may better promote smoking cessation was first investigated through a review of previous incentive programmes (Chapter 5). No support for an association between FI amounts and quit rates was observed. However, understanding of this relationship was complicated by the ubiquitous variations in previous programme designs, including the populations targeted. Insufficient information was available to consider potential difference between income groups. Unfortunately, the variations in previous programme designs means consideration of optimal amounts may not be viable through review methods.
An experimental approach to investigating FI amounts was adopted in subsequent work to minimise and/or quantify the impact of other programme design characteristics. Responses to hypothetical incentive programmes and growth models suggested people who currently smokes’ perceptions of FI programmes (e.g., the programme appeal and potential uptake rates) increase in a concave quadratic manner as the FI amount increases (Chapter 6). A ceiling point beyond which increasing the FI amount did not improve perceptions was observed at £50-75/week (£500 to £750 total across the programme: AUD$896 to $1340). Findings further suggest that although high-income people who currently smoke may not perceive FIs to be as appealing as other income groups, they appear equally willing to enrol.
The final study used a discrete choice experiment to consider FI amounts in relation to other programme design attributes (Chapter 7). People who currently smokes’ preferred incentives of higher monetary amounts, paid in cash, with a consistent amount offered for abstinence at each session. Providing sessions once per week in healthcare settings was most preferred. An increasing quadratic trend in estimated enrolments across FI amounts was again observed, with the pattern largely consistent across several design options. This provides further evidence the association between amounts and potential uptake is non-linear and that a ceiling point in FI amounts might exist. Results indicated programme designs influenced hypothetical enrolment decisions equivalently between income groups.
Overall, the findings from this thesis highlight two novel settings wherein embedding incentive programmes into existing health settings may be feasible. Further, while higher amounts may increase predicted enrolments, this relationship is likely non-linear and will contain a peak FI amount. Within this thesis, this peak amount was at approximately £50 to £75 per week, suggesting increasing the FI amount beyond this point may not better encourage uptake. Income level may influence some perceptions of programmes but was not observed to impact estimated enrolments. These findings are applicable to researchers, policymakers, and others interested in the use of incentives, providing indications of feasible implementation areas, and developing understanding of the impact of programme design, particularly the FI amount. Future work will be necessary to extend understanding of incentive effectiveness in the highlighted locations, examine the identified amounts and designs under more realistic decision-making conditions, and consider the acceptability of designs among providers and policymakers.