Abstract
BackgroundTobacco smoking is the leading avoidable cause of death in high-income countries. The smoking-related disease burden is borne primarily by the least educated and least affluent groups. Thus, there is a need for effective smoking cessation interventions that reach to, and are effective in this group. Research suggests that modest financial incentives are not very effective in helping smokers quit. What is not known is whether large financial incentives can enhance longer-term (1 year) smoking cessation rates, outside clinical and workplace settings.Trial designA randomized, parallel groups, controlled trial.MethodsParticipants: Eight hundred low-income smokers in Switzerland (the less affluent third of the population, based on fiscal taxation).Intervention: A smoking cessation program including: (a) financial incentives given during 6 months; and (b) Internet-based counseling. Financial rewards will be offered for biochemically verified smoking abstinence after 1, 2, and 3 weeks and 1, 3, and 6 months, for a maximum of 1,500 CHF (1,250 EUR, 1,500 USD) for those abstinent at all time-points. All participants, including controls, will receive Internet-based, individually-tailored, smoking cessation counseling and self-help booklets, but there will be no in-person or telephone counseling, and participants will not receive medications. The control group will not receive financial incentives.Objective: To increase smoking cessation rates.Outcome: Smoking abstinence after 6 and 18 months, not contradicted by biochemical tests. We will assess relapse after the end of the intervention, to test whether 6-month effects translate into sustained abstinence 12 months after the incentives are withdrawn.Randomization: Will be done using sealed envelopes drawn by participants.Blinding: Is not possible in this context.DiscussionSmoking prevention policies and interventions have been least effective in the least educated, low-income groups. Combining financial incentives and Internet-based counseling is an innovative approach that, if proven acceptable and effective, could be later implemented on a large scale at a reasonable cost, decrease health disparities, and save many lives.Trial registrationCurrent Controlled Trials ISRCTN04019434.
Highlights
Tobacco smoking is the leading avoidable cause of death in high-income countries
Intervention: A smoking cessation program including: (a) financial incentives given during 6 months; and (b) Internet-based counseling
A strong body of research shows that both participation in addiction treatments and the outcome of these treatments are enhanced by financial incentives [5,6,7,8]
Summary
Tobacco smoking is the leading avoidable cause of death in high-income countries. The smoking-related disease burden is borne primarily by the least educated and least affluent groups. To reduce smoking-related health disparities, it is important to design effective smoking cessation programs that reach to low-income smokers. Since this group may be harder to reach with traditional information and education interventions [3,4], other approaches need to be explored. Giving financial incentives may offset these decision errors and encourage healthy behaviors [5,9] This approach is seldom used, often because of moral considerations (‘people should not be paid to do what they ought to do by themselves’), or due to the assumption that relapse will occur when the rewards are stopped. Because of the high costs, both material and human, that smoking imposes on society [10], serious consideration must be given to any approach that may effectively and cost-effectively encourage smoking cessation
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