American Journal of Preventive Medicine
ArticleWorksite-Based Incentives and Competitions to Reduce Tobacco Use: A Systematic Review
Introduction
Tobacco use remains the leading preventable cause of death and illness in the U.S.1 Helping tobacco users to quit is one important goal of a comprehensive prevention effort, along with preventing initiation and exposure to secondhand tobacco smoke, to reduce morbidity and mortality associated with tobacco use.2 Approximately 70% of tobacco users want to quit,1 and efforts to quit are frequent, even if frequently unsuccessful. Of the 36.3 million adults who remained current, daily smokers in the U.S. in 2006, 19.9 million (44.2%) had stopped smoking for at least 1 day in the previous year because they were trying to quit.3 In clinical settings, a number of evidence-based interventions and therapies have been demonstrated to motivate and support tobacco-using patients in their efforts to quit.4 Interventions designed to motivate and assist the cessation efforts of tobacco users are also important options for health promotion efforts in most community settings, including worksites.
Because employee populations use tobacco products in roughly the same proportions as the adult population as a whole and because many adults spend the majority of their day in a workplace environment, worksites are viable places to conduct health promotion activities. As noted by others,5, 6, 7, 8 the worksite provides a number of advantages as a setting for health promotion interventions, including (1) accessibility to a large and rather stable population, which provides the potential for achieving intervention exposure; (2) the potential for adequate or enhanced promotion, recruitment, and participation in comparison to non-worksite environments; and (3) the potential for reinforcing social support networks and peer influences among co-workers.
The negative health effects and associated costs of tobacco use by employees are substantial, including both the direct costs (such as healthcare costs) as well as indirect costs (including lost productivity, absenteeism, and the recruitment and retraining of replacement workers).9 The health benefits of tobacco-use cessation include a rapid reduction in the additional risks for cardiovascular disease and a more gradual reduction in the additional risks for a variety of cancers.10 When the onset of disease and premature death can be prevented, it is generally accepted that some of the costs associated with treatment of the diseases can also be prevented or at least substantially reduced.5
Incentives and competitions to reduce tobacco use represent one intervention option for consideration by worksite health promotion programs. Alone or as part of a coordinated program, incentives and competitions can contribute to cessation efforts among workers by (1) increasing or improving motivations to quit; (2) increasing or improving action to quit; and (3) increasing or improving maintenance of an effort to quit. Incentives and competitions may be effective in increasing one or more of these pathways for an individual tobacco user. In addition, participation might prompt the individual to make use of new or existing cessation support resources offered within the workplace, through the workplace (such as a healthcare cessation benefit), or in the community. For a designated population (at a worksite or within a workforce), effectiveness of incentives or competitions within a cessation program would be demonstrated by a reduction in the number of baseline smokers who continue to use tobacco (i.e., fewer tobacco product users). The objective of this set of reviews is to examine the evidence on effectiveness of incentives and competitions, alone or when combined with additional interventions, in increasing the cessation of tobacco use among workers.
The systematic reviews in this report present the findings of the independent, nonfederal Task Force on Community Preventive Services (Task Force). The Task Force is developing the Guide to Community Preventive Services (Community Guide) with the support of the USDHHS in collaboration with public and private partners. The CDC provides staff support to the Task Force for development of the Community Guide. The book, The Guide to Community Preventive Services. What Works to Promote Health?11 (also available at www.thecommunityguide.org) presents background and the methods used in developing the Community Guide.
The interventions reviewed here may be useful in reaching several objectives specified in Healthy People 2010.12 These include objectives to:
27-1 Reduce cigarette smoking among adults (aged ≥18 years) from 24% (1998, age adjusted to Year 2000 standard population) to 12%
27-5 Increase the percentage of adult smokers (aged ≥18 years) stopping smoking for 1 day or longer because they were trying to quit from 43% (1998, age adjusted to Year 2000 standard population) to 75%
Section snippets
Methods
This review was conducted according to the methods developed for the Community Guide, which have been described in detail elsewhere.13, 14 Inclusion criteria for this review were: (1) primary research published in a peer-reviewed journal; (2) published in English in the period 1980 to February 2009; (3) met the minimum research quality criteria for study design and execution;13 and (4) evaluated the effects of worksite-based incentives and competitions, alone or in combination with other
Review of Evidence: Worksite-Based Incentives and Competitions When Implemented Alone to Reduce Tobacco Use
Worksite-based incentives and competitions to reduce tobacco use among workers offer rewards to individual workers and to teams as a motivation to participate in a cessation program or effort. Rewards can be provided for participation, for success in achieving a specified behavior change (such as abstaining from tobacco use for a period of time), or for both. In this review, the types of rewards evaluated included guaranteed financial payments, lottery chances for monetary or other prizes, and
Conclusion
According to Community Guide rules,13 there is insufficient evidence to determine whether or not worksite-based incentives and competitions alone are effective in reducing tobacco use among workers. Evidence was considered insufficient because no studies qualified for consideration in this review, and only one study of least suitable design was identified.
Conclusion
According to Community Guide rules,13 there is strong evidence that worksite-based incentives and competitions, when combined with additional interventions to support individual cessation efforts, are effective in reducing tobacco use among workers. The qualifying studies included a variety of intervention combinations. For the subset of studies that consisted of multicomponent efforts that combined incentives with worksite-based cessation groups and additional educational activities or
Discussion
The studies included in this review evaluated the impact of incentives and competitions when combined with additional interventions designed to motivate and support cessation efforts by tobacco-using workers. This review included evidence from worksite-based cessation programs only and did not include studies that evaluated the use of these interventions in other settings such as healthcare systems (for patients) and communities (such as community-wide smoking cessation contests).
Summary
The Task Force on Community Preventive Services has reviewed the evidence on effectiveness of a number of interventions that practitioners can use to achieve the Healthy People 2010 “Objectives for Tobacco Use.”12 In this article, the team reported results from a systematic review of worksite-based incentives and competitions to reduce tobacco use. There was insufficient evidence to draw a conclusion regarding the effectiveness of worksite-based incentives and competitions when implemented
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