The effect of financial incentives on top of behavioral support on quit rates in tobacco smoking employees: study protocol of a cluster-randomized trial

Tobacco use is a major health threat and responsible for deaths due to cancer, chronic obstructive pulmonary disease (COPD), coronary heart disease, stroke and heart failure [1]. The life expectancy for smokers is at least 10 years shorter than for nonsmokers [1, 2]. Not only is smoking a serious health risk, it is also responsible for an estimated 8.7 % of annual healthcare costs in the US [3]. Employees who smoke also represent a significant cost to their employers [4]. These costs can be distinguished as the cost due to sickness absenteeism and the cost due to smoking breaks. Smokers are about 1.5 more days per year absent from work than non-smokers [5, 6]. Smoking is associated with absenteeism [5, 7], and with reduced performance [8, 9]. The amount of time that employees spend smoking each workday depends on several factors, such as the number of smoking breaks and whether the employee has to go outside to smoke. An employee who works fulltime and takes four smoking breaks of ten minutes per day spends about 150 (work) hours per year on smoking. It was estimated that in the US, employees who smoke cost their employer an excess of $5816 per smoker per year [4]. On the other hand, when employees quit smoking, their absenteeism declines within several years [5]. In addition, the productivity of former smokers is higher than that of current smokers [5]. It is therefore profitable for employers to invest in smoking cessation both from a company perspective as well as from a societal viewpoint.

An approach in stimulating employees to stop smoking is to use incentives for quit success. The rationale behind incentives for healthy behavior is twofold. Firstly, people value present benefits and costs more than future ones [10]. Secondly, people are more motivated by tangible gains such as a financial benefit, than by long-term intangible gains like a reduction in the chance of negative health outcomes. These two irrational ‘decision biases’ can be used to nudge people toward healthy behavior that is beneficial for them in the long run [11]. An incentive in the form of money or vouchers can be the immediate, concrete reward which can motivate people to stop smoking.

Several studies have shown that financial incentives for smoking cessation success can be an effective method to stimulate smoking cessation [12‐18]. For instance, incentives have proven to be successful in increasing continuous abstinence in pregnant women [15], in homeless smokers [16], and in substance abusers [17]. A long-term study by Volpp et al. [18] conducted in the United States involved 878 participating employees of a multinational corporation. Participants were given the opportunity to follow behavioral counseling for smoking cessation near their hometown and, if desired, in combination with pharmacological treatment. Both behavioral counseling and medication were fully reimbursed by the employer. Participants in the intervention group received an incentive of $100 for completing a smoking cessation program, $250 for smoking abstinence at 6 months after study enrollment, and $400 for smoking abstinence at 12 months after study enrollment. Participants in the intervention group (with incentive) were significantly more likely to be completely abstinent after 6, 12, and 15 months than in the control group. Furthermore, participants in the intervention group were more likely to have started a smoking cessation program and to have completed the program. While incentives thus can motivate smokers to enroll in a cessation program, only few participants in the Volpp study [18] actually did enroll (incentive group 15.4 % vs control group 5.4 %). Importantly, the rate of quitters was substantially higher in participants from the incentive group who participated in the smoking cessation program than participants from the control group who enrolled in the training (46.3 % vs 20.8 %). It is therefore likely that the combination of an effective smoking cessation program with incentives for quit success will prove to be the most effective in increasing smoking cessation rates.

The chance to quit successfully increases when people receive professional stop smoking support [19]. Yet, smoking cessation treatment is relatively expensive for people with low incomes and the cost of medication can be a barrier [20]. Since a lower income is also related to a higher smoking prevalence [21], it is particularly important to make smoking cessation counseling accessible for people with lower incomes. If smoking cessation therapy is fully reimbursed, more smokers will make use of it which can lead to twice as many long term quitters [22, 23]. It is therefore conceivable that smokers are more willing to start a smoking cessation treatment when their employer accounts for the costs. For a smoking cessation training combined with incentives to be widely adopted by commercial companies as a common smoking cessation intervention, it needs to be cost-effective. To our knowledge, no study that has investigated the effect of incentives on long-term smoking abstinence in a workplace setting has incorporated an economic evaluation. We are only aware of a randomized controlled trial in pregnant women which found that incentives of 400 pounds were highly cost-effective [24]. Smoking cessation training in combination with incentives might therefore be attractive to employers in light of employee health improvement but also from a cost saving perspective.

The proposed study: “Continuous Abstinence Through Corporate Healthcare” (CATCH) is conducted in Dutch companies. Currently, about a quarter of Dutch adults smoke. Smoking prevalence is much higher among low (28 %) and moderate educated adults (27 %) than among high educated adults (19 %) [25]. This socioeconomic difference has been increasing over time in the Netherlands [26]. The higher prevalence of smoking in individuals from lower socioeconomic groups is the single most important cause of socioeconomic differences in mortality [27, 28]. In order to decrease these differences, it is vital to specifically target the lower socioeconomic population.

The aim of this study is to investigate whether financial incentives combined with a smoking cessation training can improve quit success. In addition, an economic evaluation is conducted to assess the costs and benefits of this intervention. The results of this study can provide key evidence for the applicability and effectiveness of incentives for smoking cessation and can offer recommendations for implementing incentives to reduce employee smoking in a corporate context.

The primary aim of this study is to evaluate whether adding a financial incentive (compared with no additional incentive) is effective and cost-effective in increasing 12-month continuous abstinence rates in tobacco smoking employees participating in a smoking cessation group training. A secondary aim is to investigate the effect of the incentive on the quit rate immediately after the training, after three and after six months. Furthermore, this study investigates the cost-effectiveness of the incentive in terms of quit rate and utilities, both from a societal perspective and from the employer’s perspective.

A cluster-randomized controlled trial is conducted in 44 Dutch companies who offer their employees an evidence-based treatment for smoking cessation. Participants from the intervention companies receive incentives when smoking abstinence is achieved at a fixed time schedule (Fig. 1), whereas participants from the control companies do not receive incentives (care as usual).

This paper presents the protocol of the intervention study “Continuous Abstinence Through Corporate Healthcare” (CATCH). The aim of the study is to investigate the effectiveness of incentives on continuous abstinence in employees. A total of 516 employees, divided over 22 control and 22 intervention companies participate in a cluster-randomized controlled trial. In both groups, participants follow a seven-week smoking cessation program. In the intervention group, employees additionally receive vouchers for cessation success up to a total value of 350 euro. It is hypothesized that employees in the incentive group achieve a higher 12-month continuous abstinence rate.

The proposed study is the first in the Netherlands that investigates the effect of financial rewards on smoking cessation and the first study worldwide that assesses the cost-effectiveness of incentives to decrease smoking in employees. The results of this study can provide important recommendations for the use of financial incentives to motivate employees to quit smoking.