In helping smokers quit, cash is king, e-cigarettes strike out

"Smoking remains the leading cause of preventable deaths in the United States, and nearly all large employers offer wellness programs aimed at getting people to quit. But, these programs vary considerably, and to date, there has been little evidence to suggest which designs and strategies are most effective," said lead author Scott D. Halpern, MD, PhD, an associate professor of Medicine, Epidemiology, and Medical Ethics and Health Policy, and a member of the Steering Committee of the Penn Center for Health Incentives and Behavioral Economics (CHIBE). "The new study drives forward previous research by showing that even among smokers who are not cherry picked on the basis of their motivation to quit, financial incentives still triple quit rates, whereas offering free conventional cessation aids or free e-cigarettes accomplishes nothing at all."

The study enrolled more than 6,000 participants from across 54 U.S.-based companies. Participants were assigned to one of four smoking cessation intervention groups or usual care (consisting of access to information regarding the benefits of quitting smoking and a motivational text-messaging service). Smoking cessation interventions included usual care plus one of the following: free e-cigarettes, in flavors of participants' choosing; free cessation aids (nicotine patches, gum, and other medications, with free e-cigarettes only available for participants who've tried standard therapies previously); free cessation aids plus $600 in rewards for sustained abstinence from smoking; or free cessation aids plus $600 in redeemable funds, which were deposited in an account for each participant and removed if smoking cessation milestones were not met.

The study found that overall, only 1.3 percent of participants remained smoke-free for at least six months. However, the quit rates for redeemable deposits were significantly higher than with free cessation aids or with free e-cigarettes, and the quit rate for the rewards group was also higher than for cessation aids. By contrast, no differences were found in the quit rates among participants assigned to free e-cigarettes, free cessation aids, or usual care.

Of the more than 6,000 participants enrolled in the trial, 1,191 actively engaged with their assigned program. Those engaged in the trial were more motivated to quit, making them similar to smokers enrolled in prior studies that only enrolled participants who expressed an active interest in quitting. These motivated smokers were four to six times more likely to stay smoke-free for six months after the target quit date compared to those who did not actively engage. The authors say the quit rates observed among these engaged participants are consistent with those found in prior studies of incentives among motivated smokers. However, in the new study, even among these engaged participants, neither free e-cigarettes nor free cessation aids produced higher quit rates than usual care.

"Knowing that offering free e-cigarettes does not help smokers quit should inform the policies being deliberated at the FDA regarding whether or how to regulate e-cigarettes," Halpern said. "The result is concerning because it suggests that e-cigarettes may do more harm than good." A study by the National Academy of Science, Engineering, and Medicine concluded earlier this year that if e-cigarette use by adult smokers does not "lead to long-term abstinence from combustible tobacco cigarettes," then "e-cigarette use could cause considerable harm to public health in the short- and long-term."

Additional results of the study showed that the overall costs of the programs per participant who remained smoke-free for at least six months was lower in the financial incentives groups than in either the free e-cigarettes or cessation aids groups. "One of the key virtues of incentive programs is that they only cost money if people succeed in changing their behavior," said senior author Kevin Volpp, MD, PhD, director of CHIBE, and chief of the division of Health Policy in Penn's department of Medical Ethics and Health Policy. "By contrast, employers that offer free cessation aids to their employees are paying money whether or not the aids help the smokers quit."

"It's estimated that it costs employers anywhere from $3,000 to 6,000 more per year to employ a smoker over a non-smoker, making the initial financial investment in smoking cessation programs well worth the cost," Volpp noted.

In addition to having a large sample size, the authors say having participants from 54 different companies suggests the results may be generalizable to most workplace settings. Additionally, because nearly everyone who was identified as a smoker at these companies was enrolled automatically, the results are more indicative of the real-world effects employers can expect when offering these programs to all employees who smoke, compared with prior studies that only enrolled people who were already motivated to quit.