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Competitions and incentives for smoking cessation

  1. Kate Cahill*,
  2. Rafael Perera

Editorial Group: Cochrane Tobacco Addiction Group

Published Online: 13 APR 2011

Assessed as up-to-date: 23 NOV 2010

DOI: 10.1002/14651858.CD004307.pub4


How to Cite

Cahill K, Perera R. Competitions and incentives for smoking cessation. Cochrane Database of Systematic Reviews 2011, Issue 4. Art. No.: CD004307. DOI: 10.1002/14651858.CD004307.pub4.

Author Information

  1. University of Oxford, Department of Primary Health Care, Oxford, UK

*Kate Cahill, Department of Primary Health Care, University of Oxford, 23-38 Hythe Bridge Street, Oxford, OX1 2ET, UK. kate.cahill@phc.ox.ac.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 13 APR 2011

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Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

Competitions and incentives routinely feature in many smoking cessation programmes, in support of the quitting process. They are used either to encourage recruitment into the programme, or to reward cessation achieved at predefined stages.

There is a growing enthusiasm within the UK for incentive-based programmes to change unhealthy behaviours (NICE 2010). In 2007, the Tayside area of Scotland launched an incentive scheme for pregnant smokers, called 'Give It Up For Baby', in which grocery vouchers to the value of £12.50 per week were awarded for verified abstinence (Ballard 2009). While the interim report confirms that 140 women stopped smoking in the first year of the programme, the long-term validity of such initiatives for smoking cessation, especially once the rewards are withdrawn, remains to be determined.

A variety of rewards have been used for these purposes, including cash payments, salary bonuses, promotional items such as T-shirts, pens and bags, lottery tickets, raffles, holidays, and luxury goods such as cars or boats. Rewards can be given for attendance, irrespective of subsequent performance (i.e. guaranteed), or can be paid and scaled relative to the participant's success within the programme (i.e. contingent). Some workplace initiatives have operated a policy of disincentives, whereby employees have payments deducted for non-compliance with a smoking policy, but this is less frequently used than a system of positive rewards.

Workplaces
The workplace is a common setting for use of competitions and incentives. This is briefly addressed in a companion review from the Tobacco Addiction Group (Cahill 2008a), but we explore it more fully here. Most of the relevant studies have been conducted in the United States of America (USA), in part because of the structure of the healthcare system there, which obliges employers to cover health insurance costs for their workforce. In other countries, where the state or private insurance companies are the main healthcare provider, there may be less tangible incentive for employers to take direct responsibility for the health of their workers.

There are a number of advantages to offering smoking cessation support in the workplace, including the accessibility of the target population, the availability of occupational health support and the potential for peer pressure and peer support. Because of the existing salary and bonus structure, it is also relatively easy to set up a rewards system to supplement the programme, if that is the chosen mechanism. There are a number of smoking cessation studies in which groups are encouraged to compete against each other, either within a single workplace or between workplaces, often for material prizes as well as for financial incentives. More usually rewards are offered for individual participation or cessation, or both.

Communities
Quit and Win contests, and similar population-based initiatives, are examined in a companion review by the same authors (Cahill 2008b).

Participation
Some studies have tested incentives as a way of increasing participation in smoking cessation programmes. While this may be an effective method of boosting enrolment, any enhanced participation rate that incentives may deliver also must also be weighed against the stability of the long-term quit rates that are achieved. Incentives may also lead to increased rates of deception, either by participants falsely claiming to be abstinent, or by non-smokers taking part and then claiming to have quit. Individuals who elect to take part in a cessation programme that offers material rewards may be differently motivated from those who sign up to more conventional cessation methods, and this may be reflected in differential relapse rates.

Cost effectiveness
The use of rewards and incentives increases the costs of running smoking cessation programmes. Tobacco control programmes need to assess whether the outlay is justified by the benefits that the component delivers. In other words, how many more quit attempters will join a programme that rewards their participation, and how much, if at all, is the quit rate enhanced by the end of programme follow up?

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

To assess the effects of competitions and incentives as aids to smoking cessation. We addressed the following questions:
Cessation:
1. Do competitions, contests and incentives reduce the prevalence of smoking and relapse?
2. Does the amount and type of incentive affect cessation and relapse prevention?

Recruitment:
3. Do incentives improve recruitment to smoking cessation programmes, both within the community and within the workplace?
4. Does the amount and type of incentive affect recruitment?

General:
5. What are the cost implications, to employers and to the community, of incentives and competitions?
6. Are incentives and competitions more or less effective in combination with other aids to recruitment, cessation and relapse prevention?
7. How great is the risk of disbenefits arising from the use of competitions and incentives, e.g. false claims, ineligible applicants?

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Criteria for considering studies for this review

 

Types of studies

Randomized controlled trials allocating individuals, communities, workplaces or groups within workplaces to intervention or to control conditions.
Controlled trials with baseline measures and post-intervention outcomes

 

Types of participants

Adult smokers, of either gender, in any setting. We have not included trials aimed exclusively at adolescent smokers, as they are covered by other Cochrane reviews. We have not included trials aimed at pregnant smokers, since they are covered by the review Interventions for promoting smoking cessation during pregnancy (Lumley 2009).

 

Types of interventions

Contests, competitions, incentive schemes, lotteries, raffles, and contingent payments, to reward cessation and continuous abstinence in smoking cessation programmes. We have not included reports of the effectiveness of incentives or rewards to healthcare workers (physicians, nurses) for the delivery of smoking cessation interventions, as these will be covered in a forthcoming companion review. We have also excluded reimbursement to patients for smoking cessation treatment costs, as these are covered in another Cochrane review (Reda 2009).

 

Types of outcome measures

Cessation:
The primary outcome for this review is cessation rates, including point prevalence and sustained abstinence, for a minimum of six months from the start of the intervention, whether or not they are biochemically validated (Hughes 2003). The gold standard is biochemically verified sustained abstinence for at least six months. Trials which did not report cessation rates are excluded from this review.

Recruitment:
Rates of recruitment to and participation in smoking cessation programmes, where they are reported in addition to cessation rates, but not where they are the primary outcome of interest.

 

Search methods for identification of studies

We searched the Cochrane Tobacco Addiction Group Specialized Register, which includes studies identified by systematic electronic searches of multiple databases, handsearching of specialist journals, and 'grey' literature (conference proceedings and unpublished reports not normally covered by most electronic indexing systems). In addition, we used specifically developed strategies to search four electronic databases, MEDLINE, EMBASE, CINAHL and PsycINFO. Search terms included incentive*, competition*, contest*, lotter*, reward*, prize*, contingent payment*, deposit contract*. The most recent searches were in November 2010.

 

Data collection and analysis

There were four stages in the review process:

Stage 1 One author prescreened all search results (abstracts), for possible inclusion or as useful background

Stage 2 Both authors independently assessed relevant studies for inclusion. We resolved discrepancies by consensus. We noted reasons for the non-inclusion of studies.

Stage 3 One author extracted data, and the second author checked them. This stage included an evaluation of quality. Both authors assessed each study according to the presence and quality of the randomization process, concealment of allocation, whether or not trialists and assessors were 'blinded', whether the analysis was appropriate to the study design, and the description of withdrawals and drop-outs.

Stage 4: Analysis:

The method of synthesizing the studies depended on the type, quality, design and heterogeneity of studies identified. We used the χ2 test and the I2 statistic to assess statistical heterogeneity. We have combined eligible studies using a generic inverse variance model. We have used the intraclass correlation coefficient reported by Martinson (Martinson 1999) (ICC for percentage quit smoking in Worksite) to obtain an adjusted estimate of the effect size for the studies that were cluster randomized. These adjusted estimates are then displayed in a descriptive meta-analysis, but without a pooled estimate, because of high levels of clinical and statistical heterogeneity. Wherever possible, and whether or not the trialists themselves used this approach, we have used an intention-to-treat analysis, deploying as the denominator the numbers randomized in their original groups.

We include the Tobacco Addiction Group's glossary of tobacco-related terms as an appendix (Appendix 1).

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of ongoing studies.

We identified 19 studies which met our inclusion criteria. All the included studies rewarded smoking cessation, either alone or in combination with recruitment or participation or both (See the Characteristics of included studies table for full details).

Seven of the studies were set in clinics or health centres (Crowley 1995 [COPD patients]; Gallagher 2007 [psychiatric patients, including people with schizophrenia]; Paxton 1980; Paxton 1981; Paxton 1983; Shoptaw (A) 2002 [narcotic abuse patients]; Volpp 2006), one in academic institutions (Tevyaw 2009), and the rest in worksites. Fourteen were based in the USA, three in the UK, one in Australia, and one in USA and Canada.

Incentives
Two studies used lottery tickets as the incentive (Crowley 1995; Gomel 1993). Seven rewarded verified abstinence with cash payments (De Paul 1994; Gallagher 2007; Rand 1989; Shoptaw (A) 2002; Volpp 2006; Volpp 2009; Windsor (A) 1988). Three studies (Glasgow 1993; Hennrikus 2002; Koffman 1998) combined cash payments to individual quitters with one or more site-wide prize draws. Two trials rewarded individuals in the experimental group with cash payments based on their team's performance within the worksite (Klesges 1986; Klesges 1987).

Four studies (Maheu 1990; Paxton 1980; Paxton 1981; Paxton 1983) tested a system of deposits refunded for abstinence over the course of the programme. The Paxton studies compared possible reward schedules by varying the timing and the amount of deposits and repayments. Koffman 1998 required a non-refundable cash payment from the incentive programme registrants to entitle them to compete for staged cash rewards.

Four studies compared the effects of automatic payments with payments contingent upon cessation, with the guaranteed payment regimen generally serving as the control condition (Crowley 1995; Maheu 1990; Rand 1989; Tevyaw 2009).

Two studies (Glasgow 1993; Maheu 1990) included lottery tickets for a prize draw for smoking 'buddies', who supported those smokers trying to quit.

Although all the studies rewarded smoking cessation as the primary outcome, several added incentives for other performance indicators. Participation and compliance were rewarded by Crowley 1995, Gallagher 2007, Glasgow 1993, De Paul 1994, Hennrikus 2002, Klesges 1986, Klesges 1987, Maheu 1990, Volpp 2006 and Volpp 2009. Koffman 1998 also paid those smokers who 'faded' their cigarettes to no more than 80 in the first month of the programme, as a preparation for stopping completely.

Cessation methods
Only one trial (Glasgow 1993) of the 19 did not deploy any kind of cessation support programme.

Four of the earlier studies used aversive smoking as part of a multi-component programme (Maheu 1990; Paxton 1980; Paxton 1981; Paxton 1983). Five included nicotine replacement therapy to support their participants (Crowley 1995; Gallagher 2007; Maheu 1990 [supplementing aversive smoking]; Shoptaw (A) 2002; Volpp 2006).

The ten remaining studies all used some form of multi-component support programme. Five studies primarily offered a self-help programme (De Paul 1994; Gomel 1993; Koffman 1998; Rand 1989; Windsor (A) 1988), four offered individual or group counselling (Hennrikus 2002; Klesges 1986; Klesges 1987; Tevyaw 2009), while Volpp 2009 steered all participants towards locally-provided smoking cessation resources.

 

Risk of bias in included studies

Randomization
Thirteen of the included studies were described as randomized (Crowley 1995; De Paul 1994; Gallagher 2007; Glasgow 1993; Gomel 1993; Hennrikus 2002; Klesges 1987; Rand 1989; Shoptaw (A) 2002; Tevyaw 2009; Volpp 2006; Volpp 2009; Windsor (A) 1988), with six of them also using stratification (Crowley 1995; De Paul 1994; Glasgow 1993; Hennrikus 2002; Volpp 2006; Volpp 2009). Two studies were described as 'quasi-experimental' (Klesges 1986; Koffman 1998). In the remaining four studies randomization was not used, with Maheu 1990 assigning two worksites to experimental or control status, and the Paxton trials allocating individual attenders to the next available treatment group.

Three studies (Volpp 2006; Volpp 2009; Windsor (A) 1988) were considered to have conducted adequate randomization procedures (sequence generation and allocation concealment), and a further two to have followed adequate procedures for sequence generation but possibly not for allocation concealment (Gallagher 2007; Shoptaw (A) 2002). Eight studies (De Paul 1994; Glasgow 1993; Gomel 1993; Hennrikus 2002; Klesges 1986; Klesges 1987; Rand 1989; Tevyaw 2009) were considered to have given insufficient detail for the integrity of the randomization to be assessed. The remaining studies either used inadequate randomization procedures or did not use randomization at all. Summary assessments of the risk of bias for key items in each study are shown in Figure 1. A sensitivity analysis excluding two studies (Gallagher 2007; Paxton 1980) which did not conceal allocation did not alter the overall findings (analysis not shown).

Figure 1

 FigureFigure 1. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Blinding
Because of the explicit mechanism of rewards, only four trials reported any attempt to blind participants, trialists or assessors (Crowley 1995; De Paul 1994; Tevyaw 2009; Volpp 2006). See the relevant risk of bias tables for details.

Drop-outs and losses to follow up
Eleven studies (Crowley 1995; De Paul 1994; Gallagher 2007; Glasgow 1993; Gomel 1993; Klesges 1987; Koffman 1998; Rand 1989; Volpp 2006; Volpp 2009; Windsor (A) 1988) treated programme drop-outs and losses to follow up as continuing smokers, and conducted the analyses on an intention-to-treat basis, i.e. the denominator included all persons randomized at the start of the trial in their original groups.

Outcomes
Raw outcome data, particularly in the older studies, were often difficult to extract, with 12 of the 19 studies presenting results as percentages only, in tabular or graphic form. Seven trials followed up participants for a maximum of six months (Crowley 1995; Klesges 1986; Klesges 1987; Paxton 1980; Paxton 1981; Rand 1989; Tevyaw 2009), two for between six and twelve months (Gallagher 2007; Volpp 2006), six for twelve months (Gomel 1993; Koffman 1998; Maheu 1990; Paxton 1983; Shoptaw (A) 2002; Windsor (A) 1988), one for 15 to 18 months (Volpp 2009), and three for 24 months (De Paul 1994; Glasgow 1993; Hennrikus 2002).

All the included studies used some form of biochemical validation procedure. Seventeen tested levels of cotinine (a metabolite of nicotine) in blood, saliva or urine, either at baseline to confirm initial smoking status (Crowley 1995; Gallagher 2007; Gomel 1993; Klesges 1986; Klesges 1987; Shoptaw (A) 2002; Windsor (A) 1988), to validate reports of abstinence (Crowley 1995; De Paul 1994; Gallagher 2007; Glasgow 1993; Gomel 1993; Klesges 1986; Klesges 1987; Maheu 1990; Tevyaw 2009; Volpp 2006; Volpp 2009; Windsor (A) 1988), among claimants of rewards (Hennrikus 2002) or among random samples of quitters (Hennrikus 2002; Paxton 1980; Paxton 1981; Paxton 1983). Eleven trials (Crowley 1995; De Paul 1994; Gallagher 2007; Glasgow 1993; Klesges 1986; Klesges 1987; Koffman 1998; Maheu 1990; Rand 1989; Shoptaw (A) 2002; Tevyaw 2009) verified abstinence by testing breath samples for carbon monoxide (CO) levels.

In order to test the robustness of the cessation interventions, we have included in our review only those studies which follow up participants for at least six months from the beginning of the intervention. Three of the trials, however, (Klesges 1986; Klesges 1987; Rand 1989) delivered their final cessation rewards six months into the programme, which was also the end of the designated follow-up period, thereby confounding the intervention rewards with testing at the longest follow up.

Appropriateness of analysis
Four of the eight trials which used a cluster-randomized design made due allowance for this in their analyses, either by testing for intra-class correlation (De Paul 1994; Glasgow 1993), by including worksite as a random effect (Hennrikus 2002) or by incorporating a nested design structure into the analyses of variance and testing retrospectively for intra-cluster correlations (though not in smoking prevalence) (Gomel 1993). The remaining four cluster-randomized trials did not report adjustments for the possible effects of clustering (Klesges 1986; Klesges 1987; Koffman 1998; Maheu 1990).

Crowley 1995 collapsed the three-way groupings for the six-month follow-up results, since differences between groups were by then negligible, and Windsor (A) 1988 collapsed the incentive/non-incentive groupings for analyses after the six-week assessment, as contradictory differences had emerged between the two pairs of groups. Our own analysis of Windsor (A) 1988 and Windsor (B) 1988 compares the effect of the smoking cessation components with and without the incentives.

 

Effects of interventions

Details of the results for the 19 included studies in this review are tabulated in the Analyses section (Analysis 1.1).

Only one trial (Volpp 2009) detected a significant effect of rewards, competitions or incentives on smoking abstinence at the longest follow up, and not confounded by rewards paid out for abstinence at that timepoint. At 15 or 18 months, quit rates for the incentivized and control groups were 9.4% vs 3.6% respectively (P = 0.001). A secondary endpoint in this trial was the completion of a smoking cessation programme, for which the intervention participants received a $100 payment. While all participants received information about local smoking cessation services, 15.4% of the intervention group enrolled in a cessation programme, compared with 5.4% of the controls (P < 0.001); 10.8% of the incentivized group completed the programme compared with 2.5% of the controls (P < 0.001).

We have conducted a descriptive meta-analysis of 11 of the included studies (13 comparisons), grouping by evaluation points (six to 24 months;  Analysis 2.1). Because of high measures of heterogeneity between the studies (I2 values of 62% at six months and 69% at 12 months) we have not produced pooled estimates. The forest plot indicates that only the Volpp 2009 trial demonstrated a clear benefit for incentives at all evaluation points. For this trial, in which assessments began at three or six months after enrolment, abstinence at 9 or 12 months is included in the 6-month forest plot, and abstinence at 15 or 18 months in the 12-month forest plot. Crowley 1995 and Hennrikus 2002 were excluded from the formal analyses since no extractable data were available on programme participants at follow up; Klesges 1986, Koffman 1998 and Maheu 1990 were excluded because they were not fully randomized, and Paxton 1981 and Paxton 1983 because all the participants (experimental and control) received incentives. Shoptaw (A) 2002 and Windsor (A) 1988 are both presented with two separate comparisons, since each study evaluated incentives with two different interventions in a factorial design.

Two studies (De Paul 1994 and Windsor (A) 1988) had paid out their final reward to coincide with the six-month follow up, which may have compromised the results.

Analysis of cost benefits was not appropriate, since most of the trials failed to demonstrate a clinically significant long-term benefit of the intervention. However, cost considerations for Volpp 2009 are briefly discussed below.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

Only one included study in this review offers evidence that incentives may improve long-term smoking cessation, whether conducted in the community, in healthcare settings or in the workplace. Volpp 2009 was a well-conducted trial, with adequate power and sufficiently robust long-term outcomes to raise the question of why its results are at variance with other trials in this review. The authors speculate that their study population was large enough (878 participants) to detect an effect, and that their rewards were substantial enough (a total of $750 available for completion of a smoking cessation programme and sustained abstinence at 9 or 12 months) to consolidate the target behaviour change. Six months after the final payment, the incentivized group maintained a higher quit rate than the control group. The trialists may have felt able to offer these considerable rewards because their trial design did not require them to provide and fund their own smoking cessation programme; instead, they encouraged their participants to avail themselves of local smoking cessation services, thereby freeing up resources to enhance the reward schedule. While the findings of this trial are promising, such a paradigm may only work in communities or situations where independent and well-resourced smoking cessation services already operate.

Many of the early studies were underpowered and of variable quality. Three studies (Klesges 1986; Klesges 1987; Rand 1989) confounded the final delivery of cessation rewards with the final follow-up assessment. Similarly, although De Paul 1994 and Koffman 1998 reported significantly higher cessation rates for the incentives groups at the six-month assessment, this evaluation coincided with the final phase of the rewards programmes. At later follow up points in these studies all such differences had disappeared. The only early study (Maheu 1990) to detect a clear difference between the long-term quit rates of the intervention and control groups (50% versus 25%) was not randomized, had too small a sample to reach statistical significance, tested the allocation of incentives rather than the presence or absence of them, and may have confounded the intervention programme by including a sponsorship component which was not offered in the control site. Encouraging early quit rates at 30 days (Volpp 2006) and at 21 days (Tevyaw 2009) dwindled to non-significant differences by the six-month follow ups. Although Gallagher 2007 achieved significantly different CO-validated quit rates, the cotinine-validated quit rates did not achieve clinically significant differences, suggesting that while some participants could achieve temporary abstinence for their clinic visit, the more rigorous urinary cotinine test did not indicate abstinence sustained beyond a few hours.

Glasgow 1993 reported one-year cessation rates for HIP participants more than double those of non-registrants (22.1% versus 9.4%, P < 0.005), but this difference had become non-significant at the two-year follow up; and again, the one-year evaluation was very close to the final lottery draw for HIP participants and may well have been influenced by that proximity. Gomel 1993 indicated that at three months (two weeks after programme end) the incentives group had a quit rate of 20%, compared with 17% in the comparison (BC) group, but that by 12 months the rates had switched to 20% for the BC group compared with 4% for the incentives group (estimated from graphical percentage figure). Shoptaw (A) 2002 reported the same long-term pattern of relapse, with significant benefit to the contingency management groups in the first three months rapidly vanishing over the nine-month post-programme follow-up period.

The picture that emerges from these examples is that incentives may improve compliance while they are in place, but that once they are withdrawn the normal pattern of relapse is likely to re-establish itself. Although many of the studies in this review were underpowered to detect sustained effects, we have explored the likelihood of erosion of the intervention effect at longest follow up (Figure 2). We include only those studies which followed up participants beyond the six-month assessment point (the 12-month assessment point, in the case of Glasgow 1993). This scatterplot suggests that for studies with positive effects (OR greater than 1 at six months), there is evidence for an erosion of intervention effect over time (De Paul 1994; Windsor (A) 1988; Shoptaw (B) 2002; Volpp 2009). For studies with negative effects (OR less than 1 at six months, or 12 months for the Glasgow trial) the relationship is less clear, with two trials (Windsor (B) 1988; Gomel 1993) showing an erosion of effect, and two (Glasgow 1993; Shoptaw (A) 2002) demonstrating an increased effect over time. Neither increase, however, achieved statistical significance.

 FigureFigure 2. Erosion of intervention effect over time, based on ORs at longest follow up. The X axis represents the OR at 6m assessment (12m for Glasgow 1983), and the Y axis the OR at longest follow up (12, 18 or 24m).

Incentives
The use of tangible rewards will always be a trade-off between maximizing participation and attracting smokers who are motivated more by the rewards than by the wish to stop smoking. The type and scale of the incentive has therefore been considered a critical element in the design of a cessation programme, although from the perspective of this review, which is primarily concerned with sustained or permanent cessation, the type and scale of the incentives may be less significant than the negative effects of removing them altogether. The incentives varied considerably across the studies in this review, including cash prizes, vouchers for goods and services, state lottery tickets, prize draws, a catered meal and combinations of cash and state lottery tickets. Only the Volpp 2009 trial, with substantial cash payments both for compliance and for prolonged abstinence, demonstrated a sustained beneficial effect beyond the expiry of the payment schedule. However, participants in this trial were all employees of a large American company, were predominantly white, and enjoyed relatively high levels of education and income. The success of this trial may not be readily generalisable to other populations of smokers, with different regional, socio-economic and ethnic mixes.

Participation rates
In this review we have included only those studies which specified smoking cessation as a primary outcome, and which applied the intervention rewards to achievement of abstinence. However, higher recruitment rates may have a role to play in improving long-term cessation rates. A recurrent feature of several studies in this review, both included and excluded, was the effect of incentives upon participation rates. A widespread assumption seemed to be that, since incentives are frequently shown to improve participation rates in cessation programmes, this would surely lead to higher quit rates (Grunberg 1990; USDHHS 1989). Our review has not found this to be the case. While the studies' authors noted the effectiveness of immediate or possible rewards in raising recruitment levels, this was generally not reflected in the long-term cessation rates (Hennrikus 2002; Klesges 1986; Maheu 1990; Paxton 1983; Volpp 2006). The primary outcome of the Volpp 2006 study, for example, was to enhance enrolment into a free cessation programme by offering incentives for attendance, compliance and cessation. Although the incentives doubled participation rates (41.3% of invitees versus 19.5%), the confirmed six-month cessation rates were low in both groups (6.5% versus 4.6%), with negligible difference between the absolute numbers of quitters.

Given the potential for incentives to improve recruitment rates, the absolute numbers of successful long-term quitters may in some cases be increased, even if cessation rates do not differ between the intervention and control groups. It is plausible that incentives may have value as a mechanism for cessation induction, as distinct from their role in aiding or enhancing the cessation process (Hughes 2003).

Deception
All the included studies in this review used some form of biochemical verification to confirm the smoking status of those claiming abstinence. While this procedure is now the recommended gold standard for good trial design (Benowitz 2002), it is particularly important that quitters in an incentives- or competition-based trial are shown to be truly abstinent at the evaluation points. Eligibility for cessation rewards depended in all the included studies upon biochemical confirmation of the claim of abstinence.

Three of the studies in this review reported a good correspondence between claims of abstinence and their biochemical verification, with Koffman 1998 noting a 96% agreement, Windsor (A) 1988 100% agreement for more than 600 saliva thiocyanate samples, and De Paul 1994 a 95% agreement. Maheu 1990 used the 'bogus pipeline' method (i.e. collecting saliva samples but not testing them for cotinine), but also verified abstinence throughout by CO testing. The Paxton studies took random urine samples to deter false reporting, and also occasionally cross-checked smoking status with family members or friends. They reported that levels of deception were 'very low', and attributed this to having warned subjects in advance about the random biochemical checks.

Three studies which targeted high-risk smoking groups went to some trouble to control for possible levels of deception. Crowley 1995, dealing with moderately-ill COPD patients who had been co-opted into the programme, anticipated a measure of deception, and calculated an expected ratio of CO divided by cigarettes smoked. This confirmed a greater disparity between cigarettes smoked and numbers reported among the non-verified self-report group and the control group than among the intervention group, who were rewarded only for verified abstinence. Shoptaw (A) 2002, dealing with methadone-maintained drug abusers with high levels of smoking, reported similar findings between self-reported abstinence and its biochemical verification, but cautioned that it was possible that participants had found ways of subverting the breath-testing schedule. Against this possibility, however, was the fact that subjects had averaged only 44% of the available prize vouchers for abstinence, suggesting that any subversion had not been particularly successful. Gallagher 2007, dealing with smokers with schizophrenia or other serious mental disorders, found considerable disparities between quit claims validated by CO breath samples (confirming abstinence for a few hours) and those validated by urinary cotinine (a few days of abstinence). This need not indicate deception, but suggests that the achieved abstinence for which the rewards were being claimed was not robust or sustained (SRNT 2002).

The two studies which found a striking disparity between self-reported abstinence and biochemical verification of the claims were both large, worksite-based, cluster-randomized trials, which followed their subjects for 24 months. Hennrikus 2002 reported a 33.6% mismatch between self report and confirmation at 24 months, and Glasgow 1993 a 27% mismatch at the12-month evaluation. Both trials had 'sprung' the biochemical validation requirement on the quitters at follow up. The clear discrepancies suggest that people responding indirectly (not face-to-face) to a question about their smoking, and not expecting to have their answer checked, may be significantly more likely to say what they think the questioner wants to hear.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

 

Implications for practice

  • Incentives and competitions do not generally appear to enhance long-term cessation rates. Early success tended to dissipate when the rewards were no longer offered, and the normal relapse pattern re-established itself.
  • The only trial to achieve sustained success rates beyond the reward schedule concentrated its resources into substantial cash payments for abstinence rather than into running its own smoking cessation programme. Such an approach may be feasible only where independently-funded smoking cessation programmes are already established.
  • Rewarding participation in contests and cessation programmes may have the potential to deliver higher absolute numbers of quitters.
  • Although these interventions risk attracting smokers motivated more by the material rewards than by the desire to quit, there was little evidence that levels of deception varied between experimental and control subjects, or that rates of disconfirmation were unacceptably high.

 
Implications for research

  • The scale and longevity of different reward schedules for smoking cessation should be evaluated.
  • The respective merits of cash payments versus payments in kind (e.g. grocery vouchers) should be assessed and compared.
  • The stability of successful payment schedules needs to be tested in varying populations of smokers, from different socio-economic, regional and ethnic backgrounds.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

We would like to thank Suzanne Colby, Sandra Gallagher, Leonard Jason, Susan McMahon, Erin Rotherham-Fuller, Damaris Rohsenow, Steven Shoptaw, Tracy Tevyaw and Kevin Volpp for supplying additional data or clarification, and Harry Lando and Esteve Salto for commenting on an earlier version of this review.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
Download statistical data

 
Comparison 1. RESULTS OF INCLUDED STUDIES

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 RESULTS TABLEOther dataNo numeric data

 
Comparison 2. Smoking cessation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Smoking cessation (Adjusted)14Adjusted Odds Ratio (Fixed, 95% CI)Totals not selected

    1.1 6 months
13Adjusted Odds Ratio (Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 12 months
8Adjusted Odds Ratio (Fixed, 95% CI)0.0 [0.0, 0.0]

    1.3 18 months
2Adjusted Odds Ratio (Fixed, 95% CI)0.0 [0.0, 0.0]

    1.4 24 months
2Adjusted Odds Ratio (Fixed, 95% CI)0.0 [0.0, 0.0]

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Appendix 1. Glossary of tobacco-related terms


TermDefinition

AbstinenceA period of being quit, i.e. stopping the use of cigarettes or other tobacco products, May be defined in various ways; see also:
point prevalence abstinence; prolonged abstinence; continuous/sustained abstinence

Biochemical verificationAlso called 'biochemical validation' or 'biochemical confirmation':
A procedure for checking a tobacco user's report that he or she has not smoked or used tobacco. It can be measured by testing levels of nicotine or cotinine or other chemicals in blood, urine, or saliva, or by measuring levels of carbon monoxide in exhaled breath or in blood.

BupropionA pharmaceutical drug originally developed as an antidepressant, but now also licensed for smoking cessation; trade names Zyban, Wellbutrin (when prescribed as an antidepressant)

Carbon monoxide (CO)A colourless, odourless highly poisonous gas found in tobacco smoke and in the lungs of people who have recently smoked, or (in smaller amounts) in people who have been exposed to tobacco smoke. May be used for biochemical verification of abstinence.

CessationAlso called 'quitting'
The goal of treatment to help people achieve abstinence from smoking or other tobacco use, also used to describe the process of changing the behaviour

Continuous abstinenceAlso called 'sustained abstinence'
A measure of cessation often used in clinical trials involving avoidance of all tobacco use since the quit day until the time the assessment is made. The definition occasionally allows for lapses. This is the most rigorous measure of abstinence

'Cold Turkey'Quitting abruptly, and/or quitting without behavioural or pharmaceutical support.

CravingA very intense urge or desire [to smoke].
See: Shiffman et al 'Recommendations for the assessment of tobacco craving and withdrawal in smoking cessation trials'
Nicotine & Tobacco Research 2004: 6(4): 599-614

DopamineA neurotransmitter in the brain which regulates mood, attention, pleasure, reward, motivation and movement

EfficacyAlso called 'treatment effect' or 'effect size':
The difference in outcome between the experimental and control groups

Harm reductionStrategies to reduce harm caused by continued tobacco/nicotine use, such as reducing the number of cigarettes smoked, or switching to different brands or products, e.g. potentially reduced exposure products (PREPs), smokeless tobacco.

Lapse/slipTerms sometimes used for a return to tobacco use after a period of abstinence. A lapse or slip might be defined as a puff or two on a cigarette. This may proceed to relapse, or abstinence may be regained. Some definitions of continuous, sustained or prolonged abstinence require complete abstinence, but some allow for a limited number or duration of slips. People who lapse are very likely to relapse, but some treatments may have their effect by helping people recover from a lapse.

nAChR[neural nicotinic acetylcholine receptors]: Areas in the brain which are thought to respond to nicotine, forming the basis of nicotine addiction by stimulating the overflow of dopamine

NicotineAn alkaloid derived from tobacco, responsible for the psychoactive and addictive effects of smoking.

Nicotine Replacement Therapy (NRT)A smoking cessation treatment in which nicotine from tobacco is replaced for a limited period by pharmaceutical nicotine. This reduces the craving and withdrawal experienced during the initial period of abstinence while users are learning to be tobacco-free The nicotine dose can be taken through the skin, using patches, by inhaling a spray, or by mouth using gum or lozenges.

OutcomeOften used to describe the result being measured in trials that is of relevance to the review. For example smoking cessation is the outcome used in reviews of ways to help smokers quit. The exact outcome in terms of the definition of abstinence and the length of time that has elapsed since the quit attempt was made may vary from trial to trial.

PharmacotherapyA treatment using pharmaceutical drugs, e.g. NRT, bupropion

Point prevalence abstinence (PPA)A measure of cessation based on behaviour at a particular point in time, or during a relatively brief specified period, e.g. 24 hours, 7 days. It may include a mixture of recent and long-term quitters. cf. prolonged abstinence, continuous abstinence

Prolonged abstinenceA measure of cessation which typically allows a 'grace period' following the quit date (usually of about two weeks), to allow for slips/lapses during the first few days when the effect of treatment may still be emerging.
See: Hughes et al 'Measures of abstinence in clinical trials: issues and recommendations'; Nicotine & Tobacco Research, 2003: 5 (1); 13-25

RelapseA return to regular smoking after a period of abstinence

Secondhand smokeAlso called passive smoking or environmental tobacco smoke [ETS]
A mixture of smoke exhaled by smokers and smoke released from smouldering cigarettes, cigars, pipes, bidis, etc. The smoke mixture contains gases and particulates, including nicotine, carcinogens and toxins.

Self-efficacyThe belief that one will be able to change one's behaviour, e.g. to quit smoking

SPC [Summary of Product Characteristics]Advice from the manufacturers of a drug, agreed with the relevant licensing authority, to enable health professionals to prescribe and use the treatment safely and effectively.

TaperingA gradual decrease in dose at the end of treatment, as an alternative to abruptly stopping treatment

TitrationA technique of dosing at low levels at the beginning of treatment, and gradually increasing to full dose over a few days, to allow the body to get used to the drug. It is designed to limit side effects.

WithdrawalA variety of behavioural, affective, cognitive and physiological symptoms, usually transient, which occur after use of an addictive drug is reduced or stopped.
See: Shiffman et al 'Recommendations for the assessment of tobacco craving and withdrawal in smoking cessation trials'
Nicotine & Tobacco Research 2004: 6(4): 599-614



 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

Last assessed as up-to-date: 23 November 2010.


DateEventDescription

14 April 2011AmendedMinor typographical errors corrected



 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

Protocol first published: Issue 2, 2003
Review first published: Issue 2, 2005


DateEventDescription

24 November 2010New search has been performed15 new trials added: 2 included, 13 excluded.

24 November 2010New citation required and conclusions have changedNew included study (Volpp 2009) found long-term positive effects of their incentive-based trial. Risk of bias tables added for all studies.

6 August 2008AmendedSource of support added

29 April 2008New citation required but conclusions have not changedName change for first author

2 April 2008AmendedConverted to new review format.

2 April 2008New search has been performedTwo new included studies, nine new excluded studies, conclusions unchanged.



 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

KC and RP extracted data. KC wrote the review, with comments from RP. RP conducted the statistical analysis and the forest plots.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

None known.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Internal sources

  • Department of Primary Health Care, Oxford University, UK.
  • National School for Health Research School for Primary Care Research, UK.

 

External sources

  • NHS Research and Development Fund, UK.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractResumen摘要Résumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to ongoing studies
  21. Additional references
  22. References to other published versions of this review
Crowley 1995 {published data only}
De Paul 1994 {published data only}
Gallagher 2007 {published data only}
  • Gallagher SM, Penn PE, Schindler E, Layne W. A comparison of smoking cessation treatments for persons with schizophrenia and other serious mental illnesses. Journal of Psychoactive Drugs 2007;39(4):487-97.
Glasgow 1993 {published data only}
  • Glasgow RE, Hollis JF, Ary DV, Boles SM. Results of a year-long incentives-based worksite smoking-cessation program. Addictive Behaviors 1993;18:455-64.
  • Glasgow RE, Hollis JF, Ary DV, Lando HA. Employee and organizational factors associated with participation in an incentive-based worksite smoking cessation program. Journal of Behavioral Medicine 1990;13(4):403-18.
  • Glasgow RE, Hollis JF, Pettigrew L, Foster L, Givi MJ, Morrisette G. Implementing a year-long worksite-based incentive program for smoking cessation. American Journal of Health Promotion 1991;5(3):192-9.
Gomel 1993 {published data only}
  • Gomel M, Oldenburg B, Simpson JM, Owen N. Work-site cardiovascular risk reduction: a randomized trial of health risk assessment, education, counseling, and incentives. American Journal of Public Health 1993;83(9):1232-8.
Hennrikus 2002 {published data only}
  • Hennrikus DJ, Jeffery RW, Lando HA, Murray DM, Brelje K, Davidann B, et al. The SUCCESS project: the effect of program format and incentives on participation and cessation in worksite smoking cessation programs. American Journal of Public Health 2002;92(2):274-9.
  • Lando HA, Thai DT, Murray DM, Robinson LA, Jeffery RW, Sherwood NE, et al. Age of initiation, smoking patterns, and risk in a population of working adults. Preventive Medicine 1999;29:590-8.
  • Martinson BC, Murray DM, Jeffery RW, Hennrikus DJ. Intraclass correlation for measures from a worksite health promotion study: estimates, correlates and applications. American Journal of Health Promotion 1999;13:347-57.
  • Sherwood NE, Hennrikus DJ, Jeffery RW, Lando HA, Murray DM. Smokers with multiple behavioral risk factors: how are they different?. Preventive Medicine 2000;31(4):299-307.
Klesges 1986 {published data only}
Klesges 1987 {published data only}
  • Klesges RC, Glasgow RE, Klesges LM, Morray K, Quayle R. Competition and relapse prevention training in worksite smoking modification. Health Education Research 1987;2(1):5-14.
Koffman 1998 {published data only}
  • Koffman DM, Lee JW, Hopp JW, Emont SL. The impact of including incentives and competition in a workplace smoking cessation program on quit rates. American Journal of Health Promotion 1998;13(2):105-11.
  • Matson D M. The impact of an incentive/competition program on participation and smoking cessation among high-risk smokers at the worksite. Proquest Digital Dissertations AAT 9300218, DAI-B 53/12, p.6252, June 1993 1992.
Maheu 1990 {published data only}
  • Maheu MM, Gervitz RN, Sallis JF, Schneider NG. Competition/cooperation in worksite smoking cessation using nicotine gum. Preventive Medicine 1990;18(6):867-76.
Paxton 1980 {published data only}
Paxton 1981 {published data only}
Paxton 1983 {published data only}
Rand 1989 {published data only}
Shoptaw (A) 2002 {published data only}
Shoptaw (B) 2002 {published data only}
  • See Shoptaw (A) 2002.
Tevyaw 2009 {published data only}
  • Tevyaw TO, Colby SM, Tidey JW, Kahler CW, Rohsenow DJ, Barnett NP, et al. Contingency management and motivational enhancement: a randomized clinical trial for college students. Nicotine & Tobacco Research 2009;11(6):739-49.
Volpp 2006 {published data only}
  • Volpp KG, Levy AG, Asch DA, Berline JA, Murphy JJ, Gomez A, et al. A randomized controlled trial of financial incentives for smoking cessation. Cancer Epidemiology, Biomarkers and Prevention 2006;15(1):12-8.
Volpp 2009 {published data only}
  • Volpp KG, Troxel AB, Pauly MV, Glick HA, Puig A, Asch DA, et al. A randomized, controlled trial of financial incentives for smoking cessation. New England Journal of Medicine 2009;360(7):699-709. [: clinicaltrials.gov ID NCT00128375]
Windsor (A) 1988 {published data only}
  • Windsor RA, Lowe JB. Behavioral impact and cost analysis of a worksite self-help smoking cessation program. Progress in Clinical and Biological Research 1989;392:231-42.
  • Windsor RA, Lowe JB, Bartlett EE. The effectiveness of a worksite self-help smoking cessation program: a randomized trial. Journal of Behavioral Medicine 1988;11(4):407-21.
Windsor (B) 1988 {published data only}
  • See Windsor (A) 1988.

References to studies excluded from this review

  1. Top of page
  2. AbstractResumen摘要Résumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to ongoing studies
  21. Additional references
  22. References to other published versions of this review
Alessi 2008 {published data only}
  • Alessi SM Petry NM, Urso J. Contingency management promotes smoking reduction in residential substance abuse patients. Journal of Applied Behavior Analysis 2008;41:617-22. [: Clinicaltrials.gov ID NCT00408265]
Bowers 1987 {published data only}
Cavallo 2007 {published data only}
  • Cavallo DA, Cooney JL, Duhig AM, Smith AE, Liss TB, McFetridge AK, et al. Combining cognitive behavioral therapy with contingency management for smoking cessation in adolescent smokers: a preliminary comparison of two different CBT formats. American Journal on the Addictions 2007;16(6):468-74.
  • Duhig A, Cavallo D, McFetridge A, Liss T, Dahl T, Krishnan-Sarin S. Contingency management for smoking cessation in adolescent smokers (POS2-51). Society for Research in Nicotine and Tobacco 12th Annual Meeting February 15-18, Orlando FLA. 2006:87.
  • Krishnan-Sarin S, Duhig AM, McKee SA, McMahon TJ, Liss T, McFetridge A. Contingency management for smoking cessation in adolescents. Experimental and Clinical Psychopharmacology 2006;14(3):306-10.
  • Krishnan-Sarin S, Reynolds B, Duhig AM, Smith A, Liss T, McFetridge A, et al. Behavioral impulsivity predicts treatment outcome in a smoking cessation program for adolescent smokers. Drug and Alcohol Dependence 2007;88(1):79-82.
Chivers 2008 {published data only}
  • Chivers LL, Higgins ST, Heil SH, Proskin RW, Thomas CS. Effects of initial abstinence and programmed lapses on the relative reinforcing effects of cigarette smoking. Journal of Applied Behavior Analysis 2008;41:481-97.
Correia 2006 {published data only}
Crowley 1991 {published data only}
Cummings 1988 {published data only}
Curry 1991 {published data only}
  • Curry SJ, Wagner EH, Grothaus LC. Evaluation of intrinsic and extrinsic motivation interventions with a self-help smoking cessation program. Journal of Consulting and Clinical Psychology 1991;59(2):318-24.
Dallery 2008 {published data only}
De Paul 1989 {published data only}
  • Jason LA, Lesowitz T, Michaels M, Blitz C, Victors L, Dean L, et al. A worksite smoking cessation intervention involving the media and incentives. American Journal of Community Psychology 1989;17:785-99.
  • Salina D, Jason LA, Hedeker D, Kaufman J, Lesondak L, McMahon SD, et al. A follow-up of a media-based, worksite smoking cessation program. American Journal of Community Psychology 1994;22:257-71.
Donatelle 2000a {published data only}
  • Donatelle RJ, Prows SL, Champeau D, Hudson D. Randomised controlled trial using social support and financial incentives for high risk pregnant smokers: Significant Other Support (SOS) program. Tobacco Control 2000;9(Supplement III):iii67-iii69.
Donatelle 2000b {published data only}
  • Donatelle RJ, Prows SL, Champeau D, Hudson D. Using social support, biochemical feedback, and incentives to motivate smoking cessation during pregnancy: comparison of three intervention trials. Poster at American Public Health Association meeting, Boston MA 2000.
Donatelle 2002 {published data only}
  • Donatelle RJ, Hudson D. Using 5 A's and incentives to promote prenatal smoking cessation [presentation to National Conference of Tobacco or Health, 2002]. http://ncth.confex.com/ncth/responses/2002/257.ppt retrieved August 10 2004 2002.
Dunn 2010 {published data only}
  • Dunn KE, Sigmon SC, Reimann EF, Badger GJ, Heil SH, Higgins ST. A contingency management intervention to promote initial smoking cessation among opioid-maintained patients. Experimental and Clinical Psychopharmacology 2010;18:37-50.
  • Dunn KE, Sigmon SC, Thomas CS, Heil SH, Higgins ST. Voucher-based contingent reinforcement of smoking abstinence among methadone-maintained patients: a pilot study. Journal of Applied Behavior Analysis 2008;41:527-38.
Elliott 1968 {published data only}
  • Elliott R, Tighe T. Breaking the cigarette habit: Effects of a technique involving threatened loss of money. Psychological Record 1968;18:503-13.
Emont 1992 {published data only}
Fortmann 1995 {published data only}
  • Fortmann SP, Killen JD. Nicotine gum and self-help behavioral treatment for smoking relapse prevention: results from a trial using population-based recruitment. Journal of Consulting and Clinical Psychology 1995;63(3):460-8.
Gadomski 2010 {published data only}
  • Gadomski A, Adams L, Tallman N, Krupa N, Jenkins P. Effectiveness of a combined prenatal and postpartum smoking cessation program. Maternal and Child Health Journal 2010;14:nn-n.
Gilbert 1999 {published data only}
  • Gilbert DG, Crauthers DM, Mooney DK, McClernon FJ, Jensen RA. Effect of monetary contingencies on smoking relapse: Influences of trait depression, personality, and habitual nicotine intake. Experimental and Clinical Psychopharmacology 1999;7(2):174-81.
  • Gilbert DG, McClernon FJ, Rabinovich NE, Plath LC, Jensen RA, Meliska CJ. Effects of smoking abstinence on mood and craving in men: influences of negative-affect-related personality traits, habitual nicotine intake and repeated measurements. Personality and Individual Differences 1998;25:399-423.
Gilbert 2002 {published data only}
  • Gilbert DG, McClernon FJ, Rabinovich NE, Plath LC, Masson CL, Anderson AE, et al. Mood disturbance fails to resolve across 31 days of cigarette abstinence in women. Journal of Consulting and Clinical Psychology 2002;70(1):142-52.
Gottlieb 1990 {published data only}
Graham 2007 {published data only}
  • Graham AL, Cobb NK, Raymond L, Sill S, Young J. Effectiveness of an internet-based worksite smoking cessation intervention at 12 months. Journal of Occupational and Environmental Medicine 2007;49(8):821-8.
Hanewinkel 2007 {published data only}
  • Etter JF, Bouvier P. Some doubts about one of the largest smoking prevention programmes in Europe, the smokefree class competition. Journal of Epidemiology and Community Health 2006;60(9):757-9.
  • Hanewinkel R. ["Be smart - don't start". Results of a non-smoking competition in Germany 1997-2007] [German]. Gesundheitswesen 2007;69(1):38-44.
  • Hanewinkel R, Wiborg G. [Diffusion of the non-smoking campaign "Be smart - don't start" between 1997 and 2003 in Germany] [German]. Gesundheitswesen 2003;65(4):250-4.
  • Hanewinkel R, Wiborg G. [Primary and secondary prevention of smoking in adolescents: results of the campaign "Be smart - don't start"] [German]. Gesundheitswesen 2002;64(8-9):492-8.
  • Hanewinkel R, Wiborg G, Abdennbi K, Ariza C, Bollars C, Bowker S, et al. European smokefree class competition: a measure to decrease smoking in youth. Journal of Epidemiology and Community Health 2007;61(8):750.
  • Hanewinkel R, Wiborg G, Isensee B, Nebot M, Vartiainen E. "Smoke-free Class Competition": Far-reaching conclusions based on weak data. Preventive Medicine 2006;43(2):150-1.
  • Pick O, Nolte B, Koller M, Vogelmeier M, Engenhart-Cabilic R. [Significance of a health campaign in 11- to 14-year-old school children for smoking prevention - Effect evaluation on the school competition "Be smart - don't start"] [German]. Gesundheitswesen 2005;67(7):542.
  • Schneider S, Mohnen SM, Tonges S, Potschke-Langer M, Schulze A. Are competitions an appropriate instrument for youth smoking cessation? A 1-year follow-up of the Germany-wide 'Smoke-free 2004' campaign. Medizinische Klinik 2006;101(9):711-7.
  • Schulze A, Mons U, Edler L, Potshcke-Langer M. Lack of sustainable prevention effect of the "Smoke-free Class Competition" on German pupils. Preventive Medicine 2006;42(1):33-9.
  • Wiborg G, Hanewinkel R, Kliche KO. ["Be smart - don't start" campaign to prevent children from starting to smoke: an analysis according to type of school they attend] [German]. Deutsche Medizinische Wochenschrift 2002;127(9):430-6.
Heil 2008 {published data only}
Higgins 2004 {published data only}
  • Higgins ST, Heil SH, Badger GJ, Skelly JM, Solomon LJ, Bernstein IM. Educational disadvantage and cigarette smoking during pregnancy. Drug & Alcohol Dependence 2009;104:s100-5.
  • Higgins ST, Heil SH, Dumeer AM, Thomas CS, Solomon LJ, Bernstein IM. Smoking status in the initial weeks of quitting as a predictor of smoking-cessation outcomes in pregnant women. Drug and Alcohol Dependence 2006;85(2):138-41.
  • Higgins ST, Heil SH, Solomon LJ, Bernstein IM, Lussier JP, Abel RL, et al. A pilot study on voucher-based incentives to promote abstinence from cigarette smoking during pregnancy and postpartum. Nicotine & Tobacco Research 2004;6(6):1015-20.
  • Higgins TM, Higgins ST, Heil SH, Badger GJ, Skelly JM, Bernstein IM, et al. Effects of cigarette smoking cessation on breastfeeding duration. Nicotine & Tobacco Research 2010;12(5):483-8.
  • Yoon JH, Higgins ST, Heil SH, Sugarbaker RJ, Thomas CS, Badger GJ. Delay discounting predicts postpartum relapse to cigarette smoking among pregnant women. Experimental and Clinical Psychopharmacology 2007;15(2):176-86.
Jason 1990 {published data only}
Jeffery 1988 {published data only}
  • Jeffery RW, Pheley AM, Forster JL, Kramer FM, Snell MK. Payroll contracting for smoking cessation: a worksite pilot study. American Journal of Preventive Medicine 1988;4:83-6.
Jeffery 1989 {published data only}
  • Jeffery RW, Forster JL, Schmid TL. Worksite health promotion: feasibility testing of repeated weight control and smoking cessation classes. American Journal of Health Promotion 1989;3(4):11-16.
Jeffery 1993 {published data only}
  • Jeffery RW, Forster JL, Baxter JE, French SA, Kelder SH. An empirical evaluation of the effectiveness of tangible incentives in increasing participation and behavior change in a worksite health promotion program. American Journal of Health Promotion 1993;8(2):98-100.
  • Jeffery RW, Forster JL, French SA, Kelder SH, Lando HA, McGovern PG, et al. The Healthy Worker Project: a work-site intervention for weight control and smoking cessation. American Journal of Public Health 1993;83(3):395-402.
Kassaye 1984 {published data only}
Kollins 2010 {published data only}
  • Kollins SH, McClernon FJ, Van Voorhees EE. Monetary incentives promote smoking abstinence in adults with attention deficit hyperactivity disorder (ADHD). Experimental and Clinical Psychopharmacology 2010;18(3):221-8.
Lamb 2004 {published data only}
Lamb 2010 {published data only}
Lussier 2005 {published data only}
Monti 2006 {published data only}
  • Monti P, Tevyaw TO, Tidey J, Colby S, Kahler C, Barnett N, et al. Combining motivational enhancement and contingency management for young adult smokers (SYM3D). Society for Research on Nicotine and Tobacco, 12th Annual Meeting February 15-18, Orlando FLA. 2006.
  • Ohmura Y, Takahashi T, Kitamura N. Discounting delayed and probabilistic monetary gains and losses by smokers of cigarettes. Psychopharmacology Berl 2005;182(4):508-15.
  • Tevyaw TO, Tidey J, Colby S, Kahler C, Barnett N, Luboyeski E, et al. Contingency management and MET for young adult smokers,: preliminary results (RP-065). Society for Research on Nicotine and Tobacco, 11th Annual Meeting March, Prague, Czech Republic. 2005.
Mooney 2004 {unpublished data only}
  • Mooney ME. Interventions to increase use of nicotine gum: a randomized, controlled single-blind trial. Dissertation Abstracts International: Section B: The Sciences and Engineering 2004; Vol. 64:4052.
Olsen 1990 {published data only}
  • Olsen GW, Lacy SE, Sprafka JM, Arceneaux TG, Potts TA, Kravat BA, et al. A 5-year evaluation of a smoking cessation incentive program for chemical employees. Preventive Medicine 1991;20:774-84.
  • Olsen GW, Shellenberger RJ, Lacy SE, Fishbeck WA, Bond GG. A smoking cessation incentive program for chemical employees: design and evaluation. American Journal of Preventive Medicine 1990;6(4):200-7.
Pardell 2003 {published data only}
  • Pardell H, Faixedas MT, Salto E, Valverde A, Tresserras R, Taberner JL, et al. Influence of an economical incentive on smoking cessation at community level. Society for Research on Nicotine and Tobacco 5th European Meeting November 20-22 2003 Padua: Abstract book. 2003; Vol. Poster 41.
Perkins 2010 {published data only}
  • Perkins KA, Lerman C, Fonte CA, Mercincavage M, Stitzer ML, Chengappa KN, et al. Cross-validation of a new procedure for early screening of smoking cessation medications in humans. Clinical Pharmacology and Therapeutics 2010;88(1):109-14.
Poole 2001 {published data only}
Rohsenow 2005 {unpublished data only}
  • Rohsenow D, Martin R, Tidey J, Monti P, Swift R. Motivational and contingency interventions for unmotivated smokers in substance abuse treatment (PA-7). Society for Research on Nicotine and Tobacco, 11th Annual Meeting March, Prague, Czech Republic. 2005.
Roll 2008 {published data only}
Sloan 1990 {published data only}
Spring 1978 {published data only}
  • Spring FL, Sipich JF, Trimble RW, Goeckner DJ. Effects of contingency and noncontingency contracts in the context of a self-control-oriented smoking modification program. Behavior Therapy 1978;9(5):967-8.
Stitzer 1983 {published data only}
Stitzer 1984 {published data only}
Stitzer 1985 {published data only}
Stoops 2009 {published data only}
  • Stoops WW, Dallery J, Fields NM, Nuzzo PA, Schoenberg NE, Martin CA, et al. An internet-based abstinence reinforcement smoking cessation intervention in rural smokers. Drug & Alcohol Dependence 2009;105(1-2):56-62.
Strecher 1983 {published data only}
Tanaka 2006 {published data only}
  • Tanaka H, Yamato H, Tanaka T, Kadowaki T, Okamura T, Nakamura M, et al. Effectiveness of a low-intensity intra-worksite intervention on smoking cessation in Japanese employees: a three-year intervention trial. Journal of Occupational Health 2006;48(3):175-82.
Winett 1973 {published data only}
Wiseman 2005 {published data only}
  • Wiseman EJ, Williams DK. Effectiveness of payments for reducing carbon monoxide levels and noncontingent payments on smoking behaviors in cocaine-abusing outpatients wearing nicotine or placebo patches. Experimental and Clinical Psychopharmacology 2005;13(2):102-10.
Yi 2008 {published data only}
  • Yi R, Johnson MW, Giordano LA, Landes RD, Badger GJ, Bickel WK. The effects of reduced cigarette smoking on discounting future rewards: an initial evaluation. Psychological Record 2008;58:163-74.
Yoon 2009 {published data only}
  • Yoon JH, Higgins ST, Bradstreet MP, Badger GJ, Thomas CS. Changes in the relative reinforcing effects of cigarette smoking as a function of initial abstinence. Psychopharmacology Berl 2009;205:305-18.

References to ongoing studies

  1. Top of page
  2. AbstractResumen摘要Résumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to ongoing studies
  21. Additional references
  22. References to other published versions of this review
NCT00273793 {unpublished data only}
  • Lamb RJ. Increasing contingency management success using shaping. Clinicaltrials.gov 2006.
NCT00508560 {unpublished data only}
  • Saxon A. Contingency management for smoking cessation among veterans with schizophrenia or other psychoses. Clinicaltrials.gov 2007.
NCT00690131 {unpublished data only}
  • Bennett ME. An integrated approach to smoking cessation in Severe Mental Illness (SMI). Clinicaltrials.gov 2008.
NCT00718835 {unpublished data only}
  • Sigmon SC. Incentive-based smoking cessation for methadone patients. Clinicaltrials.gov 2008.
NCT00865254 {unpublished data only}
  • Ledgerwood DM. Prize reinforcement for smoking cessation. Clinicaltrials.gov 2009.
NCT01145001 {unpublished data only}
  • Krishnan-Sarin S. Enhancing a High School-based smoking cessation program. Clinicaltrials.gov 2010.

Additional references

  1. Top of page
  2. AbstractResumen摘要Résumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to ongoing studies
  21. Additional references
  22. References to other published versions of this review
Ballard 2009
  • Ballard P, Radley A. Give it up for Baby: A smoking cessation intervention for pregnant women in Scotland. Cases in Public Health Communication & Marketing 2009; Vol. 3, issue www.gwumc.edu/sphhs/departments/pch/phcm/casesjournal/volume3/showcase/cases_3_09.pdf:147-60.
Benowitz 2002
  • SRNT Subcommittee on Biochemical Verification [Benowitz NL, Jacob P, Ahijevych K, Jarvis MJ, Hall S, LeHouezec J, et al. Biochemical verification of tobacco use and cessation. Nicotine and Tobacco Research 2002;4(2):149-59.
Cahill 2008a
  • Cahill, K, Moher M, Lancaster T. Workplace interventions for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 4. [DOI: 10.1002/14651858.CD003440.pub3]
Cahill 2008b
  • Cahill K, Perera R. Quit and win contests for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 2. [DOI: 10.1002/14651858.CD004986.pub2]
Grunberg 1990
  • Grunberg N. Cigarette smoking at work: data, issues, and models. In: Weiss S, Fielding J, Baum A editor(s). Health at Work. Hillsdale, New Jersey: Erlbaum, 1990.
Hughes 2003
  • Hughes JR, Keely JP, Niaura RS, Ossip-Klein DJ, Richmond RL, Swan GE. Measures of abstinence in clinical trials: issues and recommendations. Nicotine and Tobacco Research 2003;5(1):13-25.
Lumley 2009
Martinson 1999
  • Martinson BC, Murray DM, Jeffery RW, Hennrikus DJ. Intraclass correlation for measures from a worksite health promotion study: estimates, correlates, and applications. American Journal of Health Promotion 1999;13(6):347-57.
NICE 2010
  • National Institute of Health and Clinical Excellence (NICE). Should incentives be used to help people quit unhealthy habits? NICE's Citizens Council reveals its view. http://www.nice.org.uk/newsroom/pressreleases/CitizensCouncilIncentives.jsp (accessed 30/11/2010) 2010.
Reda 2009
SRNT 2002
  • SRNT Subcommittee on Biochemical Verification. Biochemical verification of tobacco use and cessation. Nicotine & Tobacco Research 2002;4(2):149-59.
USDHHS 1989
  • US Department of Health and Human Services, Office on Smoking and Health. Reducing the health consequences of smoking: 25 years of progress. CDC 89-8411, Rockville, Maryland 1989.