7.17 Incentives and rewards for quitting

Contingency management is a behavioural intervention that uses incentives or rewards, such as cash payments, vouchers for goods and groceries, material goods, or the return of money deposited by participants, to prompt or reinforce behaviour change. Incentives are often included as part of smoking cessation programs in order to encourage participation in a program, to reward compliance, and/or to reward abstinence at various time points.¹ Such schemes have been run in the workplace, in community settings, or in clinics and health centres.

Financial incentives work differently for different people over time. Initially, they may spark or reinforce interest in stopping smoking, encouraging those who need extra motivation to change their behaviours. Later, as individuals become more engaged, incentives reinforce the value of their efforts through ongoing verification of abstinence, building confidence and self-esteem through encouragement and rewards.²

7.17.1 Efficacy of contingency management

A 2019 Cochrane review found people receiving incentives were more likely to successfully quit smoking than those in control groups.³ The effects were recorded after six months or longer and continued beyond when the incentives had ended.  Previous reviews examining contingency management expressed concern that the effects of incentives may be time limited. However, findings from the 2019 review suggest incentives continue to have a significant impact upon sustained smoking cessation beyond the end of the incentive program.³

A 2021 Cochrane review of behavioural inventions found high certainty evidence that the provision of financial incentives increases the quit rate, with similar effectiveness to counselling. Compared with those who received no smoking cessation support, people who received guaranteed financial incentives had 1.5 times greater odds of successfully quitting.⁴ Further meta-analyses have also found financial incentives to be an effective cessation intervention.⁵

7.17.2 Impact of incentive structure and amount

The 2019 Cochrane review compared the financial amount of the incentives that varied between trials, ranging from zero (self-deposits) to USD $1,185; however, no clear benefits were observed for high compared with low value incentives.^{3, 6} A 2020 meta-analysis similarly found no clear relationship between the amount of financial incentives and the quit rates. In further studies examining people who smoke’s perceptions of hypothetical incentives, greater financial incentives increased program appeal and likelihood of enrolment, but this effect slowed for higher amounts, indicating a possible ceiling point.^{7, 8} Participants preferred cash incentives delivered in consistent amounts over vouchers and programs delivered in healthcare settings.⁸ The incentive amount may also affect socioeconomic groups differently. High-income participants found incentives less appealing and motivating than low-income participants,⁷ and middle- and high-income participants preferred slightly higher incentive amounts⁸. Despite these differences, willingness to enrol in programs was similar across income groups,⁷ regardless of incentive amount⁸. For more information on financial incentives for low-income and other priority groups, see Section 7.7.3.

A randomised control trial among pharmacy employees in the US explored the efficacy of deposit or ‘commitment’ contracts. Some people who smoke were offered the chance to win $800 if they could quit for six months, while others were asked to put $150 down as a deposit. If they quit for six months, they would get their $150 back plus $650—a total of $800. Those who put in their own money had significantly higher rates of abstinence than the pure reward group; however, far fewer smokers were willing to sign up to it. Therefore, rewards for quitting were more effective overall than deposit-based contracts owing to their much higher rate of acceptance.⁹

It remains unclear whether competitions encouraging smoking cessation—i.e. giving individuals or groups an opportunity to win a prize following successful cessation—enhance long-term cessation rates. A 2019 Cochrane review determining the success of competitions was unable to draw any firm conclusions about the effectiveness of competitions, due to a lack of well-designed comparative studies.¹⁰

7.17.3 Efficacy among priority populations

Financial incentives may be particularly useful for promoting quitting among priority populations. US studies have found that offering financial incentives for smoking abstinence appeared to be an effective way to facilitate short-term smoking cessation for veterans and other people experiencing homelessness.^{11, 12} Another study found that incentives could improve abstinence rates among socio-economically disadvantaged individuals participating in smoking cessation treatment.¹³ Large financial incentives—up to USD $1,650—were shown to be effective for long-term cessation among low-income individuals. A randomised controlled trial biochemically verified abstinence in intervals for 18 months, with the incentives group consistently outperforming the control group at each interval point throughout the trial.¹⁴ Among the participants who did not quit during the trial, those who received incentives had greater motivation and intention to quit at follow-up.¹⁵

The impact of financial incentives on reducing smoking around children has shown mixed results. One study found no difference in cotinine levels (which measure exposure to nicotine) between mothers with low-income offered usual care plus incentives and those offered usual care alone.¹⁶ Another study of mothers with young children found the addition of financial incentives to usual care was associated with smoking cessation, but not a reduction in children’s exposure to secondhand smoke.¹⁷

Financial incentives did not increase quit rates or participation in cessation interventions in a study of low-income hospitalised patients.¹⁸ An Australian trial of a single small financial incentive for patients on elective surgery wait-list also found no difference in perioperative smoking abstinence between those who received incentives and usual care compared to usual care alone.¹⁹

There is evidence that incentives can be beneficial for smokers with a mental illness. A trial found that the addition of incentives to a behavioural and pharmacological cessation program  increased abstinence among smokers with depression and was highly cost-effective.²⁰ There is also evidence that contingency management increases short-term smoking abstinence among people with substance use and limited evidence supporting incentives for smoking cessation among people with psychotic disorders.^{21, 22} Contingency management also appears to be effective for helping highly impulsive adolescent smokers to quit, and to be more effective than cognitive behavioural therapy.²³ See Section 9A.3.5 for a detailed discussion of cessation interventions for people with mental health conditions.

Pregnant women have been shown to be more likely to successfully stop smoking when involved in an incentive scheme. Improved smoking cessation rates have been recorded at the end of pregnancy through biochemically verified abstinence, as well as post-partum.^{3, 24} For more information on the use of financial incentives among pregnant women, see Section 7.11.5.

Healthcare financing systems, set up to encourage smoking cessation by covering the cost of treatments for patients, have been found to increase the number of people who smoke who attempt to quit, use smoking cessation treatments, and succeed in quitting, when compared with no financial help,²⁵ see also Section 7.16.8.

Relevant news and research

For recent news items and research on this topic, click here. (Last updated August 2024)

References

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2. Siersbaek R, Kavanagh P, Ford J, Burke S, and Parker S. How and why do financial incentives contribute to helping people stop smoking? A realist review. BMC Public Health, 2024; 24(1):500. Available from: https://www.ncbi.nlm.nih.gov/pubmed/38365629

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