7.17 Contingency management/incentives

Last updated: May 2021

Suggested citation: Jenkins, S., Hanley-Jones, S., & Greenhalgh, EM., 7.17 Contingency management/incentives. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2021. Available from: http://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-17-financial-incentives

 

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.

A 2019 Cochrane review found people receiving incentives were more likely to successfully quit smoking than those in control groups.2 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.2

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, smokers who received guaranteed financial incentives had 1.5 times greater odds of successfully quitting.3

The 2019 Cochrane review compared the financial amount of the incentives that varied between trials, ranging from zero (self-deposits) to USD $1,185, although, no clear direction was observed between trials offering low or high value incentives.2, 4 A 2020 meta-analysis similarly found no clear relationship between the amount of financial incentives and the quit rates. In a further study, examining smokers’ perceptions of hypothetical incentives, greater financial incentives increased program appeal, though it did not significantly increase likelihood of enrolment.5 The incentive amount may also affect socioeconomic groups differently. In the hypothetical incentives study, high-income smokers reported that the incentives were less appealing and motivating than low-income smokers, though both groups were equally likely to enrol in the programs.5

A randomised control trial among pharmacy employees in the US explored the efficacy of deposit or ‘commitment’ contracts. Some smokers 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.6

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.7

Financial incentives may be useful for promoting quitting among priority populations. One small study in the US found that offering small financial incentives for smoking abstinence appeared to be an effective way to facilitate smoking cessation for people experiencing homelessness.8 Another study found that incentives could improve abstinence rates among socio-economically disadvantaged individuals participating in smoking cessation treatment.9 Large financial incentives—up to USD $1,650—have proven to be effective for long-term smoking cessation among low-income smokers. A Swiss 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.10 Though a study examining the impact of financial incentives for mothers with low incomes to reduce smoking around children found that there was no difference in cotinine levels (which measure exposure to nicotine) between caregivers who were offered usual care plus incentives and those who were offered usual care alone. The intervention was also not effective in reducing children’s exposure to secondhand smoke.11 Another study found that incentives did not significantly increase quit rates or intervention participation among low-income hospitalised patients.12

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.13 There is also evidence that contingency management increases short-term smoking abstinence amoung people with substance use and limited evidence supporting contingency management for smoking cessation among people with psychotic disorders.14, 15 Contingency management also appears to be effective for helping highly impulsive adolescent smokers to quit, and to be more effective than cognitive behavioural therapy.16 See Section 7.12 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.2  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 smokers who attempt to quit,   use smoking cessation treatments, and succeed in quitting, when compared with no financial help,17 see also Section 7.16.8.


Relevant news and research

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References 

1. Cahill K, Hartmann-Boyce J, and Perera R. Incentives for smoking cessation. Cochrane Database of Systematic Reviews, 2015; 5:CD004307. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25983287

2. Notley C, Gentry S, Livingstone-Banks J, Bauld L, Perera R, et al. Incentives for smoking cessation. Cochrane Database of Systematic Reviews, 2019; 7:CD004307. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31313293

3. Hartmann-Boyce J, Livingstone-Banks J, Ordonez-Mena JM, Fanshawe TR, Lindson N, et al. Behavioural interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database of Systematic Reviews, 2021; 1:CD013229. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33411338

4. Baker TB and McCarthy DE. Smoking Treatment: A Report Card on Progress and Challenges. Annual Review of Clinical Psychology 2021; 17:1-30.

5. Breen RJ, Ferguson SG, and Palmer MA. Smokers' perceptions of incentivised smoking cessation programmes: Examining how payment thresholds change with income. Nicotine and Tobacco Research, 2021. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33621322

6. Halpern SD, French B, Small DS, Saulsgiver K, Harhay MO, et al. Randomized trial of four financial-incentive programs for smoking cessation. New England Journal of Medicine, 2015; 372(22):2108–17. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25970009

7. Fanshawe TR, Hartmann‐Boyce J, Perera R, and Lindson N. Competitions for smoking cessation. Cochrane Database of Systematic Reviews, 2019; (2). Available from: https://doi.org//10.1002/14651858.CD013272

8. Businelle MS, Kendzor DE, Kesh A, Cuate EL, Poonawalla IB, et al. Small financial incentives increase smoking cessation in homeless smokers: a pilot study. Addictive Behaviors, 2014; 39(3):717–20. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24321696

9. Kendzor DE, Businelle MS, Poonawalla IB, Cuate EL, Kesh A, et al. Financial Incentives for Abstinence Among Socioeconomically Disadvantaged Individuals in Smoking Cessation Treatment. American Journal of Public Health, 2015; 105(6):1198–205. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25393172

10. Etter JF and Schmid F. Effects of Large Financial Incentives for Long-Term Smoking Cessation: A Randomized Trial. Journal of the American College of Cardiology, 2016; 68(8):777–85. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27539168

11. Jassal MS, Lewis-Land C, Thompson RE, and Butz A. Randomised pilot trial of cash incentives for reducing paediatric asthmatic tobacco smoke exposures from maternal caregivers and members of their social network. Archives of Disease in Childhood, 2020. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33004310

12. Ladapo JA, Tseng CH, and Sherman SE. Financial Incentives for Smoking Cessation in Hospitalized Patients: A Randomized Clinical Trial. American Journal of Medicine, 2020. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31982494

13. Gonzalez-Roz A, Weidberg S, Garcia-Perez A, Martinez-Loredo V, and Secades-Villa R. One-year efficacy and incremental cost-effectiveness of contingency management for cigarette smokers with depression. Nicotine and Tobacco Research, 2020. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32772097

14. Ledgerwood DM. Contingency management for smoking cessation: where do we go from here? Current Drug Abuse Reviews, 2008; 1(3):340–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19630730

15. Secades-Villa R, Aonso-Diego G, Garcia-Perez A, and Gonzalez-Roz A. Effectiveness of contingency management for smoking cessation in substance users: A systematic review and meta-analysis. Journal of Consulting and Clinical Psychology, 2020; 88(10):951-64. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33048571

16. Morean ME, Kong G, Camenga DR, Cavallo DA, Carroll KM, et al. Contingency management improves smoking cessation treatment outcomes among highly impulsive adolescent smokers relative to cognitive behavioral therapy. Addictive Behaviors, 2015; 42:86–90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25462659

17. van den Brand FA, Nagelhout GE, Reda AA, Winkens B, Evers S, et al. Healthcare financing systems for increasing the use of tobacco dependence treatment. Cochrane Database of Systematic Reviews, 2017; 9:CD004305. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28898403