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 The financial amount of the incentives 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.
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.3
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.4
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.5 Another study found that incentives could improve abstinence rates among socio-economically disadvantaged individuals participating in smoking cessation treatment.6 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.7 Limited evidence also supports contingency management for smoking cessation among people with substance use and psychotic disorders.8 Contingency management also appears to be effective for helping highly impulsive adolescent smokers to quit, and to be more effective than cognitive behavioural therapy.9
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,10 see also Section 7.16.8.
Relevant news and research
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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. 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
4. 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
5. 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
6. 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
7. 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
8. 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
9. 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
10. 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