Smoking really is that addictive

I will never understand the appeal of smoking. It’s expensive, leaves an unpleasant scent, and eventually wreaks havoc on the body. Enough preaching. Quitting is hard. There was a nice study in NEJM looking at whether cash rewards help get smoker’s to quit. I found a handful of findings interesting.

 

First the details of the study: People who expressed an interest in quitting were randomized into different groups. Smoking cessation was measured at 2 weeks, 1 month, 6 months, and 12 months (verified by a urine test).

Everyone got the standard of care consisting of smoking cessation guides/counseling.

  • One group got only this standard of care.
  • Another group was given a reward ($800 total across various time points) if they remained successful quitters at each time point.
  • A third group had to pay $150 at the start. If they quit smoking for two weeks, they got $200 (initial deposit back plus a bonus). On top of that, they got more money at each additional time point they were still abstinent from smoking. However, if they were not abstinent at the first check (week two), they forfeited their deposit.

 

The results (also see the table below)

  • Only 14% of those assigned to the group that had to pay a deposit ($150 they’d lose if they didn’t quit for two weeks) agreed to participate. Almost everyone (90%) randomized to the reward-only group agreed to participate (that’s a no-brainer).
  • The few who agreed to pay an initial deposit were serious – 100% quit at week two (they made it to get back their deposit). For emphasis, however, only 14% of randomized to this group agreed to participate.
  • Aside from those who agreed to pay a deposit, success rates started low and dropped progressively over time.

* 53% quit rate is of the 14% who agreed to participate in “pay to play.” This represents only about 7% of the total number randomized to this group.

 

Data for those who participated (“Per protocol analysis”)
Quit rate Standard care Reward for quitting “Pay to play” plus reward
quit rate – 2 weeks 14% 28% 100%
quit rate – 1 month 11% 24% 98%
quit rate – 6 months 6% 17% 53%*
quit rate – 12 months 3% 9% 36%

Ok… on to the observations I found interesting:

  • Of the people who were asked to be in the “pay a deposit” group, 86% said “no thanks.” Wow. Remember they would get their money back (plus some) if they quit for a mere two weeks. Even that was too daunting for most. Either most people weren’t serious about quitting, or if they were serious they had no confidence to make it even two weeks.
  • Of the people in the straight reward group, only 28% quit at two weeks. The remaining 72% could not even make it two weeks. Remember, all of the people in the study expressed some interest in quitting. Even the promise of getting $100 couldn’t get most people to quit for just two weeks.**
  • In the study, people with insurance provided through CVS Caremark got free behavioral modification programs and free nicotine replacement therapy. These freebies had no difference on quit rates. I was a little surprised by that. My take is that will power is the main (perhaps only) determinant.
  • Quit rates are abysmal. At one year, less than 5-10% had quit.

**I think $100 seems like a nice monetary reward, but maybe it doesn’t matter to smokers. A pack of cigarettes costs $6 on average across the US ($12.85 in New York). AT $6/pack, a pack-a-day smoker who quits will save $84 in two weeks just by not buying cigarettes. That translates to savings of $2,200 per year.

Interesting stuff. Quitting is tough. It goes without saying (but I’ll say it anyway), this is a habit best never started in the first place.

 

Source: New England Journal of Medicine Abstract ‘Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation’; New England Journal of Medicine (Full Article) ‘Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation’

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