In a large, workplace-based randomized trial, smokers offered up to $600 to remain tobacco-free for 6 months were significantly more successful than those given free access to conventional cessation aids or to e-cigarettes.
But in absolute terms, the efforts were all wildly unsuccessful, with 6-month abstinence rates not even reaching 3% with the top-performing inducements, researchers reported in the New England Journal of Medicine.
“This trial showed that among unselected smokers, workplace smoking-cessation programs yielded low rates of smoking abstinence,” acknowledged Scott Halpern, MD, PhD, of the University of Pennsylvania in Philadelphia, and colleagues.
Moreover, “offering free cessation aids or free e-cigarettes did not increase abstinence among smokers who were given access to information and motivational text messages.”
The best rates were among participants offered both free cessation aids and a monetary reward of up to $600 at the 6-month benchmark.
But advocates of e-cigarettes for smoking cessation may take comfort in the study’s finding that sustained quit rates among those assigned to receive free NJOY vaping devices were twice as great as among participants offered a variety of free cessation aids (1.0% vs 0.5%) which could include e-cigarettes as well as conventional medications and nicotine replacement products.
The study involved employees at 54 companies, where a total of 6,131 were identified as smokers and were invited to participate in the trial through an opt-out procedure. After 125 proactively declined, the remaining 6,006 were randomized to be offered one of five interventions:
- “Usual care” consisting of information and motivational text messages (n=813)
- Free NJOY e-cigarettes in multiple flavors with no free access to other cessation aids (n=1,199)
- Free cessation aids including any approved nicotine replacement product or medication such as varenicline (Chantix) or bupropion (Zyban), as well as e-cigarettes (n=1,588)
- $600 paid in increments through the study period, based on remaining abstinent, plus free cessation aids (n=1,198)
- $600 deposit account redeemable at 6 months, but reduced in increments for failing to meet interim milestones, plus free cessation aids (n=1,208)
Participants could accept the intervention or not at their discretion. They were asked to report whether they were abstinent at months 1, 3, and 6, and also provided urine samples at these time points for cotinine testing as confirmation. Alternative tests were employed for participants using nicotine replacement therapies or e-cigarettes. If participants reported continued smoking or the testing indicated non-abstinence, the financial incentives were docked accordingly.
Because participants had not volunteered on their own initiative to stop smoking, Halpern and colleagues did not expect large numbers of cessation attempts or successes. As part of the study, participants were invited to access a website with smoking-cessation information that was also the portal through which they could order cessation aids or e-cigarettes. The researchers used participants’ history of website visits to gauge “engagement” with the program — that is, a demonstrated effort to quit smoking. Overall, only about 20% visited the website, with little variation among intervention groups.
Confirmed abstinence rates at 6 months among all those assigned to the interventions were as follows:
- Usual care: 0.1%
- Free cessation aids: 0.5%
- Free e-cigarettes: 1.0%
- $600 rewards paid during the study: 2.0%
- $600 deposit account redeemable after the study: 2.9%
But among the 1,191 who used the website and thus were considered engaged, “sustained abstinence rates were four to six times as high as those among participants who did not actively engage,” Halpern and colleagues wrote. In this group, 6-month abstinence rates ranged from 0.7% with usual care to 12.7% for the redeemable $600 deposit.
When the researchers looked for statistically significant differences among the interventions in the engaged subgroups, they found three:
- Redeemable deposit was superior to free cessation aids (OR 4.85, 95% CI 2.21-10.67)
- Redeemable deposit was superior to free e-cigarettes (OR 2.93, 95% CI 1.49-5.79)
- Reward was superior to free cessation aids (OR 3.47, 95% CI 1.53-7.87)
Although abstinence among those assigned to free e-cigarettes was numerically higher than for those assigned to a variety of cessation aids, both in the intention-to-treat population and the engaged subgroups, the differences did not come close to statistical significance when adjustments were made for the multiple comparisons.
Among the study limitations listed by Halpern and colleagues was the lack of a group receiving free conventional cessation aids only, without access to e-cigarettes. Nor was the combination of financial incentives plus e-cigarettes tested. But the researchers found that only one-third of engaged participants who could use a variety of cessation aids ever ordered e-cigarettes, versus 55% of the engaged subgroup assigned to free e-cigarettes. This, they argued, “supports the conclusion that offering free-e-cigarettes does not promote smoking cessation.”
The study was funded by the Vitality Institute.
Two co-authors reported relationships with VAL Health (behavioral economics consultant), CVS Health, Humana, Merck, Weight Watchers, Oscar Health Insurance, and Hawaii Medical Services Association. Halpern and other authors declared they had no relevant financial interests.
Primary Source
New England Journal of Medicine
