Incentive-based smoking cessation programs could work in hard-to-reach pockets of smokers across the developing world

While rates of cigarette smoking continue to inch down worldwide, tobacco use still accounts for 6.4 million deaths a year. Low- and middle-income countries (LMICs) are particularly hard hit, seeing nearly three-quarters of those deaths. In a study published today in BMJ, Justin White, PhD – an assistant professor of health economics jointly appointed in the Philip R. Lee Institute for Health Policy Studies and the Department of Epidemiology and Biostatistics – shows that employee wellness programs have the potential to make a significant difference. These programs have become commonplace in the United States but have not yet taken off in LMICs.

White and colleagues at UC Berkeley and Mahidol University conducted a cluster-randomized trial that considered eight monetary incentive programs for smoking cessation. The control group received group counseling and individual quitting support by text message. The incentive programs tested combinations of multiple strategies: receiving a smaller or larger individual bonus for quitting, making financial deposits that are refunded if the individual successfully quits, and earning a larger bonus if both an individual and their assigned teammate successfully quit. The study assigned worksites to different arms to make for easier implementation and to avoid having participants compare their incentives to their coworkers’.

White and his colleagues recruited more than 4,000 blue-collar workers from 101 Bangkok-area worksites in Thailand. Nearly three in five smokers employed at the worksites voluntarily joined the program, suggesting a significant unmet demand for smoking cessation support. The workers in the study were mainly factory workers, who have higher smoking prevalence than white-collar workers in Thailand and face more barriers to access to smoking cessation medications.

This study was one of the largest to date to evaluate incentive-based smoking cessation programs and one of the first to look at workplace programs in an LMIC context.

All interventions led to greater rates of successful quitting at 12 months than the control. In the most effective arm – a $40 individual bonus – the share of participants who had quit at 12 months was 13 percentage points (or 135%) higher than in the control group. Many participants in the bonus groups continued to abstain from smoking even after the bonuses were handed out at the three-month mark, according to the urine tests at 12 months. Even in combination with other interventions, a bonus stood out as the most effective strategy.

“Any incentive was more effective than the control group, but incentive design matters,” White said, summing up the findings. “It’s not a one size fits all.” This builds on similar recent findings from behavioral economics research.   

The researchers had expected to find refundable deposits more effective than bonuses, as research in the United States has suggested. “The people who agree to put their own money at risk tend to be more motivated,” White said. He suggested that study designs should account for different types of smokers selecting into different types of interventions. The BMJ study did so by following up with all eligible individuals, regardless of whether they accepted their assigned program.

The authors also expected team-based interventions to contribute to higher rates of successful abstinence, particularly in a culture which values collectivity. But the individual incentives proved more effective. White hypothesizes that this could also be a question of how the incentive was set up. Teammates were assigned randomly, which meant in practice that many buddies had never met before and worked in different parts of the large companies studied. In future work, White hopes to leverage existing social networks to promote greater support and accountability.

The published work makes the case that incentive-based employer programs can help drive down smoking in LMICs. And the employers generally expressed interest in continuing the incentive programs. The companies would likely need organizational support to get the programs up and running, White said, but cost would not be a significant barrier.

In Thailand, employers pay part of the health insurance costs of their workers. White noted, “There’s still a motivation even in settings where the employer isn’t paying for employee health insurance to care about the wellness and productivity of their workforce.”