Tobacco Use: Incentives and Competitions to Increase Smoking Cessation Among Workers – When Combined With Additional Interventions

The CPSTF finding is based on evidence from a systematic review of 12 studies (search period January 1980 – March 2005).

The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to reducing tobacco use and secondhand smoke exposure.

More details about study results are available in the CPSTF Finding and Rationale Statement.

The systematic review included 12 studies.

• One group randomized trial found a reduction in self-reported tobacco use of 2.1 percentage points (p=0.03) among workers from 32 worksites that offered smoking cessation programs and self-imposed payroll withholdings.
• Tobacco quit rates increased by a median of 4.3 percentage points (14 study arms in 11 studies).
  • Program participants achieved a median quit rate of 15%.
  • The median period of follow-up was 12 months.
• A subset of five studies evaluated a similar combination of interventions (including at a minimum, an incentive, a worksite-based tobacco cessation group, and educational materials or activities). In these studies, tobacco quit rates increased by a median of 10 percentage points.
  • Program participants achieved a median quit rate of 21%.
  • The median period of follow-up was 12 months.

A review of economic evidence found inconsistencies in study designs making it difficult to draw conclusions about potential cost savings.

Findings from this review should be applicable to U.S. worksites where there are more than 100 employees. Studies included in this review were done in urban and suburban areas in the United States and comprised manufacturing plants, healthcare facilities, government offices, a university, chemical plants, and an ambulance service.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

• Which combinations of incentives and rewards are most effective?
• What are short and long term cessation rates for tobacco users based on the inclusion or absence of an incentive or competition?
• What would be the effect of giving workers access to nicotine replacement therapies (and other effective pharmacotherapies), as part of a combined cessation program?
• What are program participation rates?

• Interventions that were combined with incentives and competitions included the following:
  • Client education
  • Smoking cessation groups
  • Self-help cessation materials
  • Telephone cessation support
  • Workplace smoke-free policies
  • Social support networks
• Individual rewards ranged from $10 to $237.
• Lottery prizes ranged from $40 to $500.
• Studies included in this review were conducted in the United States
  • Manufacturing plants, healthcare facilities, government offices, a university, chemical plants, and an ambulance service
  • Companies or worksites with more than 100 employees
  • Urban and suburban settings
• The presence of an incentive or competition was not associated with a consistent increase in participation in worksite tobacco programs in the studies considered in this review; however participation rates were high in most of the intervention and comparison study arms.

Leeks KD, Hopkins DP, Soler RE, Aten A, Chattopadhyay SK, Task Force on Community Services. Worksite-based incentives and competitions to reduce tobacco use: a systematic review. American Journal of Preventive Medicine 2010;38(2S):263-274.

Task Force on Community Services. Recommendations for worksite-based interventions to improve workers’ health. American Journal of Preventive Medicine 2010;38(2S):232-236.

Effectiveness Review

Analytic Framework – See Figure 1 on page S265

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table — Effectiveness Review

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Burling TA, Marotta J, Gonzalez R, et al. Computerized smoking cessation program for the worksite: treatment outcome and feasibility. J Consult Clin Psychol 1989;57(5):619-22.

Glasgow RE, Hollis JF, Ary DV, Boles SM. Results of a year-long incentives-based worksite smoking-cessation program. Addict Behav 1993;18(4):455-64.

Gomel M, Oldenburg B, Simpson JM, Owen N. Work-site cardiovascular risk reduction: a randomized trial of health risk assessment, education, counseling, and incentives. Am J Public Health 1993;83(9):1231-8.

Hennrikus DJ, Jeffery RW, Lando HA, et al. The SUCCESS project: the effect of program format and incentives on participation and cessation in worksite smoking cessation programs. Am J Public Health 2002;92(2):274-9.

Jason LA, Jayaraj S, Blitz CC, Michaels MH, Klett LE. Incentives and competition in a worksite smoking cessation intervention. Am J Public Health 1990;80(2):205-6.

Jason LA, Salina D, McMahon SD, Hedeker D, Stockton M. A worksite smoking intervention: a 2 year assessment of groups, incentives and self-help. Health Educ Res 1997;12(1):129-38.

Jeffery RW, Forster JL, French SA, et al. The Healthy Worker Project: a work-site intervention for weight control and smoking cessation. Am J Public Health 1993;83(3):395-401.

Klesges RC, Glasgow RE, Klesges LM. Competition and relapse prevention training in work site smoking modification. Health Educ Res 1987;2:5-14.

Koffman DM, Lee JW, Hopp JW, Emont SL. The impact of including incentives and competition in a workplace smoking cessation program on quit rates. Am J Health Promot 1998;13(2):105-11.

Olsen GW, Lacy SE, Sprafka JM, et al. A 5-year evaluation of a smoking cessation incentive program for chemical employees. Prev Med 1991;20(6):774-84.

Salina D, Jason LA, Hedeker D, et al. A follow-up of a media-based, worksite smoking cessation program. Am J Community Psychol 1994;22(2):257-71.

Windsor RA, Lowe JB. Behavioral impact and cost analysis of a worksite self-help smoking cessation program. Prog Clin Biol Res 1989;293:231-42.

Economic Review

Jason LA, Lesowitz T, Michaels M, et al. A worksite smoking cessation intervention involving the media and incentives. Am J Community Psychol 1989;17(6):785 99.

Jason LA, McMahon SD, Salina D, et al. Assessing a smoking cessation intervention involving groups, incentives, and self-help manuals. Behav Ther 1995;26(3):393 408.

Serxner S, Adams VG, Hundahl LS, Lau S, Adessa CJ Jr, Hopkins D. A smoking cessation pilot program. Hawaii Med J 1993;52(10):266 72.

Tanaka H, Yamato H, Tanaka T, et al. Effectiveness of a low-intensity intra-worksite intervention on smoking cessation in Japanese employees: a three-year intervention trial. J Occup Health 2006;48(3):175 82.

The following outlines the search strategy for incentives and competitions to increase smoking cessation among workers, when used alone or in combination with other interventions.

Effectiveness Review

The articles to be reviewed were obtained from systematic searches of multiple databases, reviews of bibliographic reference lists, and consultations with experts in the field. The following databases were searched for the period January 1980 March 2005: Medline, PsycINFO, EMBASE, and the database of the CDC’s Office on Smoking and Health. The keywords used for the search were health behavior, health education, primary prevention, work, workplace, occupational health, smoke, tobacco, air pollution, indoor, tobacco smoke pollution, smoking cessation, insurance coverage, nicotine dependence treatment, motivation, incentives, compete, competition, and contest. Other relevant sources were identified from the bibliographies of pertinent articles.

Database: Ovid MEDLINE(R)

1. exp health behavior/ (22792)
2. exp health education/ (30978)
3. health promotion/(12410)
4. exp primary prevention/ (23463)
5. 1 or 2 or 3 or 4 (82228)
6. exp work/(2185)
7. workplace/(3661)
8. occupational health/ (7101)
9. 6 or 7 or 8 (11786)
10. (smok$ or tobacco).mp. [mp=title, original title, abstract, name of substance, mesh subject heading] (58152)
11. 5 and 9 and 10 (132)
12. air pollution, indoor/lj (44)
13. smoking/lj or tobacco smoke pollution/lj (911)
14. smoking cessation/ and insurance coverage/(27)
15. smoking cessation/ and nicotine dependence treatment$.mp. [mp=title, original title, abstract, name of substance, mesh subject heading] (12)
16. 12 or 13 or 14 or 15 (977)
17. 11 or 16 (1100)
18. limit 17 to (english language and yr=2002 – 2004) (315)
19. limit 18 to “review articles” (38)
20. from 19 keep 1-38 (38)
21. 21 18 not 19 (277)

Database: EMBASE

1. (smok$ or tobacco).mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name] (52779)
2. Health Behavior/ (6295)
3. health promotion/ (11391)
4. health care psychology.mp. or health education/ [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name] (10276)
5. prevention/ or health screening/(5934)
6. 2 or 3 or 4 or 5 (30601)
7. exp occupational health/ (34897)
8. exp workplace/ (5259)
9. 7 or 8 (37311)
10. 1 and 6 and 9 (220)
11. indoor air pollution/ and (polic$ or law$ or ordinance$).mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name] (73)
12. smoking/ and ((ban$ or restriction$).mp. or pollution/ or passive smoking/) [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name] (831)
13. smoking cessation/ and insurance/ (4)
14. smoking cessation/ and nicotine dependence treatment$.mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name] (18)
15. 11 or 12 or 13 or 14 (920)
16. 10 or 15 (1126)
17. limit 16 to (english language and yr=2002 – 2004) (412)
18. limit 17 to “review” (65)
19. from 18 keep 1-65 (65)
20. 17 not 18 (347)
21. from 20 keep 1-347 (347)

Database: PsycINFO

1. health behavior/(2320)
2. exp health care psychology/(913)
3. exp health education/(1449)
4. health promotion/(1688)
5. exp prevention/(6047)
6. exp health screening/(1003)
7. 1 or 2 or 3 or 4 or 5 or 6 (11545)
8. work$.hw. (6748)
9. 7 and 8 (206)
10. (smok$ or tobacco).mp. [mp=title, abstract, subject headings, table of contents, key concepts] (5334)
11. 9 and 10 (18)
12. (indoor air and (polic$ or law$ or ordinance$)).mp. [mp=title, abstract, subject headings, table of contents, key concepts] (4)
13. tobacco smoking/and (ban$ or restriction$).mp. [mp=title, abstract, subject headings, table of contents, key concepts] (121)
14. (second-hand smoke or passive smoking).mp. [mp=title, abstract, subject headings, table of contents, key concepts] (37)
15. smoking cessation/and health insurance/(5)
16. smoking cessation/and nicotine dependence treatment$.mp. [mp=title, abstract, subject headings, table of contents, key concepts] (2)
17. 12 or 13 or 14 or 15 or 16 (162)
18. 11 or 17 (180)
19. limit 18 to (english language and yr=2002 – 2004) (123)
20. 20 limit 19 to “1300 literature review” (8)
21. from 20 keep 1-8 (8)
22. 19 not 20 (115)
23. from 22 keep 1-115 (115)

CDP Search Criteria- Smoking and Health Database

Descriptors: (“health behaviors” or “health education” or “health promotion” or “prevention of smoking”) and (work*) and
(smok* or tobacco*) and
Publication Year: 2002 To 2004

Descriptors: “indoor air pollution” or “tobacco pollution” and
Textwords: polic* or law* or ordinance* and
Publication Year: 2002 To 2004

Descriptors: “smoking cessation” and
Textwords: insurance or nicotine adj dependence adj treatment* and
Publication Year: 2002 To 2004

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• Implementers should understand state policies regarding application of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to the use of economic incentives in the workplace.
• The logistics of verifying smoking cessation may present additional costs.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce current tobacco use in adults — TU‑01
• Reduce current cigarette smoking in adults — TU‑02
• Reduce current cigarette, cigar, and pipe smoking in adults — TU‑03
• Reduce current tobacco use in adolescents — TU‑04
• Reduce current cigarette smoking in adolescents — TU‑06
• Reduce current cigar smoking in adolescents — TU‑07
• Reduce current use of smokeless tobacco products among adolescents — TU‑08
• Increase past-year attempts to quit smoking in adults — TU‑11
• Increase use of smoking cessation counseling and medication in adults who smoke — TU‑13
• Increase successful quit attempts in adults who smoke — TU‑14