Floor Van Den Brand

Tobacco smoking causes serious and often fatal conditions including cardiovascular disease, cancer and respiratory disease. Smoking is therefore a serious health threat and leads to high healthcare costs.

In 2018, 22% of people aged 18 years and older smoked in the Netherlands. However, the percentage of smokers in Western countries is not equally divided among the population. Smoking is more prevalent among people with a low socioeconomic status than among people with a high socioeconomic status. In the Netherlands, 27% of the lower educated and 16% of the higher educated population smoked in 2018. Although the number of smokers in Western countries, including the Netherlands, has slowly declined in recent years, this gap in smoking prevalence has widened. Smoking is therefore the main cause of socioeconomic differences in health and mortality in Western countries.

There are several treatments that can effectively help people to quit smoking, such as behavioral support and pharmacological therapy. However, many interventions are less effective for people with a lower socioeconomic status. This is partly because there are barriers for them to receive treatment and to quit smoking, such as financial thresholds or a lack of social support for quitting smoking. To decrease smoking in society and to reduce the socioeconomic gap in smoking prevalence, it is therefore important to develop effective interventions that help people quit smoking. The aim of this dissertation was to investigate whether financial incentives for smoking cessation can enhance quit success among employees who participate in a workplace smoking cessation group training.

In this thesis, we answered the following research questions:

1. Can providing free smoking cessation treatment increase use of treatment, quit attempts and smoking cessation in people who smoke?

2. Are financial incentives for quit success on top of a workplace smoking cessation group training program effective at increasing smoking cessation in employees who smoke?

3. How does a workplace smoking cessation group training program with incentives increase quit success?

4. Are financial incentives on top of a workplace smoking cessation group training program a cost-effective intervention?

5. According to employers, what are the barriers and facilitators for the implementation of a smoking cessation group training program with incentives in workplaces?

The first research question is addressed in Chapters 2 and 3. In Chapter 2, we describe a systematic review that examines the impact of reducing the costs for smokers or health care providers in using or giving smoking cessation treatments. The results showed that financial interventions for smokers led to more use of smoking cessation treatments, more quit attempts, and more successful quitters. There was no consistent evidence for an effect of financial interventions targeting healthcare providers.

In chapter 3, we describe a questionnaire study among representative cohorts of 1164 Dutch smokers and 768 smokers from the United Kingdom (UK). The aim was to investigate whether free or lower-cost smoking cessation medication was a trigger for respondents to think about quitting smoking. The results showed that smokers from the Netherlands and the UK who mentioned this trigger were more likely to actually use medication during a quit attempt. In addition, in the UK only, we saw an association between quit attempts and mentioning free or lower-cost smoking cessation medication as a trigger to think about quitting smoking. We found no statistically significant associations with smoking cessation success. Based on the two studies described above, it can be concluded that funding smoking cessation treatments for smokers can have a positive impact on the number of people using these treatments, and may increase quit attempts and quit success. Therefore, reimbursing smoking cessation treatments can be a good strategy to promote smoking cessation in society.

We address the second research question in Chapters 4 and 5: Are financial incentives for quit success on top of a workplace smoking cessation group training program effective at increasing smoking cessation in employees who smoke? Chapter 4 describes the protocol of a cluster randomized controlled trial (RCT), the results of which we present in chapter 5. In the study, we evaluated the effect of adding financial incentives for smoking cessation to a workplace group smoking cessation training program on abstinence from smoking. The survey involved 604 smoking employees from 61 Dutch companies. All participants followed a smoking cessation group training program at the workplace, consisting of 7 weekly 90-minute sessions. In half of the companies, employees who successfully quit smoking also earned financial incentives in the form of digital gift certificates with a total value of € 350. In the other half of the companies, employees only attended a group training and were not rewarded for quit success. The results showed that after 12 months in the group of employees who only attended smoking cessation training, 26% had stopped smoking. In the group of employees who also earned financial incentives, 41% had stopped; a statistically significant increase. An important finding was that the incentives also had a positive effect on quit success among participants with a low socioeconomic status. The results of this study show that financial incentives can substantially increase the effectiveness of a smoking cessation group training. This finding can motivate employers to organize a smoking cessation training with financial incentives to support their employees in quitting smoking.

The studies in chapters 6, 7 and 8 answer the third research question: How does a workplace smoking cessation group training program with incentives increase quit success? In chapter 6, we describe a qualitative study in which we interviewed 24 participants who participated in a smoking cessation group training at the workplace and earned gift vouchers for quit success. The purpose of the interviews was to find out the factors that, according to the interviewees, had contributed positively to smoking cessation. According to the participants, important success factors were the accessibility of a workplace training, the social support and peer pressure of colleagues, support from family members, strategies for not smoking that were learned during the training, and personal motivation to quit smoking. The incentives were considered a nice added bonus, but not the reason for quitting smoking. Interviewees with a low income found the incentives more attractive. This study shows that a smoking cessation group training with financial incentives at the workplace is a pleasant way to quit smoking, according to participants.

In chapter 7, we investigated the influence of smoking behavior and social support of persons in the social environment on the quit success of employees who participated in a group smoking cessation training at the workplace by means of a questionnaire study. We found that social support from colleagues was positively associated with quit success immediately after training completion and after 12 months. Partner support was also positively associated with quit success, but only in the short term. In addition, the smoking behavior of the partner was associated with quit success; participants without a partner or with an (ex-) smoker as a partner quit smoking less often. Finally, there was a negative relationship between having more smokers in the immediate social environment and quit success. These results underline the important influence that the social environment has on smoking cessation success. It is therefore important not only to look at the individual who wants to quit smoking, but also to include his or her social environment in the attempt to quit.

In chapter 8, we performed a path analysis with the aim of investigating how financial incentives can lead to smoking cessation success. We tested a model in which we examined the effect of financial incentives via the mediators: training evaluation, medication use, use of nicotine substitutes, attitudes, self-efficacy and social influences, on quit success. The results showed that personal incentive sensitivity did not affect the relationship between incentives and quit success. The effect of financial incentives on quit success was mediated by higher self-efficacy and was associated with higher medication use. The latter implies that it may also be important to offer smoking cessation medication along with interventions that provide financial incentives.

We investigated the fourth research question, whether financial incentives for smoking cessation are cost effective, in an economic evaluation described in chapter 9. The analysis from a societal perspective, which included all costs over the 14 months of the study, resulted in an incremental cost-effectiveness ratio (ICER) for a training with financial incentives compared to a training without incentives of € 11,546. If only the costs that are relevant to the employer were included, the ICER was € 5,686. The analysis based on a lifetime perspective showed an ICER of € 1,249 per QALY (an extra year in good health). This amount falls well within the “willingness to pay” (the amount that the company is willing to pay for a QALY), which is set at € 20,000; demonstrating that financial incentives can be a cost effective intervention.

We answer the last research question in chapter 10: according to employers, what are the barriers and facilitators for the implementation of a smoking cessation group training program with incentives in workplaces? Here we describe a qualitative study in which we interviewed 18 employers. The knowledge that we gained from the interviews on the promoting and hindering factors is necessary to be able to develop a targeted strategy to stimulate the implementation of stop-smoking training with incentives. The following action points emerged from these interviews: 1) train employers in how to reach and convince their employees to participate in a smoking cessation group training, 2) explain to employers that their employees will not consider financial incentives unfair or come up with some form of alternative (non-financial) incentives, 3) explain the cost-effectiveness of a smoking cessation group training with financial incentives, and 4) make smoking cessation a part of the organization’s existing health policy.

This dissertation ends with Chapter 11, in which we discuss the results of the studies described above and compare them with the literature. In addition, methodological issues are discussed and recommendations are made for further research and for future policies.

For further research, we make the following recommendations:

1. determine how financial incentives should be designed to be effective. This includes the amount of the incentives, the schedule in which the incentives are provided and the type of incentive;

2. consider whether incentives for smoking cessation can also be used effectively in an environment other than the workplace, such as in healthcare, so that people without work can also be encouraged to stop smoking;

3. investigate the cost-effectiveness of incentives in combination with other forms of smoking cessation treatments such as individual treatment and e-health interventions.

Our policy recommendations are the following:

1. develop national policies that make employers accountable for the structural provision of smoking cessation support to their employees;

2. expand the smoking ban in public areas and raise tobacco product excise taxes;

3. launch mass media campaigns to inform the public that smoking cessation treatments are fully reimbursed under basic health insurance and to show where people can go for treatment. In addition, media campaigns are needed to change the societal view on smoking so that stigmatization of smokers is reduced and there is more support for research on smoking cessation interventions such as financial incentives;

4. create accessible smoking cessation treatments by increasing the provision of treatment by healthcare providers including GPs, whereby GPs take a more active role in discussing smoking cessation with their patients.