worksite-based incentives and competitions to reduce tobacco use
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Worksite-Based Incentives andCompetitions to Reduce
Tobacco UseA Systematic Review
Kimberly D. Leeks, PhD, MPH, David P. Hopkins, MD, MPH, Robin E. Soler, PhD,Adam Aten, MPH, Sajal K. Chattopadhyay, PhD, the Task Force on Community
Preventive Services
Abstract: The Guide to Community Preventive Service (Community Guide) methods for systematicreviews were used to evaluate the evidence of effectiveness of worksite-based incentives and compe-titions to reduce tobacco use among workers. These interventions offer a reward to individuals or toteams of individuals on the basis of participation or success in a specifıed smoking behavior change(such as abstaining from tobacco use for a period of time). The review team identifıed a total of 26published studies, 14 of which met study design and quality of execution criteria for inclusion in thefınal assessment. Only one study, which did not qualify for review, evaluated the use of incentiveswhen implemented alone. All of the 14 qualifying studies evaluated incentives and competitionswhen implemented in combination with a variety of additional interventions, such as client educa-tion, smoking cessation groups, and telephone cessation support. Of the qualifying studies, 13evaluated differences in tobacco-use cessation among intervention participants, with a medianfollow-up period of 12 months. The median change in self-reported tobacco-use cessation was anincrease of 4.4 percentage points (a median relative percentage improvement of 67%). The presentevidence is insuffıcient to determine the effectiveness of incentives or competitions, when imple-mented alone, to reduce tobacco use. However, the qualifying studies provide strong evidence,according to Community Guide rules, that worksite-based incentives and competitions in combina-tion with additional interventions are effective in increasing the number of workers who quit usingtobacco. In addition, these multicomponent interventions have the potential to generate positiveeconomic returns over investment when the averted costs of tobacco-associated illnesses are consid-ered. A concurrent systematic review identifıed four studies with economic evidence. Two of thesestudies provided evidence of net cost savings to employers when program costs are adjusted foraverted healthcare expenses and productivity losses, based on referenced secondary estimates.(Am J PrevMed 2010;38(2S):S263–S274) Published by Elsevier Inc. on behalf of American Journal of PreventiveMedicine
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ntroductionobacco use remains the leading preventable cause ofeath and illness in the U.S.1 Helping tobacco users touit is one important goal of a comprehensive preventionffort, along with preventing initiation and exposure toecondhand tobacco smoke, to reduce morbidity andortality associated with tobacco use.2 Approximately
rom the Community Guide Branch, Division of Health Communicationsnd Marketing Strategy, National Center for Health Marketing, CDC,tlanta, GeorgiaAddress correspondence and reprint requests to: Robin E. Soler, PhD,
ommunity Guide Branch, Centers for Disease Control and Prevention,600 Clifton Road, MS-E69, Atlanta GA 30333. E-mail: [email protected]/00/$17.00
wdoi: 10.1016/j.amepre.2009.10.034
ublished by Elsevier Inc. on behalf of American Journal of Preventi
0% of tobacco users want to quit,1 and efforts to quit arerequent, even if frequently unsuccessful. Of the 36.3illion adults who remained current, daily smokers in
he U.S. in 2006, 19.9 million (44.2%) had stopped smok-ng for at least 1 day in the previous year because theyere trying to quit.3 In clinical settings, a number ofvidence-based interventions and therapies have beenemonstrated tomotivate and support tobacco-using pa-ients in their efforts to quit.4 Interventions designed tootivate and assist the cessation efforts of tobacco usersre also important options for health promotion efforts inost community settings, including worksites.Because employee populations use tobacco products in
oughly the same proportions as the adult population as a
hole and because many adults spend the majority ofve Medicine Am J Prev Med 2010;38(2S)S263–S274 S263
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heir day in a workplace environment, worksites are via-le places to conduct health promotion activities. Asoted by others,5–8 the worksite provides a number ofdvantages as a setting for health promotion interven-ions, including (1) accessibility to a large and rathertable population, which provides the potential forchieving intervention exposure; (2) the potential for ad-quate or enhanced promotion, recruitment, and partic-pation in comparison to non-worksite environments;nd (3) the potential for reinforcing social support net-orks and peer influences among co-workers.The negative health effects and associated costs of to-acco use by employees are substantial, including bothhe direct costs (such as healthcare costs) as well as indi-ect costs (including lost productivity, absenteeism, andhe recruitment and retraining of replacement workers).9
he health benefıts of tobacco-use cessation include aapid reduction in the additional risks for cardiovascularisease and a more gradual reduction in the additionalisks for a variety of cancers.10 When the onset of diseasend premature death can be prevented, it is generallyccepted that some of the costs associated with treatmentf the diseases can also be prevented or at least substan-ially reduced.5
Incentives and competitions to reduce tobacco useepresent one intervention option for consideration byorksite health promotion programs. Alone or as part ofcoordinated program, incentives and competitions canontribute to cessation efforts among workers by (1) in-reasing or improving motivations to quit; (2) increasingr improving action to quit; and (3) increasing or im-roving maintenance of an effort to quit. Incentives andompetitions may be effective in increasing one or moref these pathways for an individual tobacco user. In ad-ition, participation might prompt the individual toake use of new or existing cessation support resourcesffered within the workplace, through the workplacesuch as a healthcare cessation benefıt), or in the commu-ity. For a designated population (at a worksite or withinworkforce), effectiveness of incentives or competitionsithin a cessation program would be demonstrated by aeduction in the number of baseline smokers who con-inue to use tobacco (i.e., fewer tobacco product users).he objective of this set of reviews is to examine thevidence on effectiveness of incentives and competitions,lone or when combined with additional interventions,n increasing the cessation of tobacco use amongworkers.
uide to Community Preventive Services
he systematic reviews in this report present the fındingsf the independent, nonfederal Task Force on Commu-
ity Preventive Services (Task Force). The Task Force is reveloping the Guide to Community Preventive ServicesCommunity Guide) with the support of the USDHHS inollaboration with public and private partners. The CDCrovides staff support to the Task Force for developmentf the Community Guide. The book, The Guide to Com-unity Preventive Services. What Works to Promoteealth?11 (also available at www.thecommunityguide.rg) presents background and themethods used in devel-ping the Community Guide.
ealthy People 2010 Goals and Objectives
he interventions reviewed here may be useful in reach-ng several objectives specifıed in Healthy People 2010.12
hese include objectives to:
7-1 Reduce cigarette smoking among adults (aged �18years) from 24% (1998, age adjusted to Year 2000 stan-dard population) to 12%
7-5 Increase the percentage of adult smokers (aged �18years) stopping smoking for 1 day or longer becausethey were trying to quit from 43% (1998, age adjustedto Year 2000 standard population) to 75%
ethodshis review was conducted according to the methods devel-ped for the Community Guide, which have been describedn detail elsewhere.13,14 Inclusion criteria for this reviewere: (1) primary research published in a peer-reviewedournal; (2) published in English in the period 1980 to Feb-uary 2009; (3) met the minimum research quality criteriaor study design and execution;13 and (4) evaluated the ef-ects of worksite-based incentives and competitions, aloner in combination with other interventions, on tobacco-useutcomes of interest to this review.
onceptual Approach
igure 1 shows the conceptual approach (analytic frame-ork) that guided the review process for the selected inter-entions. Incentives and competitions, which provide aeam or individual reward, are usually coordinated withdditional interventions to increase or improve individualfforts to abstain from tobacco use. Incentives and compe-itions may reduce the number of tobacco product users by1) increasing the number of tobacco users who participaten an effective cessation program; (2) increasing the numberf tobacco product users who initiate a quit attempt; or3) increasing the number of tobacco users who maintain auit effort. Health promotion techniques often incorporatencentives to stimulate individuals who otherwise would notonsider doing so to participate in a positive behaviorhange, to promote the initial adoption of the change, oro reinforce the sustainability of the positive behaviorhange.15 Researchers have previously noted that incorpo-
ating incentives in worksite health promotion programswww.ajpm-online.net
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an increase program participation, health behavior change,rogram visibility, and employee productivity while de-reasing health risk factors and healthcare costs.15
earch Strategy
he articles to be reviewed were obtained from systematicearches of multiple databases, reviews of bibliographic ref-rence lists, and consultations with experts in the fıeld. Theollowing databases were searched for the period betweenanuary 1980 and February 2009: MEDLINE, PsycINFO,MBASE, and the database of the CDC’s Offıce on Smokingnd Health. The keywords used for the search were healthehavior, health education, primary prevention, work, work-lace, occupational health, smoke, tobacco, air pollution, in-oor, tobacco smoke pollution, smoking cessation, insur-nce coverage, nicotine dependence treatment, motivation,ncentives, compete, competition, and contest. Other rele-ant sources were identifıed from the bibliographies of per-inent articles.
valuating and Summarizing the Studies
ach study that met the inclusion criteria was evaluated forhe suitability of the study design and study execution usinghe standardizedCommunity Guide abstraction form.14 Theuitability of each study design was rated as greatest, mod-rate, or least, depending on the degree to which the designrotected against threats to validity. The execution of eachtudy was rated as good, fair, or limited based on severalactors, predetermined by the systematic review team (the
igure 1. Analytic framework indicating the hypothesiompetitions on reducing tobacco use among workers. Tated to work through one or more of the following pathwaf tobacco users who participate in cessation efforts;obacco users who initiate an attempt to quit; and (3) incsers who sustain a successful quit effort. Workers who quo reductions in tobacco-related morbidity and mortality.
eam), that could potentially limit a study’s utility for assess- a
ebruary 2010
ing effectiveness. All stud-ies were reviewed by at leasttwo trained researchers. Anydisagreements about qual-ity of study design and exe-cution were discussed andresolved by team consen-sus.The teamdecided to in-clude only studies ratedgreatest or moderate in de-sign suitability and good orfair in execution. For thesequalifying studies, the effectsizes were calculated for thestudy outcomes whereversuffıcient information wasavailable to do so.
Outcomes Evaluated
The primary outcomes ex-amined in this reviewwere: (1) self-reported ab-stinence (and duration ofabstinence) from tobaccouse; (2) self-reported ab-
tinence from tobacco use, with biochemical verifıcation;3) self-reported prevalence of tobacco use within the work-ite population or study sample; and (4) calculations ofhange in the total number of tobacco users. The team alsoollected information on worksite participation rates.
alculation of Effect Sizes
he qualifying studies in this review all included a concur-ent comparison group not exposed or less exposed to thentervention. If the results were not reported in absoluter relative percentage change, the review team calculatedhem as:bsolute percentage change (difference is described as “per-entage point change”),
(Ipost � Ipre) � (Cpost � Cpre);
nd relative percentage change (result is described as “per-entage change”)
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Cpost ⁄ Cpre� � 1� � 100%.
For all calculations, I�intervention group; C�comparisonroup; and “pre” and “post” subscripts indicate measure-ents taken before and after intervention implementation,espectively. The postmeasurements usedwere the lastmea-urements after the intervention. In addition to the calcula-ion of differences for each study, an overall median studyifference and interquartile interval were calculated for both
effect of incentives ande interventions are postu-(1) increasing the numberincreasing the number ofing the number of tobaccoing tobacco will contribute
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ethods for Conducting Economic Evaluations
conomic evaluations are conducted only when the effec-iveness of the interventions has been established. Methodssed in assessing economic evaluations are described else-here.16 For comparability, all costs and benefıts are re-orted in 2008 U.S. dollars using the Consumer Price Indexavailable at www.bls.gov). World Bank development indi-ators onpurchasing power parity rateswere used to convertoreign currency toU.S. dollars. Referenced estimates on theost-of-illness-averted per smoker were used in two studieso calculate cost-effectiveness ratios by dividing the net costintervention costminus cost of illness averted) by the num-er of quitters following the intervention, resulting in the netost per quitter.17,18 In accordance with the accepted prac-ice found in the literature,19 actual numeric values of nega-ive cost-effectiveness ratios are not reported.The search for economic evidence for interventions in-
olving incentives and competitions for worksite smokingessation was conducted using Medical Subject HeadingsMeSH) terms for program effectiveness combined withconomic key terms such as cost analysis, cost-effectivenessnalysis, cost–benefıt analysis, and cost–utility analysis.elevant databases that were used in the search included theollowing: EconLit, MEDLINE, EMBASE, CDC’s Offıce onmoking andHealth database, PsycINFO, and the Social Sci-nce Citation Index. In addition, references suggested byational experts from the consultation team were also con-idered. The team’s search was open to all available peereviewed economic studies published in English in the pe-iod January 1980–February 2009, and located in countriesesignated by the World Bank as having a high-incomeconomy.a,20
esultseview of Evidence: Worksite-Based
ncentives and Competitions Whenmplemented Alone to Reduce Tobacco Use
orksite-based incentives and competitions to reduce to-acco use amongworkers offer rewards to individual work-rs and to teams as amotivation to participate in a cessationrogram or effort. Rewards can be provided for participa-ion, for success in achieving a specifıed behavior change
World Bank High-Income Economies (as of May 5, 2009): Andorra,ntigua and Barbuda, Aruba, Australia, Austria, The Bahamas, Bahrain,arbados, Belgium, Bermuda, Brunei Darussalam, Canada, Cayman Is-ands, Channel Islands, Cyprus, Czech Republic, Denmark, Equatorialuinea, Estonia, Faeroe Islands, Finland, France, French Polynesia, Ger-any, Greece, Greenland, Guam, Hong Kong (China), Hungary, Iceland,reland, Isle of Man, Israel, Italy, Japan, Republic of Korea, Kuwait, Liech-enstein, Luxembourg,Macao (China),Malta,Monaco,Netherlands,Neth-rlands Antilles, New Caledonia, New Zealand, NorthernMariana Islands,orway, Oman, Portugal, Puerto Rico, Qatar, San Marino, Saudi Arabia,ingapore, SlovakRepublic, Slovenia, Spain, Sweden, Switzerland, Trinidadnd Tobago, United Arab Emirates, United Kingdom, U. S., Virgin Islands
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such as abstaining from tobacco use for a period ofime), or for both. In this review, the types of rewardsvaluated included guaranteed fınancial payments, lot-ery chances for monetary or other prizes, and self-mposed payroll withholdings.
ffectiveness. The team identifıed one study21 evaluat-ng the impact of a worksite-based incentive programhen implemented alone to reduce tobacco use amongorkers. This study, which did not qualify for inclusionn this review, was evaluated as fair in quality of executionnd with a least suitable (single group, before-and-after)esign (www.thecommunityguide.org/tobacco/worksite/ncentives.html). The intervention consisted of a work-ite-based tobacco cessation contest with a precontestromotion, an enrollment period, biochemical verifıca-ion of self-reported abstinence at each assessment, andhree lottery drawings over a 12-month intervention pe-iod (at 1, 6, and 12 months). The lottery-chance prize at2months was worth 15,000 Swedish crowns (US$2355).here was no follow-up after the end of the intervention.he lottery-qualifying assessments were used as veri-ıed cessation among participants. Over the 12-monthntervention period, continuous abstinence was deter-ined for 24 of 73 (32.8%) of the baseline participants.erifıed cessation rates were, respectively, 49% and 36%t 6 and 12 months into the contest period. The authorseported that 10% of tobacco-using workers participatedn the intervention.
onclusionccording to Community Guide rules,13 there is insuffı-ient evidence to determine whether or not worksite-ased incentives and competitions alone are effective ineducing tobacco use among workers. Evidence was con-idered insuffıcient because no studies qualifıed for con-ideration in this review, and only one study of leastuitable design was identifıed.
eview of Evidence: Worksite-Basedncentives and Competitions When Combinedith Additional Interventions to Reduceobacco Use Among Workers
orksite-based incentives and competitions to reduceobacco use among workers offer rewards to individualsr to teams of individuals based on participation in aessation effort or success in behavior change (such asbstaining from tobacco use for a period of time). In thiseview, incentives and competitions were offered in con-unction with additional interventions to support an in-ividual’s efforts to quit using tobacco products. The
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ncluded guaranteed fınancial rewards, lottery chancesor fınancial rewards, and self-imposed payroll withhold-ngs. Additional interventions used in conjunction withncentives and competitions to promote smoking cessa-ion among participants included smoking cessationroups, self-help cessation materials, telephone cessationupport, workplace smoke-free policies, and social sup-ort networks.
ffectiveness. The team identifıed a total of 26 stud-es22–47 evaluatingworksite-based incentives and compe-itions when combined with additional interventions toeduce tobacco use among workers. Nine studies withimited quality of execution22,24,32,35,38,40,42–44 and threetudies with least suitable study designs27,28,33 were ex-luded from the fınal body of evidence. Seven pa-ers17,18,34,48–51 provided additional information fromtudies already included in the review. Details of the 14ualifying studies23,25,26,29–31,34,36,37,39,41,45–47 (with 17tudy arms) are available at www.thecommunityguide.rg/tobacco/worksite/index.html.
tudy design and implementation characteristics. Ofhose qualifying for the team’s fınal assessment, 13 stud-es23,25,26,29–31,34,35,37,41,45–47 evaluated the effect of thesenterventions compared with a concurrent comparisonroup not exposed or less exposed to the intervention,nd one study39 compared outcomes among programarticipants and nonparticipants in a subset of employeesver a 5-year study period. One study23 examined twontervention approaches, in which all of the participantsn the intervention and comparison groups received theame incentive (entrance in a lottery as reward for a0-day abstinence). In the remaining 12 studies, the com-arison group individuals were not offered a reward forither participation or behavior change.The 14 qualifying studies implemented the rewards
n several ways. One study36 provided rewards througheam competitions, and four studies26,30,37,41 providedewards to both individual participants and to compet-ng teams of participants. Incentives were offeredo individual participants in the remaining ninetudies.23,25,29,31,34,39,45–47
The qualifying studies evaluated a variety of differ-nt rewards as a tool to promote participation29,30,46
nd change in tobacco-use behavior (such as absti-ence).23,25,26,29–31,34,36,37,39,41,45–47 Several studies pro-ided additional rewards, such as incentives for complet-ng follow-up23,31,46or lottery-chance rewards for peopleroviding support to smokers attempting to quit.30,39,41
he most common reward in the qualifying studies wasntrance into a lottery,23,25,26,29,30,37,39,41,45 followed byınancial reward.29–31,36,37,46,47 In one study, participants
elected an amount to be withheld from their own pay- aebruary 2010
heck, as an incentive to meet their personal tobacco-useessation goals.34 Individual rewards ranged in magni-ude from $10 for participation in one study29 to a maxi-um of more than $750 for participation and extended
obacco-use abstinence in another study.46 Lottery-hance rewards ranged in size from $4026 to $500,29 andne study37 offered entrance in a $2500 lottery as part ofhe team reward.The qualifying studies evaluated the use of re-ards as part of a multicomponent worksite-basedobacco cessation program. In eight studies (ten studyrms),29–31,34,36,37,39,41 rewardswere offered in conjunctionith worksite-based tobacco cessation support groups withr without additional interventions. In 12 studies (13 studyrms),23,26,29–31,34,37,39,41,45–47 rewards were coordinatedith client education, such as lectures, instructionallasses, and self-help cessation guides, with or withoutdditional interventions. Other interventions evalu-ted include buddy participation (social support net-orks),30,39,47 telephone cessation support,23,29,37 smoke-ree worksite policies,37 counseling,26,45,47 and access toicotine replacement therapy.39,45,46 In two studies, theorksite program was coordinated with a televised newseries on smoking cessation.31,41 Finally, in fıve studiessix study arms),23,25,30,31,34 devices to measure carbononoxide in exhaled breath were used for frequent andegular testing of participants for recent tobacco usesmoking).
utcomes related to self-reported changes in tobaccose. The 14 qualifying studies23,25,26,29–31,34,36,37,39,41,45–47
rovided 17 study arms and 18 measurements of differ-nces in tobacco use. One study34 evaluated change inobacco-use prevalence; the remaining 13 studies com-ared tobacco cessation rates among study participants.One group-randomized trial34 compared changes in
elf-reported tobacco-use prevalence among 32 studyorksites (400–900 employees each) assigned to a multi-omponent smoking cessation effort (personal payrollithholding plus smoking cessation groups, with fre-uent assessment of smoking status using carbon mon-xide measurements) or to a nontreatment comparisonroup. Self-reported tobacco use was measured usingurveys, and results were analyzed using both cohort andross-sectional survey samples. At the end of 2 years (fourntervention cycles), among responding workers in thentervention companies compared to respondingworkersn the comparison companies, the prevalence of self-eported tobacco use decreased by 2.1 percentage pointsp�0.03). In the cross-sectional comparison, self-reportedobacco use decreased by 4.0 percentage points (p�0.058).Thirteen studies23,25,26,29–31,36,37,39,41,45–47 with 16 study
rms evaluated differences in tobacco-use abstinence
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mong workers (tobaccosers at baseline) re-ruited to participate inhe study. Figure 2 pre-ents the results fromhese study arm com-arisons arranged in or-er of the duration ofollow-up (following thend of the intervention).verall, the median abso-ute difference in rates ofobacco-use abstinenceas an increase of 4.4 per-entage points (interquar-ile interval: 2.7–9.4 per-entage points) in favor ofarticipants exposed toncentives or competition.he median abstinenceate observed in the 16 in-ervention arms was 13.7% (interquartile interval:%–20.5%). The median duration of follow-up was 12onths (range from 0–48 months). Two study arm com-arisons41,45 were based exclusively on self-reported absti-ence; the remaining comparisons included biochemicalerifıcation of self-reported abstinence. Six of 16 studyrm comparisons30,37,41,45–47 were reported as signifı-ant. The median relative percentage change in tobacco-se abstinence for 15 of the 16 study arm comparisonshere data were available was 67% (interquartile interval:4%–161%).The team also examined tobacco-use abstinence in the
ubset of nine studies (11 study arms)25,26,29,31,39,41,45–47
ith a minimum of 12 months of follow-up. The medianifference in tobacco-use cessation was an absolute in-rease of 3.5 percentage points (interquartile interval:.7–5.8 percentage points), and a median relative im-rovement in cessation of 42% (interquartile interval:9.5%–98%).The team stratifıed results by the number of partici-ants in the intervention arms of the qualifying studies.ost studies counted recruits lost to follow-up as current
obacco users. The median number of recruited tobaccosers in the intervention study arms was 227 (range from9 to 1344 users). In the six studies (seven studyrms)25,29,31,39,45,46 with sample sizes �227 recruits, theedian absolute difference in tobacco-use cessation wasn increase of 2.9 percentage points (interquartile inter-al: 2.7–5.8 percentage points).A subset of fıve studies30,31,37,39,41 evaluated a similar
ombination of interventions including an incentive, a
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lient educational activities or materials, with or withoutdditional interventions (such as social support, recur-ent biochemical verifıcation testing, or access to a tele-hone cessation support line). In this subset, the medianessation rate was 21%, themedian absolute difference inobacco-use abstinence was an increase of 10 percentageoints, and the median relative percentage improvementn cessation was 168% (range of improvement from2%–300%).
articipation in worksite-based tobacco cessation ef-orts. Eleven qualifying studies25,26,29–31,34,37,39,41,45,46
rovided information on participation in one or morectivities of the overall cessation program.One additionaltudy27 not eligible for inclusion in the outcome analysislso evaluated differences in participation across studyrms. Two studies26,37 reported participation rateswithinhe overall study workforce; the remaining ten stud-es25,27,29–31,34,39,41,45,46 examined participation in termsf the proportion of eligible tobacco users recruited.orkforce participation rates were reported as 2.0% inne study37 and 88% in the other study.26 Participationates among eligible tobacco users in study worksitesanged from 12%39,45 to 84%30 with a median participa-ion rate of 28% (interquartile interval: 15%–59%).Only eight study arms in seven studies27,29–31,37,41,46
ompared participation rates across intervention andomparison study arms. In one study,37 workforce par-icipation rates were 2.0% of workers in the interventionompanies and 1.3%ofworkers in companies that did notmplement an additional tobacco cessation program. Inhe seven study arms from six studies27,29–31,41,46 that
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edian absolute difference in participation was 3.0 per-entage points (interquartile interval: –3.0 to �10.5 per-entage points). However, participation rates in both thentervention (median: 55%) and comparison (median:8%) arms were relatively high.
pplicability
he interventions evaluated in this review were con-ucted in a variety of worksites including manufacturinglants,29,31,34,36,37,46 healthcare facilities,23,29,31 governmentffıces,25,29,34,36 a university,47 chemical plants,39 and anmbulance service.26Most studieswere conducted in compa-ies orworksiteswithmore than 100 employees, and in urbanr suburban settings. In seven studies,29–31,34,36,41,45 authorspecifıcally attempted to recruit a range of different companiesnd worksites, although stratifıed results were not reported.f the 14 qualifying studies,23,25,26,29–31,34,36,37,39,41,45–47 allut two26,45 were conducted in the U.S.
ther Positive or Negative Effects
he qualifying studies did not describe or evaluate anydditional benefıts of these interventions. One study de-cribed, but did not specifıcally evaluate the potential forynergy with the implementation of worksite smoke-freeolicies and worksite cessation programs.37 The diffıcul-ies involved in conducting and evaluating smoking ces-ation contests have been described in the communityetting (for example, attracting people who recently quitmoking on their own) and are potentially applicable tohe worksite setting.52 Almost all of the studies identifıed inhis review included biochemical verifıcation of tobacco-se abstinence as part of the process for determination ofottery entrants and incentive awards. Verifıcation createsn additional burden to conducting these interventions;ithout the use of these tools to verify self-reported absti-ence, however, the potential for deception by contestarticipants exists.7
conomic efficiency. The economics review teamdentifıed four qualifying studies17,18,42,45 that providedconomic evaluations of multicomponent worksite ces-ationprograms including incentives. According toCom-unity Guide quality assessment criteria for economicapers, two studies were rated as good18,45 and two asatisfactory.17,42 Due to the intricacies of interventionesigns used in each of the qualifying studies, it might beiffıcult to precisely realize the economic gains reported.ll four studies reported intermediate outcomes in termsf the number of quitters, and all costs and benefıts werestimated from the employer perspective.
osts. Total costs of the multicomponent interventions42
eported in fıve arms from four studies were $2086 ; rebruary 2010
39,80017; $987818; and $37,956.18 Costs varied due to theype and size of the intervention but were based on directntervention costs only. One study45 provided completeetails of intervention costs including opportunity costsor providers, participants, and researchers involved inhe interventions plus costs of all materials. None of thetudies provided information on intervention start-uposts and maintenance expenditures.
enefits. Three studies in this review presented eco-omic benefıts in the form of costs averted. One study18
ssessed benefıts of $454,333 and $1.5 million for twoifferent intervention groups, based on participantsaintaining smoking abstinence for 20 years after theirespective incentive interventions. A different study byhe same researcher17 reported a $2.9 million benefıt forn entire group that maintained smoking abstinence for9 years after receiving an incentive-based intervention.wo studies also approximated employer savings inealthcare expenditures at $521 per year for each em-loyee who quit smoking42 and at $55,03817 formembersf an intervention group that quit smoking. When pro-iding economic benefıts it is necessary to integrate coreconomic evaluation principles such as stating the per-pective, conducting sensitivity analyses, anddiscountingosts and benefıts. Some studies in this review referencedconomic information to derive an estimate of the bene-ıts, but they did not report if these techniques werencorporated into either the referenced study or theirwn analysis.
conomic summary measure. One study45 provided aost-effectiveness (CE) ratio defıned as “cost per addi-ional quitter.” This cost, $596, was described as lessxpensive than available estimates of “high-intensity” in-erventions administered by primary care clinicians andessation specialists and similar to estimates of cost peruitter in companies with smoke-free workplace poli-ies.45 For two studies17,18 with referenced sources, netost per quitter CE ratios were calculated from secondaryost-of-illness averted data. These calculated economicummary measures were both negative, meaning theulticomponent interventions were not only cost effec-
ive, but also cost saving. One study42 found that thentervention would pay for itself in the fırst year withdditional savings generated in later years.
ther caveats. Signifıcant attrition rates, which maylso affect costs and benefıts, occurred in all the reviewedtudies. Although one study45 from Japan was publishedn 2006, the three studies17,18,42 conducted in the U.S.ere published between 1989 and 1995, which may not
eflect present worksite conditions or concerns.
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onclusions from economic evaluation. Costs and ben-fıts were provided in all four studies, and cost-effectivenessatios in terms of net cost per quitter were derived byommunity Guide staff for two studies.17,18 These cost-ffectiveness ratios indicate cost savings for employershat implemented programs combining incentives withdditional interventions. One study,42 based on a smallumber of participants, reported that the programwouldreak even the fırst year and continue to generate addi-ional savings in later years. However, due to the paucityf studies providing primary evidence on costs avertedrom the intervention, a fırm conclusion on cost savingsannot be determined at this time.
arriers to intervention implementation. The Healthnsurance Portability and Accountability Act of 1996HIPAA) (www.hhs.gov/ocr/privacy/index.html) includestatements specifıc to the use of incentives to improvemployee health and wellness. The purpose of this law iso improve portability and continuity of health insuranceoverage in the group and individual markets; to combataste, fraud, and abuse in health insurance and health-are delivery; to promote the use of medical savings ac-ounts; to improve access to long-term care services andoverage; to simplify the administration of health insur-nce; and for other purposes. ApplyingHIPAA and otheraws to the use of economic incentives in the workplace isechnical but should inform the implementation of thisntervention.Finally, the logistics of conducting verifıcation of
moking cessation may present additional costs. Com-any size and resources may also limit the magnitude ofhe fınancial rewards offered, although the magnitude ofhe incentive has not been suffıciently demonstrated as aactor related to either participation or tobacco-use be-avior change among workers.
onclusionccording to Community Guide rules,13 there is strongvidence that worksite-based incentives and competi-ions, when combined with additional interventions toupport individual cessation efforts, are effective in re-ucing tobacco use among workers. The qualifying stud-es included a variety of intervention combinations. Forhe subset of studies that consisted of multicomponentfforts that combined incentiveswithworksite-based ces-ation groups and additional educational activities oraterials there is suffıcient evidence on effectiveness. Theresence of an incentive or competition was not associ-ted with a consistent increase in participation in work-
ite tobacco programs in the studies considered in this seview; however, participation rates were high in most ofhe intervention and comparison study arms.
iscussionhe studies included in this review evaluated the impactf incentives and competitions when combined with ad-itional interventions designed to motivate and supportessation efforts by tobacco-using workers. This reviewncluded evidence from worksite-based cessation pro-rams only and did not include studies that evaluated these of these interventions in other settings such as health-are systems (for patients) and communities (such asommunity-wide smoking cessation contests).
dditional Evidence from Outside Reviews
ther systematic reviews6–8,53 provide information onhe effectiveness of worksite smoking cessation programsimilar to and including the evidence presented here. Aecent Cochrane review update by Cahill and Perera7
rovides a different examination of the evidence on effec-iveness of competitions and incentives for smoking ces-ation. That systematic review included papers throughecember 2007. The reviewers identifıed 17 studieseeting the Cochrane inclusion criteria that capturedvaluations of incentives and competitions in workplaceettings and in healthcare settings when directed at pa-ients. Studies of community-based smoking cessationontests and studies evaluating healthcare workers wereemoved to companion reviews. The authors selected theost rigorous defınition of tobacco-use abstinence inach trial. The authors conducted a meta-analysis on aubset of nine studies based on outcomes of smokingessation for a minimum of 6 months. In this analysis,one of the included studies demonstrated signifıcantlyigher quit rates for the incentives group than for theontrol group beyond the 6-month assessment. The ad-usted OR for smoking cessation of 6 months’ durationas 1.44 (95% CI�1.01, 2.01) based on results fromleven study comparisons. The summary effect measure-ent for 12months cessation was an adjusted OR of 1.0795% CI�0.78, 1.45) based on seven comparisons in fıvetudies. The authors concluded that incentives and com-etitions did not help smokers to quit in the long-term.owever, the authors held open the possibility that thesenterventions might still be effective by increasing partic-pation in quit attempts, even if cessation rates were notignifıcantly improved.A second, updated Cochrane review by Cahill andoher6 examined the evidence through April 2008 for aariety of workplace interventions for smoking cessation.vidence from the 51 studies evaluated in this extensive
et of reviews was organized into interventions aimed atwww.ajpm-online.net
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he individual (such as group cessation therapy) and in-erventions aimed at the workforce population (such asestrictive smoking policies or bans). Analyses were pri-arily qualitative and compared results from worksite-ased studies with results from reviews of these interven-ions in other settings (especially healthcare settings).verall, the authors found strong evidence of effective-ess for advice from a health professional, individual androup counseling, and pharmacologic treatment to in-rease smoking cessation. Only fıve of the included stud-es provided an evaluation of incentives, and the authorsoncluded that there was limited evidence that participa-ion in worksite programs could be increased by compe-itions and incentives organized by the employer.Two consecutive reviews, ten years apart, examined
he overall evidence on effectiveness of a variety of smok-ng cessation interventions in the workplace includingelf-help manuals, physician advice, health education,essation groups, and incentives and competitions.8,53
he 1990 review by Fisher et al.53 included 20 controlledtudies published through 1988 with 34 study compari-ons. The average duration of follow-up was 12 months.ooled effect estimates included an overall weightedean effect size of 0.21�0.07 (OR�1.66 at 12 months)nd a weighted average quit rate from all interventionsf 13%.The second review, from 2004, by Smedslund et al.8
xamined 19 controlled trials with 28 study comparisonsublished in the period 1989–2001. Pooled effect esti-ates were generated from study results based on-month, 12-month, and �12-month follow-up. Basedn 12-month follow-up, the overall OR was 1.56 (95%I�1.17, 2.07), and the unweighted mean quit rate fromll intervention arms was 20.8%. For studies that pro-ided cessation outcomes with�12months of follow-up,he overall OR was 1.33 (95% CI�0.95, 1.87) and thenweighted mean quit rate was 17.2%.The team’s fındings differ only slightly from the con-
lusions of these systematic reviews. Most of the identi-ıed studies evaluated overlapping combinations of inter-entions to support cessation efforts by workers, and thevidence, in general, was insuffıcient to identify the inde-endent contribution of specifıc interventions. The teamound evidence on effectiveness of incentives and compe-itions only when those components were combinedwithdditional interventions such as group cessation and cli-nt education. It is possible that incentives and competi-ions do not add to the impact of the other interventionsombined within a worksite-based effort. The team’sonclusions reflect the current limitations in distinguish-ng the independent contributions of individual compo-
ents within this multicomponent evidence. sebruary 2010
As noted above, the recent Cochrane review by Cahillnd Perera7 of incentives and competitions to reduceobacco use concluded that the evidence of the impact ofhese interventions on increasing rates of successfulmoking cessation was limited. Differences in the reviewocus and conduct may explain the differences in conclu-ions. The review by Cahill and Perera7 included studiesonducted on patients in a healthcare setting, which wasot a setting included in the team’s worksite-based re-iew. The team examined impact across the studies withifferences in the duration of follow-up but did not at-empt to draw conclusions on stratifıed subsets of theverall evidence. In the present review, studies with auration of follow-up of �12 months had only a slightlymaller median difference in cessation, but the differenceas more pronounced in the studies included in theochrane review.
esearch Issues
ncentives and competitions when implementedlone. Only a single study of worksite-based incentivesr competitions when implemented alone was identifıed;hus there was an insuffıcient number of studies to draw aonclusion on the evidence on effectiveness. Conse-uently, this intervention approach remains a potentialrea for future research. An earlier Community Guideeview of community-based smoking cessation con-ests2,54 also found insuffıcient evidence to support a con-lusion on effectiveness. In the community-based inter-ention studies, evidence was considered insuffıcientecausemost studies focused on contest participants onlynd did not include either a defıned study population ofligible tobacco users or a concurrent comparison group.orksite-based interventions, in contrast to community-ased efforts, provide a study population that may beasier to quantify and defıne, and should provide an op-ortunity to evaluate participation and impact amongligible tobacco users. In addition, incentives might beffered in ways other than through tobacco cessationontests (such as rewards for setting and achieving per-onal health goals) and these intervention options remainn area for further research.
ncentives and competitions when combined withdditional interventions. Although the evidence dem-nstrates that worksite-based smoking cessation inter-entions, when implemented in combination with incen-ives and competitions, are effective, the studies evaluatedn this review do not provide suffıcient evidence to distin-uish the independent or synergistic contribution of re-ards on participation or tobacco-use behavior change.uture studies, for example, could directly compare
hort- and long-term cessation rates for tobacco users
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ecruited to a worksite-based group cessation programased on the provision or absence of an incentive orompetition.Only three studies39,45,46 specifıcally included or eval-ated access to nicotine replacement therapies as part of aorksite cessation program. Worksite-based interven-ions to increase access to nicotine replacement therapiesand other effective pharmacotherapies), as part of aombined cessation program, remain an area for furtheresearch.The team observed, as also described in other re-
iews,6,8 recurring problems in the measurement andeporting of tobacco-use outcomes. Future researcheeds to address these problems. Analyses that includehe entire workforce or an estimate of the proportionf tobacco users from a baseline survey of self-reportedmoking status (i.e., those eligible for this interven-ion) would permit calculations of program participa-ion and estimates of intervention impact (such as ahange in workforce tobacco-use prevalence or in theotal number of current tobacco users). In several stud-es, follow-up periods were calculated from the initia-ion of the intervention and not from the end of thentervention (e.g., from the last round of a smokingessation contest).
conomic. The included studies provided limited eco-omic information on multicomponent programs in-luding incentives, and no evidence to determine theelative contribution of rewards to the impact of theserograms. Furthermore, there were economic benefıtsot addressed in the research methods, including theverted costs from cigarette smoking–related fıres in theorkplace, increased worker productivity from not hav-ng to take tobacco breaks during working hours, andverted healthcare costs from decreased exposure to en-ironmental tobacco smoke. Two qualifying studies indi-ated potential cost savings based on referenced estimatesf averted healthcare costs and productivity losses out-eighing the costs of intervention. Further interventionesearch using coremethodologies for evaluating the eco-omic evidence, and based on actual changes in health-are costs and productivity are necessary to confırm suchlaims. In addition, due to established benchmarks forssessing cost effectiveness of an intervention, (e.g.,50,000 per life-year gained),55 future research agendasight consider converting intermediate outcome sum-ary measures (such as the cost per quitter or additionaluitter) to fınal outcome summary measures—the coster life-year or quality-adjusted life-year gained, to allowor better interpretation of public health economic
ındings.ummaryhe Task Force on Community Preventive Services haseviewed the evidence on effectiveness of a number ofnterventions that practitioners can use to achieve theealthy People 2010 “Objectives for Tobacco Use.”12 Inhis article, the team reported results from a systematiceview of worksite-based incentives and competitionso reduce tobacco use. There was insuffıcient evidenceo draw a conclusion regarding the effectiveness oforksite-based incentives and competitions when im-lemented alone to reduce tobacco use. Evidence wasonsidered insuffıcient because no studies qualifıed foreview, and only one study of least suitable design wasdentifıed. Therewas strong evidence that worksite-basedncentives and competitions, when combined with addi-ional interventions to support individual cessation ef-orts, are effective in reducing tobacco use among work-rs. By increasing the number of tobacco users whouccessfully quit, incentives and competitions can reduceoth the short- and long-term morbidity and mortalityssociated with tobacco use.
he team thanks the following individuals for their con-ributions to this review: Reba Norman, research librar-an; Kate W. Harris and Tony Pearson-Clarke, editors;nd the coordination team: Nico Pronk, PhD, Healthartners, Minneapolis MN; Dennis Richling, MD, Cor-olutions, Chicago IL; Deborah R. Bauer, RN, MPH,ational Center for Chronic Disease Prevention andealth Promotion, CDC, Atlanta GA; Andrew Walker,rivate Consultant, Atlanta GA; Abby Rosenthal, MPH,ffıce on Smoking and Health, CDC, Atlanta GA; Curtis. Florence II, PhD, Emory University, Atlanta GA;ee Edington, HMRC, Ann Arbor MI; and DeborahacLean, The Coca-Cola Company, Atlanta GA.The names and affıliations of the Task Force members
re listed in the front of this supplement and at www.hecommunityguide.org.No fınancial disclosures were reported by the authorsf this paper.
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