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this was a study led by my colleague scott halpern funded by the national cancer institute
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in which we enrolled smokers from cvs from around the country who were employees
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and we put them into one of five different groups one group was simply a control group
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that got free nicotine patches and other aids to help them quit smoking another group got the same free
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pharmacologic aids plus up to eight hundred dollars based on quitting smoking success
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successfully a third group got an opportunity to put a hundred fifty dollars of their own
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money at risk if they were successful in quitting smoking they would get an additional 650 dollars so they'd get the
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same 800 if they were not successful they would forfeit the 150 and then we had two group based
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incentives one in which people were pooled and had the chance to collaborate the other in which people were pooled
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and had the chance to compete and potentially win larger rewards there were three main findings to the
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research the first is that we were able to replicate earlier work done by our group among employees at general
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electric in which we found roughly a tripling of smoking cessation rates at six months
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and that was pretty exciting because as a researcher you're always hoping that when you find
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important results that those can be substantiated in other studies and the findings here were very similar to
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what we had found initially at ge a number of years ago so that that was point one
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second point was that those who are given the opportunity to put their own money at risk and who
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chose to do that did phenomenally well about 52 percent of them actually quit smoking and this was all biochemically
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confirmed the rub was that only about 14 percent of those offered the opportunity to put
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their own money at risk chose to do so so on net that was less effective than simply
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giving people a standard incentive in which if they quit smoking they would get up to eight hundred dollars
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we also found that putting people in groups was not significantly more effective
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than just offering them an individual incentive and this was important because there's a
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lot of buzz out there about making programs social and people often assume that that will
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automatically make the program more effective in this case i want to add the important
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caveat that we put people together in groups who did not know each other but giving those people an opportunity to
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collaborate did not significantly increase the rate of smoking cessation a lot of employers offer incentives for
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healthy behavior about 85 percent of employ large employers in the us offer incentives for healthy behavior of one
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kind or another but there's two big limitations to how this is commonly done
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commonly this is done by adjusting people's premiums and by adjusting them in the future
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and there's two reasons why from a behavioral standpoint that's not so likely to be effective
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one is that by tying these incentives to premiums it makes them relatively invisible so if i give somebody a
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discount on their premiums that's typically added to your paycheck it's direct deposited in the bank and
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it's thereby rendered relatively invisible so you can have an incentive of several hundred dollars that the
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employee may not even realize is being deposited in their account and from a mental accounting standpoint that's a
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very bad thing to do because you obviously want to make these incentive dollars as effective and as visible as
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possible the second issue is the time sequencing a lot of times what employers do is they
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give these incentives through premium adjustments next year or at the end of this year
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and when you're trying to change somebody's behavior given that humans are wired to focus on the here and now
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that's not a very good strategy what this study does is it provides a new path forward that i think really
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highlights two key things one is that taking these incentives out of the premiums making it more visible
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makes them much more effective so as i mentioned there's roughly a tripling in
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smoking cessation rates from having this very visible incentive available to employees
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the second is that offering employees an opportunity to put some of their own money at risk for those
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employees who are willing to do it can be very effective and what's very exciting about this study is the
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follow-up in terms of what cvs health is planning to do they are offering all their employees
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starting next month through a new program called 700 reasons to quit an opportunity to put 50 dollars of
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their own money at risk if they're successful at quitting smoking at six months and at 12 months they will
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actually match that with 700 so it's a fourteen to one match and the idea is to really make it attractive to
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people to participate for a fairly minimal contribution of seven hundred dollars all smokers would then have the
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opportunity to win an additional seven hundred dollars and the hope there is to really
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tie into a lot of what we found through this study get high rates of participation and then
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among people who participate really high success rates in quitting and i think that provides a new paradigm
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for employers to think about where these programs can be much more effective than they've typically been
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through simply adjusting people's premiums in the future one thing that surprised us a bit was
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that despite offering matching dollars of six hundred fifty dollars for everybody who put a hundred
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fifty dollar deposit down that only about fourteen percent of people were willing to do that i think that
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highlights a number of important elements of human nature people are very reluctant to
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part with their own money we know that from lots of other contexts in life and it appears that 150 dollars was just
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too high a bar for people in terms of getting them engaged in in this decision to try to quit smoking now
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that's one of the reasons i'm so excited about the new cvs program 700 reasons to
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quit because by having this lower bar of 50 dollars i think the potential and also a much
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bigger match of 700 dollars for the 50 dollars i think the potential rates of engagement are going to be very high
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because that's a very attractive proposition we have to keep in mind that about 70
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percent of smokers in the us want to quit only three to five percent per year are
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able to but part of it is trying to make it very attractive to smokers to try to quit now and i
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think the new cvs program has a real chance to do that i think there's several important
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lessons to draw one is that we we can do better than we're doing now in terms of helping people quit smoking
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clearly offering people free pharmacologic therapy is a good idea i don't think any
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medical professional would disagree with the notion that we want to lower the barriers to access to evidence-based
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therapies as much as possible but it's important to highlight here that the standard incentive arm roughly
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tripled smoking cessation rates over and above what was achieved with free pharmacologic therapy
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so we can do much better than we're doing the other important point to recognize
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is that study after study has indicated that having a smoker who's an employee
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probably costs an employer three to six thousand dollars extra a year in terms of higher health care
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costs and lower rates of productivity higher rates of absenteeism so offering an
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incentive of eight hundred dollars or something in that ballpark to employees should be financially a no-brainer
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because it really offers the opportunity to both help your employees get healthier and
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help the employer from an economic standpoint one of the common perceptions people have is that
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by making programs social they'll automatically be more effective and this study provided some pretty good
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evidence that putting people in groups doesn't automatically lead to higher quit rates i suspect that if we had been
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able to put smokers together with other people they knew they might have been able to achieve higher rates of success
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but in creating a program that we thought had the potential to be scalable we by design groups people who didn't
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know each other together because that way you could just enroll people's individuals you didn't have to have
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people enroll in groups of four or groups of five which would have made things much more challenging
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and it's important to note that putting people in these groups of five and offering them a chance to collaborate
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was not effective at increasing their smoking cessation rates there are a couple of things which
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really set this research apart from many of the other studies that have been done
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the first is that this is actually the largest study that has ever been done of financial incentives and smoking
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cessation within an employer population so we have a lot more statistical power to find differences if they exist
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a second reason is that this was done in very close collaboration with one of the
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largest employers in america cvs is the 12th largest employer in the united states
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and by working closely with them we were able to tie this in using their communications infrastructure and
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conduct a study which i think much better reflects the real world application of these kinds of programs
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than if this were an academic study done in an academic setting a third reason uh that this is i think
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relatively unique is we tested several different incentive designs head to head and i think that's very important
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because a lot of employee benefits managers they often seem to think about incentives yes no
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and it's very important to recognize that how you design these programs has a
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huge impact on how effective they are you know an incentive is not an incentive a dollar is not a dollar it all depends
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on how these programs are designed how they're delivered that has a big impact
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on how effective they are and this provides very nice comparative effectiveness research
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data that can be used by employers and benefits managers in thinking about the kinds of programs they should design
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and what exactly those look like one of the most important findings from this study is that among people who are
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given the chance to put some of their own money at risk smoking cessation rates as i mentioned were phenomenally
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high about 52 percent but only about 14 of people agreed to do that one of the key areas
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going forward for future research is how to increase that 14 percent so in a follow-up study we're doing we're
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looking at that and in essence having our sponsor agree to put the money up front for all employees who are smokers
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and then seeing can we engender the same kind of quit rates among people who now have
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this money at risk but where all of them are participating in that loss aversion
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type incentive arm so that's i think one of the key questions going forward is
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if you increase the participation rates in those kind of programs can you really increase the quit rates
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accordingly and that's going to be a central question for future research you