The Role of Behavioral Economics in Smoking Cessation

Approximately 31 million adults in the United States currently smoke cigarettes.¹ Cigarette smoking accounts for upwards of 480,000 deaths annually and is the leading preventable risk factor for cancers, respiratory and cardiovascular disease.¹

Moreover, smoking-related costs have ballooned to approximately $300 billion each year attributable to medical care and lost productivity.² Needless to say, smoking is a burden on our health care system.

While most smokers want to quit, smoking cessation can be quite challenging with less than one in ten smokers successful in quitting each year.³ Smoking cessation interventions include not only pharmacological agents, but also behavioral changes, which can be nudged by system factors.

Behavioral economics is a tool that can influence patient behaviors using concepts such as choice architecture, nudges, and loss aversion, among many others. This article highlights the value of behavioral economics concepts in smoking cessation strategies.

Financial incentives are a tool that can help achieve smoking abstinence. In a large randomized, controlled trial, researchers found that a group of smokers who received financial incentives not only achieved higher abstinence rates, but were also more likely to participate in a smoking cessation program compared to those who did not receive incentives.⁴ However, designing these incentives thoughtfully can help achieve higher abstinence rates.

In another study, researchers randomized smokers into 4 intervention groups. Two incentive programs were targeted at individuals whereas the others were group-oriented (6 participants).⁵

In each of the above groups, one group was a reward-based incentive program ($800 in rewards), and the other group was a deposit-based incentive program ($150 in refundable deposits contingent on smoking status, and $650 in reward payouts).⁵ The outcomes of these groups (individual-reward, group-reward, individual-deposit, group-deposit) were compared against usual care.

Researchers found that patients were more likely to enroll in rewards-based programs (90%) vs deposit-based programs (13.7%).5 All of the groups had better abstinence rates compared to usual care.

After adjusting for differential acceptance rates between rewards-based programs and deposit-based programs, researchers found that deposit-based programs had greater abstinence rates than rewards-based programs (D= 13.7%). In the unadjusted analysis, rewards-based programs had higher abstinence rates compared to deposit-based programs (15.7% vs 10.2%, respectively).⁵

Several behavioral economics concepts are at play in the study discussed above. Firstly, the study employs the concept of loss-aversion with the deposit groups.

Loss-aversion is a cognitive bias that is associated with people being more motivated to avoid losses than to seek equivalent gains. In the study, the deposit group has a potential loss in the $150 deposit.⁵

Next, the timing of the rewards influences persistence to the remain abstinent. The rewards were provided at different timepoints through the study—14 days, 30 days, and 6 months.⁵

Additionally, a reward at the end of the intervention is used as a tool to mitigate smokers’ tendency to discount the importance of future events. While this study did not show meaningful differences between individual and group-oriented programs, social proof/concordance/comparisons can be strong motivating factors.

Apart from incentives and their framing, other tools include framing of key messages. Informational resources, such as handouts and brochures for smoking cessation, can aid in initiating the thoughts of quitting smoking.

Traditionally, most of these resources are displayed only in health care settings, such as hospitals or physician offices. It is important to understand what information (health benefits vs financial benefits of smoking cessation) and what messaging tactic (information on benefits of smoking cessation vs information on risks of smoking) is more attractive along with strategic positioning of the resources.

Strategic positioning refers to the placement of informational resources where it will be most useful and have the greatest effect. In a field study conducted in low-income areas of Connecticut using brochures with separate health benefit vs financial benefit messages to motivate smoking cessation, displays were rotated among community settings, such as check-cashing, health clinics, and grocery stores.⁶

Health brochures were titled “Quit Smoking and Get Healthy” and financial brochures were titled “Quit Smoking and Save Money.” Each contained specific information on either health or financial gains achievable over a day, week, and year.

Researchers found that financial messages vs health-related messages were far more effective in engaging smokers. Additionally, financial messages in financial settings (non-health care) garnered more attention.⁶

While incentives can be expensive, the long-term cost-savings from smoking cessation are meaningful. Well-designed incentives that leverage behavioral economics principles are another tool to nudge smokers to make better decisions. Principles such as framing, loss aversion, messaging strategies, and social proof can be effective tools for meaningful behavior modifications among smokers who want to quit.

References

1. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion. Accessed from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm#nation
2. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion. Accessed from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/economics/econ_facts/index.htm
3. Department of Health and Human Services. Smoking Cessation. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2020.
4. Volpp KG, Troxel AB, Pauly MV, et al. A randomized, controlled trial of financial incentives for smoking cessation. N Engl J Med. 2009;360(7):699-709. doi:10.1056/NEJMsa0806819
5. Halpern SD, French B, Small DS, et al. Randomized trial of four financial-incentive programs for smoking cessation. N Engl J Med. 2015;372(22):2108-2117. doi:10.1056/NEJMoa1414293
6. Sindelar JL, O'Malley SS. Financial versus health motivation to quit smoking: a randomized field study. Prev Med. 2014;59:1-4. doi:10.1016/j.ypmed.2013.10.008