Thursday, February 12, 2009

Paying Smokers to Quit: A Report from the New England Journal of Medicine

Should employers give their employees hard cash to stop using tobacco? The Disease Management Care Blog doesn’t know the answer to that either, but it’s a little closer to understanding the numbers thanks to this publication by Volpp and colleagues appearing in the latest issue of the New England Journal of Medicine. Of approximately 1900 smoker-employees of an unnamed company with multiple worksites, about 800 agreed to be randomly assigned to ‘community based tobacco cessation resources’ within 20 miles of each of the work site (442 persons) or being assigned to the community resource plus being paid $100 if the program was completed, $250 if there was tobacco cessation within 6 months of study enrollment and another $400 if still off tobacco 6 months later (436 persons). Participants were not required to actually use the community resource; it looks like they could quit on their own if they so chose. Cessation was confirmed with a highly accurate test for the presence of cotinine in the urine or saliva.

The bottom line quit rate at 9-12 months was 14.7% in the group that was incented vs. 5.0% in the group that had no incentive. There were only two urine or saliva samples that were positive for cotinine.

The DMCB counted 47 persons completed the community resource (at $100 each or $4700), 91 had cotinine confirmed abstinence within 6 months (at $250 each or $22,750) and 64 remained abstinent at about 12 months ($400 each or $25,600), yielding a total outlay of $53,050 or $828 per smoker who quit.

So if an employer has a thousand employees, and about 15% or 150 smoke (a not unusual prevalence rate) and approximately half agree to participate (75) and the quit rate is about 15%, that means that 11 persons would quit at a total cost to the company of about $9000. The authors quote a study that contrasts the $828 figure with a report from the Centers for Disease Control that states that active smokers experience $1,760 in lost productivity and $1,623 in excess medical expenditures per year.

Take away lessons from the Disease Management Care Blog:

Quit rates based in physician offices that are supplemented with the use of pharmacotherapy typically range from 11% to 30% at one year. The quit rate of about 15% in this program seems comparatively low. However, it has the advantage of offering more persons access to a tobacco program with a respectable outcome. As a result, while the relative number of quitters is lower, the absolute number is probably higher than what can be obtained in the traditional health care system.

While the number of persons trying to game the system seemed to be low (apparently saying they stopped and submitting a sample), that may have been helped by the sentinel effect of urine or saliva testing. This would seem to be an important part of any company-sponsored tobacco cessation program that involves cash incentives.

The cost of $9000 described in the scenario above is the direct cost to the company. Other costs, such as cotinine testing, physician services or drug use (for example, nicotine replacement therapy) represent other costs, especially in a self-insured company.

Last but not least, this appears to be another business opportunity for disease management organizations. This is not the first program to use incentives, but we now have a better idea on the role of cash in incenting persons to quit. DMOs can help recruit smokers, arrange for the community-based referrals, arrange the cotinine testing and adjudicate payment.

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