November 13, 2013
By Michael Craig Miller M.D.
Harvard Medical School
"It's easy to quit smoking. I've done it many times."
With New Year's resolution season upon us, this old joke may be making its rounds. But quitting is no joke for the almost three-quarters of current smokers who want to quit. Sadly, fewer than 3% of them succeed, because the well-known dangers of smoking turn out to be easy to ignore.
Research suggest that quitting may be easier if a smoker gets a quick reward for abstaining. In other words, clear short-term gains seem to be more helpful than vague promises of better health and fitness at some unknown time in the future.
Paying Smokers To Quit
Volpp and colleagues, publishing in The New England Journal of Medicine in 2009, recruited almost 900 smokers into smoke-ending programs. Half of the subjects could earn money for completing the program and staying smoke-free. The payouts came in three stages. By the end of the program, the most successful quitters received a total of $750. The researchers protected against cheating by using a biochemical test to make sure people had actually stopped smoking.
In the end, subjects who got paid were more likely to get into and eventually complete the program. After 18 months, these folks quit smoking at a rate two to three times greater than people who didn't get paid. The authors reported that in past studies using the same approach, cash payments were not effective. But those earlier experiments used much lower dollar amounts.
Surely $750 is a fairly large sum of money. The authors also argued that these sums are justified. They predicted that employers could save $3,400 per year for each worker who quits because non-smokers are healthier than smokers. Their health care costs less. And they feel more energetic and productive.
The results of the study are impressive. Even so, fewer than 10% of smokers receiving money rewards actually quit smoking. That success rate may not be high enough to justify the cost, even if administrators could figure out a fair way to put such a program into practice.
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Rewarding the Smokers and the Doctors
A second study, published in the Archives of Internal Medicine the same year, used a different approach. Salize and colleagues tried to show that, by investing in smoking-cessation programs in a primary care setting, you can reduce medical costs. They compared three strategies:
- Strategy 1 — Researchers gave a group of physicians special training and paid them a reward (the equivalent of approximately $150) for each patient who quit.
- Strategy 2 — Researchers trained physicians and gave patients free prescriptions for nicotine replacement or bupropion (an antidepressant that reduces cravings in some smokers).
- Strategy 3 — Researchers combined elements of the first two approaches.
Which approach worked best? Smokers who received free medications quit at a greater rate than smokers who received usual treatment. Paying the doctors extra did not help patients quit. The author of a commentary that appeared in the same journal estimated that the program cost about $150 per quitter. Although this seems cheap, the writer also warned that it is very difficult to make precise cost calculations in this kind of study.
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Another Way To Quit
Maybe the best smokers can do is to practice "secondary prevention." It's a fancy term for a New Year's resolution.
Secondary prevention is when a person resolves to quit because of a smoking-induced illness. For example, a person may have had a heart attack, stroke or a cancer diagnosis. Now, the risk hits home. The threat of death makes it much more difficult for a smoker to believe he can safely inhale and live until his 100th birthday.
In fact, evidence supports many clinicians' intuition that more people stop smoking once they have a life-threatening illness.
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No matter how you add up the numbers, smoking is expensive. But people still find it difficult to quit, because the brain's reward system is finely tuned to the lure of the substance.
Costs aside, these researchers showed that one good way to fight addiction is to try to substitute one short-term gratification for another one.
So, if you plan to stop smoking, think of a way to reward yourself for doing so. Or — and I know this is a very tough suggestion, but it could just work — have people hold onto this a holiday or birthday gift and give it to you instead as a reward for quitting at some date in the future. The bonus will be a healthier you.
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Michael Craig Miller, M.D., is the former editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 30 years.