Financial Incentives, Interpersonal Communication, and Smoking Cessation in a Low Income Population: Survey Evidence from a Population-Level Telehealth Intervention

Introduction: The tobacco epidemic disproportionately affects low-income populations. A public health priority is to establish incentive-based interventions at the population level in order to promote long-term smoking cessation in low-income populations. This is exemplified by the Affordable Care Act’s section 4108. Yet randomized clinical trials show that financial incentives tend to encourage only short-term steps of cessation, not continuous smoking abstinence. However, multiple social and psychological factors can alter the effects of a financial incentive presentation in terms of promoting or unintentionally discouraging the incentivized behavior. For instance, an incentive presented within a relatively public setting can inspire social reactions such as interpersonal discussions about the incentive, and this social response has implications for both short-term and long-term behavior change. Past research has also demonstrated that interpersonal communication (IPC) in response to population-level smoking cessation interventions is a strong mechanism for increasing long-term cessation; however, this research has not considered the role of financial incentives. This project examines survey data gathered after a population-level intervention that offered $20 incentives to low-income smokers for being connected to a free tobacco quitline (QL) via three-way calls conducted by the Minnesota Department of Health in order to assess how perceived incentive importance and interpersonal communication about the incentive-based program relate to both short-term and long-term smoking cessation behavioral steps.

Methods: Using North American Quitline Consortium evidence-based measures, the two main outcomes were (1) initial utilization of quitline services, and (2) continuous smoking abstinence measured by 30 smoke-free days at seven-month follow-up. Descriptive analyses, logistic regression models, and Heckman probit models that adjusted for participant recruitment were employed.

Results: Descriptive analyses showed that IPC was positively related to QL utilization and continuous smoking abstinence, while incentive importance was weakly related to QL utilization and not related to continuous smoking abstinence. Logistic regression models showed that the adjusted odds of QL utilization increased by 120%, and the odds of continuous smoking abstinence increased by 57%, for individuals who engaged in IPC compared to those who did not. Perceived incentive importance had non-significant associations with both measures of cessation in logistic regression models. These results were supported by Heckman probit models.

Conclusions: An incentive-based population-level intervention targeting low-income smokers inspired IPC, and IPC was strongly related to utilization of intervention services as well as continuous smoking abstinence. Social effects can arise from incentive-based population-level interventions, and these social mechanisms are critical for promoting long-term smoking cessation.