The Best and Worst Ways to Stop Smoking

Tony was a gambler who could not break his habit. Nothing worked…until he volunteered for the state-run self-exclusion program. After that, if he entered a casino, he could get arrested for criminal trespass.

Where are we going? To how we change the undesirable behaviors that we enjoy doing.

The Nudge

Made famous by Cass Sunstein and Richard Thaler, the idea of the nudge has caught on. To behave appropriately, whether looking at our retirement saving or electricity saving, all we need is the right kind of incentive–the right nudge. That could mean a default so we do not have to decide to save for retirement because it happens automatically. Or, we could receive a letter saying all of our neighbors are using less power so we should too. Both approaches have had impressive results.

For smokers, though, it gets even more complicated.

How to Stop Smoking

Signing Up for the Program

CVS Caremark wanted to figure out the best way to diminish smoking among their employees. They cared because it was expensive. People who smoke cost their employers at least $5,000 more than non-smokers.

In an experimental program that university researchers designed for CVS, 2538 employees initially enrolled but 1060 wound up accepting an assignment to one of five approaches:

• Usual care: composed of pamphlets, access to nicotine replacement and behavioral modification for those who had appropriate health benefits.
• Reward based as individuals or in small groups. Each person who quit smoking got a total of $800.
• Reward based with $150 deposit as individuals or in small groups. Those who stopped smoking got their deposit returned plus $650.

As you can see below, most of the participatory acceptances came from those in the reward groups with no deposit. The actual number of acceptances (numerators) and refusals (denominators) are shown in the fractions below the bars.

Acceptance Rates

From: “Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation”

The Results

Looking at the numbers, the rewards groups had the most individuals who quit smoking because the acceptance rate for those groups was high. Within the groups though, the highest quit rate –close to 50 percent–was in the deposit group.

From: “Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation”

Where do the results take us? To loss aversion.

Our Bottom Line: Loss Aversion

Loss aversion was first identified by economics Nobel Laureate Daniel Kahneman (a psychologist) and Amos Tversky. In one experiment, told the following short term result, physicians at Harvard Medical School were asked if they would do surgery.

#1. The one month survival rate is 90%.

Asked the same question, a second group was told the same results slightly differently:

#2. There is a 10% mortality in the first month.

84 percent of the physicians given #1 and 50 percent given #2 said yes to surgery.

According to Kahneman and Tversky, the reason is that “losses loom larger than gains.” And that is why those individuals who could lose $150 had the highest smoking quit rate.

P.S.

Please note, quoting the surgery question to a physician friend after this post was published, I was told the alternatives were more dissimilar than I had believed. Need a 90 percent survival rate necessarily mean 10 percent mortality?