Real-Life Effectiveness of Smoking Cessation Delivery Modes: A Comparison Against Telephone Counseling and the Role of Individual Characteristics and Health Conditions in Quit Success.

INTRODUCTION: Professional behavioral counseling for smoking cessation can be delivered in many forms, which may not work equally well for everyone. We aim to explore in a real-world setting whether different delivery modes yield different rates of quit success and whether quit success varies based on gender, age, educational level, and being treated for a health condition. AIMS AND METHODS: We used monitoring data (n = 13 747) from a smoking cessation counseling provider in the Netherlands (September 2018 to August 2021) to compare differences in quit success immediately after the end of counseling and at 12-month follow-up between telephone and other modes of counseling. Participants chose which mode of counseling they received. At the 12-month follow-up, we also examined differences in quit success based on demographic characteristics and whether one is being treated for various health conditions. RESULTS: Participants of in-person group counseling and online in-company group counseling were significantly more likely to have quit immediately after the counseling compared with telephone counseling (OR = 1.25, 95% CI = 1.08-1.44; OR = 1.63, 95% CI = 1.18-2.24). Analyses revealed no significant differences in quit success between telephone and other modes of counseling after 12 months. Those treated for a respiratory or psychological condition were less likely to have maintained quit success, as were women, and participants with a lower educational level. CONCLUSIONS: When chosen by oneself, the mode of smoking cessation counseling received does not appear to be important for long-term quit success. However, certain groups warrant extra support to prevent excessive program attrition and unsuccessful quit attempts. IMPLICATIONS: Our findings suggest that when chosen by oneself, the delivery mode of smoking cessation counseling does not appear to be important for long-term quit success. This finding is of particular relevance for those who are unable to attend in-person cessation counseling due to, for instance, reduced accessibility or mobility. We also found that women, lower educated, and younger participants were more likely to dropout of the cessation program or to not have maintained a quit attempt, signaling that disparities in smoking cessation persist when standardized counseling is given, and therefore more tailored counseling may be necessary for these groups.

How a 5-Day Stay in the Tobacco-Free Environment of the Stoptober House Supports Individuals to Quit Smoking: A Mixed Methods Pilot Study.

INTRODUCTION: The Stoptober House is part of the annual national Stoptober smoking cessation campaign in the Netherlands. During the first week of October, 48 volunteers resided in the tobacco-free Stoptober House for 5 days and received smoking cessation counseling. This pilot study explored how the Stoptober House may have facilitated smoking cessation among participants. METHODS: We included 48 individuals who were selected for the Stoptober House (intervention group) and 67 individuals who were not selected (control group). Surveys were conducted at baseline, immediately after 2 and 8 weeks of post-intervention. We compared self-reported abstinence, psychosocial mediators related to smoking cessation, and perceived active elements of the Stoptober House between the intervention and control groups using t/χ2 tests and linear mixed model (LMM) analysis. Sixteen semi-structured qualitative interviews were conducted to explore participants' perspectives on the elements contributing to their success in quitting smoking. RESULTS: At 8 weeks of follow-up, a higher proportion of participants in the intervention group (24/48 [50%]) reported being abstinent compared to the control group (5/67 [7%]; p < 0.001). Among participants who reported making a quit attempt, 22/38 (57.9%) in the intervention group remained abstinent compared to 4/17 (23.5%) in the control group (p = 0.022). The intervention group also exhibited higher self-efficacy to quit smoking throughout the follow-up period and higher social support immediately after the Stoptober House. No significant differences were observed in other psychosocial factors. The interviews highlighted several perceived elements of the Stoptober House that contributed to smoking cessation success, including restricted smoking opportunities, access to smoking cessation counselors, and peer support. CONCLUSION: This pilot study suggests that the Stoptober House provides support that can help people quit smoking. Further research is needed to confirm these findings and determine the cost-effectiveness of this intervention in promoting long-term abstinence among specific groups of smokers.

Smoking Cessation Among Gender Minority Populations, Cis-women, and Cis-men: Findings From the International Tobacco Control Netherlands Survey.

INTRODUCTION: Little is known about smoking cessation among gender minority populations compared to cisgender individuals (whose gender matches their sex assigned at birth). We examined differences between smokers from gender minority populations, cis-women, and cis-men in the heaviness of smoking, quit intentions, use of cessation assistance, quit attempts (ever tried and number), and triggers for thinking about quitting. AIMS AND METHODS: We used cross-sectional data from the 2020 International Tobacco Control Netherlands Survey. Among smoking respondents, we distinguished (1) cis-women (female sex, identified as women, and having feminine gender roles; n = 670), (2) cis-men (male sex, identified as men, and having masculine gender roles; n = 897), and (3) gender minorities (individuals who were intersex, who identified as nonbinary, genderqueer, had a sex/gender identity not listed, whose gender roles were not feminine or masculine, or whose gender identity and/or roles were not congruent with sex assigned at birth; n = 220). RESULTS: Although gender minorities did not differ from cis-women and cis-men in the heaviness of smoking, plans to quit smoking, and quit attempts, they were significantly more likely to use cessation assistance (20% in the past 6 months) than cis-women (12%) and cis-men (9%). Gender minorities were also significantly more likely to report several triggers for thinking about quitting smoking, for example, quit advice from a doctor, an anti-smoking message/campaign, and the availability of a telephone helpline. CONCLUSION: Despite equal levels of quit attempts and heaviness of smoking, gender minority smokers make more use of smoking assistance, and respond stronger to triggers for thinking about quitting smoking. IMPLICATIONS: Smoking cessation counselors should be sensitive to the stressors that individuals from any minority population face, such as stigmatization, discrimination, and loneliness, and should educate their smoking clients on effective coping mechanisms to prevent relapse into smoking after they experience these stressors. Developing tailored smoking cessation programs or campaigns specifically for gender minority populations can also be useful. Based on the results of our subgroup analyses, programs or campaigns for younger gender minority smokers could focus on the availability of telephone helplines and on how friends and family think about their smoking behavior.

Challenges and successes in the sustainment of Dutch community-level smoking cessation interventions for residents with a low socioeconomic position.

BACKGROUND: When health promotion interventions are implemented, the gains are often short-lived, as interventions are seldom successfully sustained. The current study explores how and under what conditions community-level smoking cessation interventions for people with a lower socioeconomic position can be sustained, drawing upon interventions delivered in Dutch neighbourhoods with a predominantly low socioeconomic position. METHODS: We conducted 15 semi-structured interviews with key stakeholders from three Dutch community-level smoking cessation interventions implemented at least three years prior. The topic guide was developed based on the Determinants of Innovation framework and transcripts were analysed thematically. RESULTS: We identified several factors that promote the sustainment of smoking cessation community-level interventions: 1) structural, long-term funding through the commitment of health insurers and policy makers; 2) continued stakeholder enthusiasm and involvement; 3) training and time for professionals to discuss smoking cessation, thereby also increasing the visibility of the intervention for professionals and residents; 4) integrating the intervention with existing initiatives and adapting it to be compatible with current working practices of executive staff; and 5) planning for sustainment as a team from the outset. CONCLUSIONS: The current study highlights challenges and successes in intervention sustainment for people with a lower socioeconomic position. Lack of structural funding was one of the most challenging aspects for intervention sustainment in which health insurers and policy makers can play an important role. Planning for sustainment from the outset would enable intervention coordinators to consider the abovementioned factors early on. This need not be done alone but can best be discussed within a team of stakeholders.

How Financial Incentives Increase Smoking Cessation: A Two-Level Path Analysis.

INTRODUCTION: Financial incentives effectively increase smoking cessation rates, but it is unclear via which psychological mechanisms incentives influence quit behavior. The current study examines how receiving financial incentives for smoking cessation leads to quitting smoking and investigates several mediators and moderators of that relationship. AIMS AND METHODS: The study sample consisted of 604 tobacco-smoking employees from 61 companies in the Netherlands who completed a baseline and follow-up questionnaire. The current study is a secondary analysis from a cluster randomized trial where employees received smoking cessation group counseling at the workplace. Participants in the intervention group additionally received financial incentives of €350 in total for 12-month continuous smoking abstinence. We used a two-level path analysis to test a model that assesses the effects of financial incentives through smoking cessation program evaluation, medication use, nicotine replacement use, attitudes, self-efficacy, and social influences on quit success. We additionally tested whether an individual's reward responsiveness moderated the influence of incentives on quit success. RESULTS: The effect of financial incentives on quit success was mediated by a higher self-efficacy. Financial incentives were also associated with a higher use of cessation medication. A more positive program evaluation was related to higher self-efficacy, more social influence to quit, and more positive attitudes about quitting. The results did not differ significantly by individual reward responsiveness. CONCLUSIONS: The results of the current study suggest that financial incentives may be used to increase medication use and self-efficacy for quitting smoking, which offers an indirect way to increase successful smoking cessation. IMPLICATIONS: (1) This is the first study investigating via which psychological pathways financial incentives for quitting smoking can lead to long-term quit success. (2) The results showed a path between financial incentives and a higher likelihood of medication use. Incentives may encourage smokers to use medication in order to increase their chance of quitting smoking and receive the reward. (3) There was a path from financial incentives to quit success via a higher self-efficacy. (4) The effects of financial incentives did not depend on individual reward responsiveness.

Does free or lower cost smoking cessation medication stimulate quitting? Findings from the International Tobacco Control (ITC) Netherlands and UK Surveys.

OBJECTIVE: To investigate whether mentioning free or lower cost smoking cessation medication as a trigger for thinking about quitting is related to higher medication use, more quit attempts and quit success, and whether these associations are modified by education and income. METHODS: Data were derived from the 2013 and 2014 surveys of the International Tobacco Control Netherlands (n=1164) and UK (n=768) cohort. Logistic regression analyses were used to assess associations between mentioning in 2013 that free/lower cost smoking cessation medication was a trigger for thinking about quitting smoking and the use of medication, quit attempts and smoking cessation in 2014. RESULTS: 37.0% of smokers in the UK and 24.9% of smokers in the Netherlands mentioned free/lower cost medication as a trigger for thinking about quitting. Smokers who mentioned this trigger were more likely to have used cessation medication during a quit attempt both in the UK (OR=4.19, p<0.001) and in the Netherlands (OR=2.14, p=0.033). The association between mentioning free/lower cost medication as a trigger for thinking about quitting and actual quit attempts was significant in the UK (OR=1.45, p=0.030), but not in the Netherlands (OR=1.10, p=0.587). There was no significant association with quit success. Associations did not differ across income and education groups. CONCLUSION: Free/lower cost smoking cessation medication may increase the use of cessation medication and stimulate quit attempts among smokers with low, moderate and high education and income.

Healthcare financing systems for increasing the use of tobacco dependence treatment.

BACKGROUND: Tobacco smoking is the leading preventable cause of death worldwide, which makes it essential to stimulate smoking cessation. The financial cost of smoking cessation treatment can act as a barrier to those seeking support. We hypothesised that provision of financial assistance for people trying to quit smoking, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts. This is an update of the original 2005 review. OBJECTIVES: The primary objective of this review was to assess the impact of reducing the costs for tobacco smokers or healthcare providers for using or providing smoking cessation treatment through healthcare financing interventions on abstinence from smoking. The secondary objectives were to examine the effects of different levels of financial support on the use or prescription of smoking cessation treatment, or both, and on the number of smokers making a quit attempt (quitting smoking for at least 24 hours). We also assessed the cost effectiveness of different financial interventions, and analysed the costs per additional quitter, or per quality-adjusted life year (QALY) gained. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialised Register in September 2016. SELECTION CRITERIA: We considered randomised controlled trials (RCTs), controlled trials and interrupted time series studies involving financial benefit interventions to smokers or their healthcare providers, or both. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed the quality of the included studies. We calculated risk ratios (RR) for individual studies on an intention-to-treat basis and performed meta-analysis using a random-effects model. MAIN RESULTS: In the current update, we have added six new relevant studies, resulting in a total of 17 studies included in this review involving financial interventions directed at smokers or healthcare providers, or both.Full financial interventions directed at smokers had a favourable effect on abstinence at six months or longer when compared to no intervention (RR 1.77, 95% CI 1.37 to 2.28, I² = 33%, 9333 participants). There was no evidence that full coverage interventions increased smoking abstinence compared to partial coverage interventions (RR 1.02, 95% CI 0.71 to 1.48, I² = 64%, 5914 participants), but partial coverage interventions were more effective in increasing abstinence than no intervention (RR 1.27 95% CI 1.02 to 1.59, I² = 21%, 7108 participants). The economic evaluation showed costs per additional quitter ranging from USD 97 to USD 7646 for the comparison of full coverage with partial or no coverage.There was no clear evidence of an effect on smoking cessation when we pooled two trials of financial incentives directed at healthcare providers (RR 1.16, CI 0.98 to 1.37, I² = 0%, 2311 participants).Full financial interventions increased the number of participants making a quit attempt when compared to no interventions (RR 1.11, 95% CI 1.04 to 1.17, I² = 15%, 9065 participants). There was insufficient evidence to show whether partial financial interventions increased quit attempts compared to no interventions (RR 1.13, 95% CI 0.98 to 1.31, I² = 88%, 6944 participants).Full financial interventions increased the use of smoking cessation treatment compared to no interventions with regard to various pharmacological and behavioural treatments: nicotine replacement therapy (NRT): RR 1.79, 95% CI 1.54 to 2.09, I² = 35%, 9455 participants; bupropion: RR 3.22, 95% CI 1.41 to 7.34, I² = 71%, 6321 participants; behavioural therapy: RR 1.77, 95% CI 1.19 to 2.65, I² = 75%, 9215 participants.There was evidence that partial coverage compared to no coverage reported a small positive effect on the use of bupropion (RR 1.15, 95% CI 1.03 to 1.29, I² = 0%, 6765 participants). Interventions directed at healthcare providers increased the use of behavioural therapy (RR 1.69, 95% CI 1.01 to 2.86, I² = 85%, 25820 participants), but not the use of NRT and/or bupropion (RR 0.94, 95% CI 0.76 to 1.18, I² = 6%, 2311 participants).We assessed the quality of the evidence for the main outcome, abstinence from smoking, as moderate. In most studies participants were not blinded to the different study arms and researchers were not blinded to the allocated interventions. Furthermore, there was not always sufficient information on attrition rates. We detected some imprecision but we judged this to be of minor consequence on the outcomes of this study. AUTHORS' CONCLUSIONS: Full financial interventions directed at smokers when compared to no financial interventions increase the proportion of smokers who attempt to quit, use smoking cessation treatments, and succeed in quitting. There was no clear and consistent evidence of an effect on smoking cessation from financial incentives directed at healthcare providers. We are only moderately confident in the effect estimate because there was some risk of bias due to a lack of blinding in participants and researchers, and insufficient information on attrition rates.

The FRESHAIR4Life study: Global implementation research on non-communicable disease prevention targeting adolescents' exposure to tobacco and air pollution in disadvantaged populations.

The FRESHAIR4Life study aims to reduce the non-communicable disease (NCD) burden by implementing preventive interventions targeting adolescents' exposure to tobacco use and air pollution (AP) worldwide. This paper presents the FRESHAIR4Life methodology and initial rapid review results. The rapid review, using various databases and PubMed, aimed to guide decision-making on risk factor focus, target areas, and populations. It showed variable NCD mortality rates related to tobacco use and AP across the participating countries, with tobacco as the main risk factor in the Kyrgyz Republic, Greece, and Romania, and AP prevailing in Pakistan and Uganda. Adolescent exposure levels, sources, and correlates varied. The study will continue with an in-depth situational analysis to guide the selection, adaptation, and integration of evidence-based interventions into the FRESHAIR4Life prevention package. This package will be implemented, evaluated, assessed for cost-effectiveness, and iteratively refined. The research places a strong emphasis on co-creation, capacity building, and comprehensive communication and dissemination.

Content analysis of Dutch newspaper coverage of three tobacco control policies, 2017-2019.

OBJECTIVES: News media coverage can influence support for and implementation of tobacco control policies. This research aims to analyse and compare newspaper coverage of newly implemented policies: a substantial tobacco tax increase, point-of-sale display ban and plain packaging. DESIGN: We conducted a content analysis of articles covering the three policies from ten national Dutch newspapers. Articles published between November 2017 and November 2019 were coded for type and tone. The policy dystopia model was used to code arguments opposing the policies. Tobacco industry appearances in news articles were also analysed for frequency and type. RESULTS: A total of 134 news articles were analysed, of which the industry appeared in 28%. The majority of coverage was neutral in tone, although among articles that were coded as expressing a positive or negative tone, plain packaging and the point-of-sale ban were portrayed more negatively than positively. Negative coverage was predominantly accounted for by industry presence. Arguments opposing the policies focused on negative economic consequences, challenging the need for policy and adverse consequences for retailers for tax, plain packaging and the point-of-sale display ban, respectively. We identified six specific new arguments that fit within existing domains of the policy dystopia model. CONCLUSIONS: The tobacco industry and its allies still appear in a substantial proportion of news articles in relation to tobacco policy. This study identifies contemporary industry arguments against tobacco control policies in Europe which, alongside the policy dystopia model, can be used to predict and counter the tobacco industry's future attempts to oppose policies.

Reducing the number and types of tobacco retail outlets in the Netherlands: Study protocol for a comprehensive mixedmethods policy evaluation.

The Netherlands plans to ban tobacco sales in supermarkets in 2024. In a comprehensive policy evaluation, we aim to examine: 1) the impact of the policy on the number and types of tobacco outlets, 2) the impact on attitudes and behaviors of smoking adults and non-smoking youth, and 3) the influence of the tobacco industry on the policy process and the retail environment. In addition, our study focusses on differential effects in disadvantaged neighborhoods, where both smoking rates and tobacco outlet density are typically highest. This study brings together economic, psychological, and journalistic research methods. We investigate the impact of the new legislation on the number and type of tobacco outlets, and on the number of smokers by using routinely collected population monitoring data. We examine the impact of the legislation on smoking susceptibility of non-smoking youth and on impulse tobacco purchases by smoking adults with yearly quantitative surveys and with qualitative interviews and discussion sessions. We describe whether these impacts differ for disadvantaged versus non-disadvantaged neighborhoods. We investigate what strategies the tobacco industry uses to influence the new legislation, policy processes, and the tobacco retail environment by performing a journalistic investigation, by means of documents obtained by Freedom of Information Act (FOIA) requests, (possibly) leaked documents from insider meetings, and interviews with insiders. The methods of our evaluation can be used as a model for other comprehensive public policy evaluations. REGISTRATION: Clinical Trials ID NCT05554120, Protocol ID KWF140282021-2. ABBREVIATIONS: FOIA: Freedom of Information Act. SES-WOA: socioeconomic scores of private households. MCID: minimal clinically important difference.

A qualitative study assessing how reach and participation can be improved in workplace smoking cessation programs.

INTRODUCTION: Randomized controlled trials have demonstrated the effectiveness of workplace smoking cessation programs. However, with low participation rates reported, it is important to understand the barriers and facilitators for the reach and participation of employees in workplace smoking cessation programs. The objective of the present study is to uncover the needs of employees regarding reach and participation when implementing a workplace program to address smoking cessation. METHODS: We carried out 19 semi-structured qualitative interviews in 2019 based on the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) Framework with current and former smoking employees of organizations with ≥100 employees in the Netherlands. Some of the interviewees had experience with a cessation program. Data were analyzed using the Framework method. RESULTS: The main barriers according to employees were insufficient promotion of the cessation program, completing the program in the employee's own time and working night shifts and peak hours. Facilitators included being actively approached to participate by a colleague, positive reactions from colleagues about employee's participation in the program, providing the program on location and integrating the program as part of the organization's vitality policy. CONCLUSIONS: Effective workplace programs for smoking cessation can stimulate cessation but implementers often experience low participation rates. Our study presents recommendations to improve the recruitment and participation of employees in a workplace smoking cessation program, such as using active communication strategies, training managers to stimulate smoking employees to participate and making the program as accessible as possible by reimbursing time spent and offering the program at the workplace or nearby. Integrating the smoking cessation program into wider company vitality policy will also aid continued provision of the program.

How can vulnerable groups be recruited to participate in a community-based smoking cessation program and perceptions of effective elements: A qualitative study among participants and professionals.

INTRODUCTION: Smokers from vulnerable groups, such as smokers with a low socioeconomic position, often have more difficulty quitting smoking and often are more difficult to recruit for smoking cessation programs. It is important to know how vulnerable groups can be recruited and motivated to participate in a smoking cessation program and what participants and professionals perceive as effective elements. METHODS: Qualitative interviews were performed with participants of a communitybased smoking cessation program in the Netherlands (n=18) and professionals involved in the recruitment of participants or as trainers in the community-based smoking cessation program (n=8). They were interviewed twice: once before the program had started and once after the program had ended. Interviews were semi-structured and conducted between September 2018 and February 2019. RESULTS: We found that organizing the program in the neighborhood lowered the threshold to participate, that registration should be quick and easy, that an active approach is needed, and that personal contact is important. This study also showed that information sharing, social support, commitment of the trainer, and personal contact are perceived as effective elements of such a program. CONCLUSIONS: This study shows that vulnerable smokers can be successfully recruited for a smoking cessation program. We recommend that such interventions include a group setting, extensive personal contact between participants and a committed trainer, and implementation of the program at a location in the neighborhood of the target group. Practical recommendations for professionals are to personally approach people multiple times if needed, to make sure that registration is quick and easy, and to fill in the registration form immediately during recruitment.

Cost-effectiveness and cost-utility analysis of a work-place smoking cessation intervention with and without financial incentives.

AIMS: To perform an economic evaluation of a work-place smoking cessation group training programme with incentives compared with a training programme without incentives. DESIGN: A trial-based cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) from a societal perspective and an employer's perspective. SETTING: Sixty-one companies in the Netherlands. PARTICIPANTS: A total of 604 tobacco-smoking employees. INTERVENTION AND COMPARATOR: A 7-week work-place smoking cessation group training programme. The intervention group earned gift vouchers of €350 for 12 months' continuous abstinence. The comparator group received no incentives. MEASUREMENTS: Online questionnaires were administered to assess quality of life (EQ-5D-5 L) and resource use during the 14-month follow-up period (2-month training period plus 12-month abstinence period). For the CEA the primary outcome measure was carbon monoxide (CO)-validated continuous abstinence; for the CUA the primary outcome was quality-adjusted life years (QALY). Bootstrapping and sensitivity analyses were performed to account for uncertainty. Incremental cost-effectiveness ratio (ICER) tables were used to determine cost-effectiveness from a life-time perspective. FINDINGS: Of the participants in the intervention group, 41.1% had quit smoking compared with 26.4% in the control group. From a societal perspective with a 14-month follow-up period, the ICER per quitter for an intervention with financial incentives compared with no incentives was €11 546. From an employer's perspective, the ICER was €5686. There was no significant difference in QALYs between the intervention and control group within the 14-month follow-up period. The intervention was dominated by the comparator in the primary analysis at a threshold of €20 000 per QALY. In the sensitivity analysis, these results were uncertain. A life-time perspective showed an ICER of €1249 (95% confidence interval = €850-2387) per QALY. CONCLUSIONS: Financial incentives may be cost-effective in increasing quitting smoking, particularly from a life-time perspective.

The Association of Peer Smoking Behavior and Social Support with Quit Success in Employees Who Participated in a Smoking Cessation Intervention at the Workplace.

The current study investigated whether quit success among employees who participated in a smoking cessation intervention at the workplace was associated with social support from, and the smoking behavior of, people in their environment. Tobacco-smoking employees (n = 604) from 61 companies participated in a workplace group smoking cessation program. Participants completed questionnaires assessing social support from, and the smoking behavior of, people in their social environment. They were also tested for biochemically validated continuous abstinence directly after finishing the training and after 12 months. The data were analyzed using mixed-effects logistic regression analyses. Social support from colleagues was positively associated with 12-month quit success (odds ratio (OR) = 1.85, 95% confidence interval (CI) = 1.14-3.00, p = 0.013). Support from a partner was positively associated with short-term quit success (OR = 2.01, 95% CI = 1.23-3.30, p = 0.006). Having a higher proportion of smokers in the social environment was negatively associated with long-term abstinence (OR = 0.81, 95% CI = 0.71-0.92, p = 0.002). Compared to having a non-smoking partner, long-term quit success was negatively associated with having no partner (OR = 0.48, 95% CI = 0.26-0.88, p < 0.019), with having a partner who smokes (OR = 0.40, 95% CI = 0.24-0.66, p < 0.001), and with having a partner who used to smoke (OR = 0.47, 95% CI = 0.26-0.86, p = 0.014). In conclusion, people in a smoker's social environment, particularly colleagues, were strongly associated with quit success. The workplace may, therefore, be a favorable setting for smoking cessation interventions.

Implementation of Financial Incentives for Successful Smoking Cessation in Real-Life Company Settings: A Qualitative Needs Assessment among Employers.

Randomized studies have shown that financial incentives can significantly increase the effect of smoking cessation treatment in company settings. Evidence of effectiveness alone is, however, not enough to ensure that companies will offer this intervention. Knowledge about the barriers and facilitators for implementation in the workplace is needed, in order to develop an implementation strategy. We performed a qualitative needs assessment among 18 employers working in companies with relatively many employees with a low educational level, and our study revealed priority actions that aim to improve the implementation process in these types of workplaces. First, employers need training and support in how to reach their employees and convince them to take part in the group training. Second, employers need to be convinced that their non-smoking employees will not consider the incentives unfair, or they should be enabled to offer alternative incentives that are considered less unfair. Third, the cost-effectiveness of smoking cessation group trainings including financial incentives should be explained to employers. Finally, smoking cessation should become a standard part of workplace-based health policies.

'Secretly, it's a competition': a qualitative study investigating what helped employees quit smoking during a workplace smoking cessation group training programme with incentives.

OBJECTIVES: Smoking cessation programmes in combination with financial incentives have shown to increase quit rates in smokers, but it is not clear which elements of this intervention help smokers to succeed in their quit attempt. The aim of this study was to explore the view of successful and unsuccessful quitters about which factors had affected their ability to quit smoking. DESIGN: Semistructured qualitative interviews were conducted and analysed using the Framework method. SETTING: Interviews were conducted in 2017 with employees from nine different Dutch companies. PARTICIPANTS: 24 successful and unsuccessful quitters from the intervention group of a cluster randomised controlled trial (RCT) who participated in a workplace smoking cessation group training programme in which smoking abstinence was rewarded with financial incentives. RESULTS: Themes that emerged were the workplace setting, quitting with colleagues, motivation, family support, strategies and the financial incentives. The interviewees reported that the smoking cessation programme was appreciated in general, was convenient, lowered the threshold to sign up, stimulated peer support and competition and provided strategies to resist smoking. Personal motivation and a mind set to never smoke again were regarded as important factors for quit success. The financial incentives were not considered as a main motivator to quit smoking, which contradicts the results from the RCT. The financial incentives were considered as more attractive to smokers with a low income. CONCLUSIONS: According to participants, contributors to quitting smoking were the workplace cessation programme, personal motivation and peer support, but not the incentives. More research is needed on the contradiction between the perceived effects of financial incentives on quit success and the actual difference in quit rates. TRIAL REGISTRATION NUMBER: NTR5657.

Effect of a workplace-based group training programme combined with financial incentives on smoking cessation: a cluster-randomised controlled trial.

BACKGROUND: Financial incentives are potentially useful tools to aid smoking cessation, but robust evidence to support their efficacy, particularly in combination with other interventions (eg, group counselling), has not been reported. We aimed to investigate whether financial incentives combined with a smoking cessation group training programme (compared with a training programme with no incentives) organised at the workplace would increase 12-month abstinence rates in tobacco-smoking employees with different education and income levels. METHODS: This cluster-randomised controlled trial was done in the Netherlands with companies that offer a smoking cessation group training programme to all of their smoking employees. Eligible participants were tobacco-smoking employees and spouses of employees who were at least 18 years of age. Participants in the control group received a weekly 90-min session of smoking cessation group training for 7 weeks at the workplace; in addition to the group training, participants in the intervention group received vouchers for being abstinent (€50 at the end of the training programme, €50 3 months after completion of the programme, €50 after 6 months, and €200 after 12 months). Companies were randomly assigned by an independent research assistant to the intervention group or the control group with a digital randomisation programme, using a biased urn method. The primary outcome was carbon monoxide-validated continuous abstinence at 12 months. All randomised participants were included in the modified intention-to-treat analyses, with the exception of unavoidable loss (participants who had died or moved to an untraceable address (according to the Russell Standard), and in the sensitivity analyses, except the complete case analysis, which included only participants for whom all variables included in the model were not missing. This study is registered with the Dutch Trial Register, number NTR5657. FINDINGS: Between March 1, 2016, and March 1, 2017, 61 companies with 604 participating smokers were enrolled. 31 companies (319 smokers) were randomly assigned to the intervention group and 30 companies (285 smokers) to the control group. 12 months after finishing the smoking cessation programme, the proportion of individuals abstaining from smoking in the intervention group was significantly higher than that in the control group (131 [41%] of 319 vs 75 [26%] of 284; adjusted odds ratio 1·93, 95% CI 1·31-2·85, p=0·0009; adjusted for education level, income level, and Fagerström score). INTERPRETATION: Financial incentives in addition to a smoking cessation group training programme can significantly increase long-term smoking abstinence. The results of the current study could motivate employers to facilitate a workplace smoking cessation programme with financial incentives to help employees to quit smoking. FUNDING: Dutch Cancer Society.