PERSonalised Incentives for Supporting Tobacco cessation (PERSIST) among healthcare employees: a randomised controlled trial protocol 339 10 Introduction Smoking is the primary preventable risk factor for disease and premature mortality.1 Smoking is highly addictive and the vast majority of cessation attempts are unsuccessful.2 In 2017, 38% of smokers in the Netherlands attempted to quit for at least 24 hours.3 Several methods exist to increase the odds of quitting, such as nicotine replacement therapy,4 individual behavioural counselling,5 and group-based smoking cessation programmes.6 However, despite the relative effectiveness of these studies, in absolute numbers the proportion of smokers that quit is still low. A promising method to encourage smoking cessation is the provision of financial incentives upon validated abstinence. A recent Cochrane review found highcertainty evidence for increased smoking cessation rates at six or twelve months follow up (RR = 1.49, 95% confidence interval (CI) 1.28 – 1.73).7 Financial incentives make the desired behaviour - in this case smoking cessation - more attractive by rewarding it. Importantly, financial incentives provide a short term reward for a behavioural change that would normally only provide rewards in the long term. Long term rewards are often valued less compared to short term rewards due to declining perceived values of a delayed reward, so-called delay discounting.8 Typically, people give disproportionally stronger relative weights to instantaneous rewards, so-called present bias,9 which gives a strong theoretical argument for providing short-term incentives for smoking cessation. Incentive-based smoking cessation programmes have previously been implemented at the workplace.10-12 Recently, the “Continuous Abstinence Through Corporate Healthcare” (CATCH) trial was carried out among 31 Dutch companies, randomising companies to group-based smoking cessation training for smoking employees with or without financial incentives to promote sustained cessation. Among those eligible to receive incentives (up to €350), the proportion of abstinent participants at one year follow-up was significantly higher compared to those assigned to group-based training alone (41% vs 26%).13 The effectiveness of incentives in promoting sustained smoking cessation depends on how and when rewards are provided. Traditionally incentives have been tested according to a one-size-fits-all approach, using incentive size as a measure of anticipated effectiveness. A recent US trial comparing four different incentive programs, however, showed that effectiveness is variable among different types and schemes of incentives.10 A deposit-based scheme, where participants commit
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