Evaluating the impact of financial incentives on inequalities in smoking cessation in primary care

Objective Financial incentives are seen as one approach to encourage more systematic use of smoking cessation interventions by healthcare professionals. A systematic review was conducted to examine the evidence for this. Methods Medline, Embase, PsychINFO, Cochrane Library, ISI Web of Science and sources of grey literature were used as data sources. Studies were included if they reported the effects of any financial incentive provided to healthcare professionals to undertake smoking cessation-related activities. Data extraction and quality assessment for each study were conducted by one reviewer and checked by a second. A total of 18 studies were identified, consisting of 3 randomised controlled trials and 15 observational studies. All scored in the mid range for quality. In all, 8 studies examined smoking cessation activities alone and 10 studied the UK’s Quality and Outcomes Framework targeting quality measures for chronic disease management including smoking recording or cessation activities. Five non-Quality and Outcomes Framework studies examined the effects of financial incentives on individual doctors and three examined effects on groups of healthcare professionals based in clinics and general practices. Most studies showed improvements in recording smoking status and smoking cessation advice. Five studies examined the impact of financial incentives on quit rates and longerterm abstinence and these showed mixed results. Conclusions Financial incentives appear to improve recording of smoking status, and increase the provision of cessation advice and referrals to stop smoking services. Currently there is not sufficient evidence to show that financial incentives lead to reductions in smoking rates. INTRODUCTION Preventing smoking-related diseases is a key international public health objective. 2 Article 14 of the WHO Framework Convention of Tobacco Control (FCTC) recommends that countries implement ‘demand reduction measures concerning tobacco dependence and cessation’ alongside population level strategies such as the introduction of smokefree workplaces, restricting advertising and raising taxation on tobacco. Individual-level smoking cessation interventions by healthcare professionals are highly cost effective when compared to other medical interventions and, if delivered equitably, can reduce health inequalities related to tobacco use. Despite their cost effectiveness, smoking cessation interventions have historically been underprovided in healthcare. Reasons for this may include practitioners’ negative attitudes towards discussing smoking cessation with their patients, doubts about the effectiveness of providing smoking cessation advice, concern about compromising the doctor-patient relationship, perceived lack of expertise, lack of time in the consultation and competing priorities. Healthcare workers who smoke are more likely to have a negative view of their personal effectiveness in giving smoking cessation advice to patients 9 and a belief that such advice is ineffective. Despite these views, practitioners generally consider disease prevention activities to be important and worth spending time on during the consultation. Pay for performance schemes are becoming more widespread in healthcare, particularly in the USA 12 and the UK. They aim to improve the quality of healthcare by providing financial incentives to practitioners for achieving performance targets. Financial incentives are seen as one approach to encourage more systematic use of smoking cessation interventions and have been incorporated into many financial incentive programmes. For example, the Quality and Outcomes Framework (QOF), introduced in the UK in 2004, rewards smoking cessation activities mainly as a part of secondary prevention management of long term conditions such as coronary heart disease, diabetes and chronic obstructive pulmonary disease. We conducted a systematic review to examine evidence for the effectiveness of providing financial incentives to healthcare professionals on the provision and impact of smoking cessation interventions. METHODS Search strategy for identification and selection of studies We identified studies by searching the electronic databases Medline, Embase, PsychINFO, the Cochrane Database of Systematic Reviews, ISI Web of Science and sources of grey literature. The search terms are described in full in online only appendix A on the Tobacco Control website. We included papers in languages other than English in the search. The titles and abstracts of those studies identified by the initial searches were scanned, and for those that appeared relevant the full paper was obtained and reviewed. Further papers were identified by looking at the citations and reference lists of review papers and papers identified in the initial search. < Additional materials are published online only. To view these files please visit the journal online (http:// tobaccocontrol.bmj.com). Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK Correspondence to Dr F L Hamilton, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London W6 8RP, UK; f.hamilton@imperial.ac. uk Received 9 May 2011 Accepted 27 October 2011 Hamilton FL, Greaves F, Majeed A, et al. Tobacco Control (2011). doi:10.1136/tobaccocontrol-2011-050048 1 of 6 Review TC Online First, published on November 28, 2011 as 10.1136/tobaccocontrol-2011-050048 Copyright Article author (or their employer) 2011. Produced by BMJ Publishing Group Ltd under licence. group.bmj. com on November 29, 2011 Published by tobaccocontrol.bmj. com Downloaded from