Trained Green Bank technicians test CARES clients’ smoking status using the NicCheck<sup>TM</sup> urine strip test for nicotine and its primary metabolite, cotinine.<sup>13</sup> NicCheck has been used in previous anti-smoking programs, including the Dutch Cancer Society’s “Quit and Win” campaign, and the financial bonus incentive testing in Volpp et al (2006; 2009). The test result provides a categorical measure of recent nicotine consumption, with values ranging from zero (no exposure) to fifteen (high exposure).<sup>14</sup> Green Bank counts only a zero result as passing, and both marketers emphasized that clients must stop smoking completely in order to be sure of passing the test.

Green Bank contacts each client three to four weeks prior to his six-month deadline to set up a urine testing appointment. If a client can not be reached initially the Bank makes repeated attempts to set up a test date within one week of the maturity date. If a client is deemed unable to take the test within the stipulated one-week grace period due to mitigating circumstances (e.g., working in another location), he is allowed an additional three weeks to take the test. If the client was reached and refused to schedule a date, the account balance was forfeited one week after the six-month commitment date.

# **III. Cue Cards Treatment Design**

The cue cards are pocket-sized, graphic depictions of the negative health consequences of smoking. Each individual received one of four pictures: a premature baby (with text "Smoking harms unborn babies"), bad teeth (with text "Smoking causes mouth and throat cancer"), black lung (with text "Smoking causes lung cancer"), or a child hooked up to a respirator (with text "Don't let children breathe your smoke"). By law, such images must be featured on cigarette packages in Australia, Canada, and New Zealand (Hoek and

> 13 Initially CARES clients were required to take a blood test at a nearby hospital lab. But delays and added costs led Green Bank to switch to urine strips that could be used in the field. NicCheck product specifications indicate that the urine strips sacrifice a bit of test specificity (the ability to detect a true negative result, which is 97% for urine strip versus 99% for lab-based cotinine analysis), but offer equivalent test sensitivity (the ability to detect a true positive result, which is roughly 97% for both urine strips and lab-based cotinine analysis) and the ability to provide results in the field, within 15 minutes. Green Bank found similar specificity (one false positive out of 18 self-reported non-smokers) and much lower sensitivity in its own pilot testing, where marketers randomly approached people on the street in our study area, asked if they were smokers, and then offered 30 pesos to take the urine strip test.

> 14 Small and portable test strips are dipped into the urine sample, stimulating a chemical reaction that changes the test strip’s color.  The color result ranges from white (no nicotine exposure), to light pink (moderate nicotine exposure), to red (high nicotine exposure).  The test administrator then compares the test strip’s color to a NicCheck color scale and assigns the test result a number ranging from 0 (no exposure) to 15 (high exposure).

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