Still smoking? Let's game it out.

Do you remember learning about the asymptote in high school geometry? It’s that funny curve that gets closer and closer to a line through infinity, but never actually touches it. We say the curve “asymptotically” approaches zero.

Smokers are a little like this. As the rate of smoking asymptotically approaches zero, we are left with a population that is more and more “hardened” in its smoking habit. Around 70% of current smokers have no interest in quitting. So the smoking behaviors of the ~14% of people still smoking now are, person-for-person, harder to change than they were in the much larger fraction of the population who smoked five years ago. That is, as the population of smokers shrinks, it becomes ever harder to get the remaining smokers to stop. So most studies of smoking interventions like drugs, nicotine replacement, or therapy, ignore people who express little interest in quitting. Coordinators for most studies instead recruit people whose “readiness to change” is higher:

But a new study (paywall) takes this population of hardened smokers head-on with, of all things, a video game. Investigators recruited 433 smokers who reported they were not ready to quit. They randomized the smokers to get usual care with nicotine replacement therapy lozenges, or to get access to nicotine replacement therapy plus “Take a Break,” a 3-week mobile “game experience” that included 5 behavioral components: motivational messaging, challenge quizzes, brief abstinence goal setting, mobile health apps for cravings management (three “relaxation” apps were offered), and reward points for participation (in the form of gift cards).

To determine if the game had an effect, they looked at the time to their first quit attempt and tested carbon monoxide levels at 6 months to verify any claims of smoking cessation (smoking increases carbon monoxide levels in your blood, which, blech).

Apps are tricky because people tend to lose interest pretty quickly. Only about half of the game participants got through 100% of their daily challenge quizzes in the first week in the study. Roughly three-fourths set a brief abstinence goal of 1-2 days away from cigarettes, and 75% used the apps to manage their nicotine cravings. The game-treated participants set a sooner “time to quit,” and at six months, 18% (28 of 160) of game participants versus 10% (17 of 171) of nicotine replacement-only participants had carbon monoxide level–verified smoking cessation, roughly a doubling of the likelihood of smoking cessation once the fancy statistical analysis was done.

Those numbers look kind of sad, but remember that we’re talking about a very difficult population in the study, people who had expressed almost no interest in changing at the study’s onset. Through that lens, this is really a remarkable outcome, albeit in a small study. The best-performing clinics in the U.S. only get around 15% of their smokers to quit in any given year, and that is in a group of patients whose readiness to quit is undoubtedly higher than the population of this study.

As far as I can tell, the app isn’t available commercially yet. When “Take A Break” or its descendant products are available, though, we should think hard about using them. Smoking is still one of the leading causes of death, disability, and medical expenditures, so even a hefty price tag for such a product would be worth doubling the number of smokers who successfully quit in any six-month period.

As we’ve talked about before, we get pitched a lot of apps at KBGH. Do you have any positive experiences with skill-building or behavior change apps? If so, please share!

As the Medical Director of the Kansas Business Group on Health, I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Vaccines: Influence, Not Mandate

The vaccines against SARS-CoV-2, the organism that causes COVID-19, are a slam-dunk, whether in terms of their economic impact, a humanistic perspective, or an observed reduction in morbidity and mortality. And the United States as a whole is doing reasonably well in getting people vaccinated (although Sedgwick County is a little behind the national average). As of the writing of this blog post, more than half of US adults have received full vaccination, and a large additional fraction has received at least partial vaccination. And while I’m not particularly interested in the pursuit of a theoretical threshold like “herd immunity,” most everyone agrees that the more people we can get vaccinated before this fall, the better. After all, the virus is still spreading among the unvaccinated population as quickly as it was at its peak.

Some universities are mandating vaccination. I can understand why. But my instincts always trend more toward influencing decisions rather than mandating behaviors. So it was helpful (and, I’ll admit, a little discouraging) to see that the Equal Employment Opportunity Commission (EEOC) recently ruled on using incentives to get employees vaccinated. In short, and to steal from our frequent collaborator Al Lewis:

“If employers set up a system in which they administer the vaccine themselves on a voluntary basis, businesses can also offer employees incentives — be they perks or penalties — so long as they are “not so substantial as to be coercive.”

If the process of setting up vaccine distribution yourself sounds tricky, you’re right. The new mRNA-based vaccines, in particular, while scientific marvels, are pretty delicate and require special handling. So we anticipate most of our members will utilize more traditional routes to vaccination, like clinics and health departments. How can we get our employees to take that leap?

In thinking out loud about this question, I’m cross-tabulating two sources. Source one is the new edition of Influence by Robert Cialdini, a seminal text in the science of persuasion. Source two is a summary by German Lopez, based mainly on Kaiser Family Foundation survey data, on the six overarching reasons some Americans are slow to be vaccinated: lack of access, lack of fear of COVID-19, fear of side effects, lack of trust in vaccines, lack of confidence in institutions, and conspiracy theories.

Let’s discuss how Cialdini’s Seven Keys to Influence might address those six big reasons for slow vaccination and how we can apply them to get more people immunized:

1. Reciprocity. Pharmaceutical representatives don’t give out medication samples, tchotchkes, and meals to doctors’ offices out of charity or even advertising. They do it to cause a feeling of indebtedness on the part of the clinical staff. Doctors who receive these gifts are far more likely to prescribe medications represented by salespeople than are doctors who don’t receive the gifts. The same goes for people who’ve received free address labels from a charity. We can copy this strategy in our employee populations by pointing out the generosity of our leave policies around COVID-19 infections or exposures. The company is doing this for you. All we ask in return is that you do your part by reducing everyone’s risk by getting vaccinated. And we’ll even help give you time off and help you get to the vaccination distribution center!

2. Commitment. When a company asks you to sign up for their newsletter, “club,” or punchcard, they’re trying to get a commitment from you, however small it may be. Consider asking your employees to sign up for a newsletter from your wellness department or vendor, and make sure vaccines are mentioned in nearly every edition.

3. Social proof. Colleges and universities once tried to discourage binge drinking by pointing out how many students were injured or killed by binge drinking behavior. It didn’t work. When those same colleges and universities pivoted to a strategy of showing how many students did not binge drink, they saw results. People do what they see others doing. So once you have an idea that a big chunk of your employees has already been vaccinated, point this out in a campaign and emphasize how proud the company is of its employees’ contribution to safety. Even an employee who doesn’t particularly fear infection may want to be part of a positive culture.

4. Authority. People trust authority figures. In the vaccine world, people trust their personal physicians most of all. So if you feel your vaccine push is falling short, encourage employees to see their doctor to talk about the minimal risks and potentially huge benefits of vaccination.

5. Liking. People prefer to be seen positively by their peers. This desire can often override other emotions or beliefs like a lack of trust. If we can make vaccination the norm in our workplace and point out the positive effect of people who’ve received the vaccine, a certain number of people will experience a change of heart.

6. Scarcity. When Amazon alerts you, “Only two remaining in stock,” they’re taking advantage of our attraction to scarce resources. Gold and platinum would not be expensive and desired if you could dig them out of your backyard with a shovel. So this summer, as we anticipate another rise in COVID-19 cases in the fall, we should point out the scarcity of time to take advantage of vaccination. Only three months left!

7. Unity. This principle takes advantage of our natural tribal instinct toward “Us versus Them.” When the anti-smoking Truth Initiative debuted, it used this exact trick by casting Big Tobacco as an opponent to be defeated by a unified, righteous group of young nonsmokers. The effect on the youth smoking rate, pre-vaping, was astonishing. By one estimate, it prevented 300,000 kids per year from smoking. The Truth Initiative essentially turned the Big Tobacco companies into conspirators and encouraged kids to rebel. And it worked.

Our goal shouldn’t be to trick anyone into doing something they don’t want to do. But in working to get the largest possible fraction of the population vaccinated, we should use the best, most scientifically sound arguments and strategies we can.

As the Medical Director of the Kansas Business Group on Health, I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

You don't pay for smoking cessation. It pays you.

Out of my email inbox’s daily deluge of medical journal push notifications and study updates, an article recently stood out. It outlined a study recently completed by Dr. Tami Gurley-Calvez and Jessica Sand at the University of Kansas School of Medicine to determine the cost-effectiveness of smoking cessation services. The study was commissioned by NAMI, the National Alliance on Mental Illness, with funding from the Kansas Health Foundation.

Increasing coverage for more quit attempts

A single “quit attempt” is defined as four sessions of counseling and 90 days of any single FDA-approved smoking cessation medications like nicotine replacement, varenicline, or bupropion. The investigators compared the costs to payers of continuing to cover two quit attempts per year (eight sessions of counseling and 180 days of medication, as currently mandated by the Affordable Care Act), versus increasing coverage to 4 quit attempts per year, equaling sixteen sessions of counseling and potentially a full year’s coverage of a medication. Costs were the sum of the cost of the counseling sessions and medication costs. Benefits were the projected reduction in medical spending attributed to a reduction in the number of smokers. The investigators assumed a 4.4% relapse rate in people who had quit smoking for more than a year.

For smokers under the age of 65, either model–two quit attempts or four quit attempts–broke even by year four; that is, money paid for counseling and medications was equaled by reduced medical spending. But by year six, the cost-savings of the additional counseling sessions and additional medication coverage really took off:

By year 10, the per-person benefit of covering four quit attempts per year–$215–was almost double that of two quit attempts, at $109. This is to say that your return on investment for paying for additional smoking cessation services appears to roughly double when you double the up-front investment in counseling services and drug coverage.

If you feel a little leery about modeling studies right now, considering the difficulty epidemiologists have had in modeling responses to COVID-19 interventions, know that the conclusions of this study in terms of quit rates are well-established by clinical trials in real people.

We should always be careful about acting on the results of a single study. But there is a strong signal here that, if your company currently covers the ACA-minimum two quit attempts per year, you may benefit financially from increasing coverage to four quit attempts per year. Dr. Gurley-Calvez and Ms. Sand rightly point out that some companies may not expect to keep employees for the five to six years needed to reach net economic benefit. But they also note, as we’ve long pointed out to KBGH members, that if this type of coverage were applied uniformly across a number of diverse companies, we could collectively achieve these economic benefits alongside a healthier employee population, even if the members of that population changed jobs frequently.

If you have strategies your company has used in smoking cessation or substance abuse that you’ve found successful, please share them with us!

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.