Study population

For the 2014 health plan year, benefit eligible LLUH employees were offered two health plan options: 1) The Wholeness Health Plan, and 2) The Base Health Plan. The Wholeness Health Plan had 50–53% lower out-of-pocket costs (monthly employee contributions, co-payments, co-pay for prescriptions) relative to the Base Plan. To qualify for the Wholeness Health Plan, employees, and covered spouses, needed to complete a health risk assessment (HRA), biometric screening, and complete a care management program, if identified, which included smoking cessation for smokers. In contrast, the Base Health Plan – with the higher out-of-pocket costs – did not require participation activities, and thus employee smokers who chose this plan were not required to participate in smoking cessation.

During biometric screening of 13081 benefit-eligible employees, 415 tobacco users were identified through their self-reported health risk assessment data and through claims data. Employee smokers identified through this assessment had the option of appealing against the findings of this assessment by undergoing am exhaled carbon monoxide (CO) test, and those with CO scores <10 ppm were re-classified as non-smokers.

This group of 415 employee smokers who were offered participation in workplace smoking cessation through a choice of the Wholeness Health Plan (described above) became the analytic sample for the present study and known as the LLUH BREATHE cohort. The secondary analysis study of these health plan data was approved by the Institutional Review Board of Loma Linda University.

Survey, interview and bio-specimen measures

The entire LLUH BREATHE cohort underwent biometric screening that included: 1) anthropometric measures (height, weight, waist circumference, BMI); 2) biomarker collection (blood pressure, triglycerides, HDL, LDL, total cholesterol, fasting and non-fasting glucose); and 3) demographic variables. Participants in the workplace smoking cessation program (by voluntary choice of the Wholeness Health Plan) underwent further baseline survey interviews to ascertain current tobacco use, tobacco dependence (Fagerström index variables), coping strategies, sources of encouragement, and desire and confidence to be tobacco-free. This survey was also administered after the 4-month smoking cessation intervention.

Two smoking cessation interventions

Cohort members who participated in the intervention were asked to complete two electronic survey forms (Intake/Pre- and Post-intervention), two physician visits, and either an online or in-person group version of the American Lung Association (ALA) ‘Freedom from Smoking’ course. This was an 8-week online course that educated participants on the benefits of smoking cessation and assisted individuals in setting a ‘quit date’. This program consisted of 8 weekly sessions that took approximately 1 hour to complete. To improve participation and completion rates, multiple messages were sent through mail, email and telephone to each potential participant. Participants were moved to the Base Health Plan if they did not complete their online intake form, missed their 1st physician visit, or missed the final deadline. A survey interview was completed at the end of the program in which a subject’s self-report of current smoking status and intensity of tobacco use were compared to the baseline results. This comparison was used as part of assessing efficacy.

Statistical analysis

Participation rates of the LLUH BREATHE cohort were computed as proportions and confidence intervals were computed using Fleiss’s Quadratic method with a continuity correction¹¹. Under the intent-to-treat principle, participants were defined as those employee smokers, and/or their covered spouse who smoked, that chose the wholeness health plan at the time it was offered. Those participants who were discontinued from employee smoking cessation due to non-completion of program activities continued to be assessed as ‘participants’ for the calculations in this report. Among participants, efficacy of the program was determined by computing the proportion and confidence interval reporting no cigarette smoking after 4 months on the program. Intensity of smoking habit (number of cigarettes smoked) was also compared between baseline and 4 months follow-up using a paired t-test.

To examine factors associated with participation in the Wholeness Health Plan in the LLUH BREATHE cohort, we conducted logistic regression analysis with participation as the binary outcome variable. We tested demographic (age, gender, employee/spouse) and biometric (anthropometric, metabolic blood panel) variables to test hypotheses about gender and ‘sick quitter’ effects on participation seen in other employee smoker samples. All analyses were conducted using the Statistical Analysis Software (SAS)® version 9.4.

Participation rates

The LLUH BREATHE cohort consisted of 415 employee smokers (aged 24–76 years) who were identified as tobacco users through health risk assessment and medical claims data. Of the 415 smokers, 302 voluntarily chose the smoking cessation through their choice of Wholeness Health Plan and this produced a participation rate of 72.7% (95% CI: 69–77%).

In Table 1, we provide a comparison of demographic and biometric characteristics of participants and non-participants. We found that subjects who enrolled in the intervention had a significantly lower blood pressure.

Variables associated with participation

In Table 2, we present the findings from univariable logistic regression models testing the association between demographic variables, biometric variables and a binary outcome for participation (in smoking cessation through a choice of the Wholeness Health Plan). We found that subjects with lower blood pressure were significantly more likely to participate in the workplace smoking cessation. Males and employees (vs spouses) were less likely to participate in the workplace smoking cessation; this did not, however, attain significance.

We also built an age-adjusted multivariable model to examine gender and spousal contrasts (findings not shown). Here, we found that both male smokers (compared to females) and employee smokers (relative to spouse smokers) were significantly less likely to participate. We further investigated this by testing an interaction of gender and spousal contrasts in Table 3. In this model, we found that the male employees who smoked were least likely to participate and were used as the reference group for the model. We found that smokers who were female employees, or the male spouses of female employees, were two-fold more likely to participate in the program relative to male employee households.

Self-reported point prevalence of smoking cessation at 4 months

Although efficacy of the intervention is best assessed in a randomized controlled trial, we did, on an exploratory uncontrolled basis, assess the efficacy of the smoking cessation intervention in participants using the self-report of cigarette smoking on the follow-up questionnaire administered after the 4-month intervention. Of the 302 participants, the analytic sample for efficacy assessment reduced to 263 participants due to subjects who were discontinued on the health plan were no longer employed by the organization, or opted out of the requirements and chose the Base Health Plan. Under a ‘per protocol’ principle of focusing on those subjects that remained on the Wholeness Health Plan protocol and employed at LLUH (n=263), the point prevalence of smoking cessation at 4 months was 55% (95% CI: 49–61%). Under an intention-to-treat principle (n=302) of including all subjects who participated, the point prevalence of smoking cessation at 4 months among these subjects was 48% (95% CI: 42–54%).

Encouraging successful smoking cessation

One factor contributing to the high participation rate in the LLUH BREATHE cohort in smoking cessation was the use of an individual ‘reward-based’ incentive (as opposed to ‘deposit-based’ incentive) – a method that has been shown in two large systematic reviews^3,5 and one large randomized controlled trial^6,7 to be very effective in accomplishing both participation and higher rates of smoking cessation^10,12.

LLUH BREATHE participants promoted smoking cessation by enrolling in the health plan that contained reduced monthly out-of-pocket contribution, prescription drug costs and co-payments – thus tangibly increasing their individual monthly income. This is a sizable reward amount even when compared to other successful reward-based programs described in the literature. Specifically, in recent analyses of reward-based incentives in workplace smoking cessation programs, individual based rewards were ‘one-time’ payments ranging from $10 up to $750 for extended abstinence. Group-based ‘employee lottery’ rewards ranged from $40 to $500, and were only given to one of the abstinent participants.

For the LLUH BREATHE cohort findings, we note that the individual rewards of a long-term reduction in ‘out-of-pocket’ costs of health coverage (monthly premiums, co-pays) in our study would vary per subject (based on family members covered, number of co-pays for visits/prescriptions) but would likely far exceed the individual rewards reported to date in the literature (i.e. up to $750 in some studies). Using the average LLUH health plan cost data we estimate that the cost savings incentive could range on average from $600 to $1200 per year. Further prospective follow-up of the BREATHE cohort for health plan costs is needed to quantify the effect of this incentive. Moreover, the LLUH BREATHE approach needs discussion relative to proposed changes to national health coverage policies. The federal government has supported US Public Health efforts by aiding nicotine cessation strategies, which can be seen in regulations released in June 2013. These regulations, which were consistent with the Affordable Care Act regarding nondiscriminatory wellness programs in group health coverage, increased the maximum permissible reward from 20% to 30% of the cost of health coverage for individuals under a health-contingent wellness program. These regulations also increased the maximum permissible reward to 50% for wellness programs designed specifically to prevent or reduce tobacco use. This type of increase in the reward, of allowed wellness programs connected to group health plans, would potentially benefit, charge or withhold thousands of dollars a year from health plan members who used tobacco. The LLUH BREATHE approach for workplace smoking cessation in 2014 required participation only (if the Wholeness Health Plan was chosen) and the cost difference of the Base Health Plan was much less than 50% of the cost of coverage.

Leeks et al.³ have proposed a framework for how incentives can enhance participation and efficacy of workplace smoking cessation. The framework divides incentives into two domains: incentive participation and incentive long-term abstinence. We note that our method in the LLUH BREATHE cohort employs both domains since choosing the Wholeness Health Plan, as a long-term option, offers the immediate financial incentive to participate and the long-term incentive to remain abstinent in order to avoid having to participate in the program again as required by the health plan. During each open enrollment period for the plan, a current smoker (whether in relapse from the previous program or a non-participant) is again encouraged to choose participation and abstinence through the substantial cost-savings in the wholeness health plan.

Participant demographic and health factors

Our findings in Table 2 indicating that male employees were significantly less likely to participate confirm the findings of several large meta-analyses of workplace preventive programs and workplace smoking cessation programs^3-6. In a meta-regression of 23 worksite prevention programs, Robroek et al.⁵ found that women had significantly higher participation than men (OR=1.67; 95% CI: 1.25–2.27), but that this advantage was not apparent for preventive programs on physical fitness (i.e. access to an employer-sponsored fitness center). Also evident from the meta-regression was that participation was in higher multi-component workplace preventive programs (i.e. diet, smoking, and physical activity programs)⁵. Recently, Halpern et al.⁶ identified, in asecondary analysis of the large CVS Caremark trial, that men were less likely to participate in reward-based workplace smoking cessation programs. Taken together, the findings from our work and other studies highlight the need to find additional programmatic design features to engage and/or encourage male employees in workplace smoking cessation programs. Potentially, including smoking as a multi-component intervention (i.e. adding a physical fitness component) for all participants could be tested as a method to improve participation in men. Mixed-method approaches to identify barriers to participation in men (i.e. privacy concerns, employer intrusion on health) may also be needed^8,9. Halpern et al.⁶ raise the possibility that deposit-based incentives perform better for workplace smoking cessation programs for men.

Our study did not find that LLUH BREATHE cohort members, who were participants in workplace smoking cessation, had biometric values that indicated poorer health relative to non-participants. Thus, at least based on the biometrics measured, we did not find evidence of a ‘sick quitter’ effect shown in other studies¹³. If confirmed, this further supports the cost-savings to employers for investing in workplace smoking cessation.

Spousal influences on employee-based smoking cessation

Our finding of an interaction between spousal contrasts and gender contrasts on participation in workplace smoking cessation is a new finding that needs testing and/or confirmation from other studies. Specifically, we found a much higher participation by the female employees whose male spouse smoked (OR=2.89; 95% CI: 1.59–5.24),compared with male employees whose female spouse smoked (OR=1.14; 95% CI: 0.33–3.95). This gender-based heterogeneity in spousal influence needs further investigation.

Overall, studies on health behavior change patterns in couples have shown that both men and women are more likely to make a positive health behavior change, if the partner is also engaged in health behavior change¹⁴, particularly in the area of smoking¹⁵. The Health and Retirement Study concluded that partnership in smoking cessation influences not only the time of quitting but also a long-term adherence to a healthier behavior¹⁶.

Limitations

A number of limitations of this study need consideration. We have assessed the point prevalence of smoking cessation at 4 months using self-reported cessation data. In a random sample of 100 participants, we did, however, find a cessation rate that exceeded 40%, which continues to exceed US norms for smoking cessation rates in adults. We note that efficacy is not measured by a randomized controlled trial design but rather by smokers who chose to participate in a smoking cessation program that is encouraged through the health plan choice. However, we note the ethical issues inherent in a randomized design that would deny smokers in the organization a wholly subsidized model for smoking cessation that has proven to be effective. Thus, our observational approach may in fact be the only design that can ethically test participation rates in a smoking cessation program that has a novel incentive that is built into health plan coverage. Lastly, we note that LLUH employees represent a sample of employed adults from an organization consisting of eight health science schools, six hospitals, and a physician practice corporation. The high prevalence of adults with higher education contributes to: 1) a lower prevalence of smoking, and 2) the need to investigate the effect of health plan incentives in employee cohorts with a wider range of sociodemographic characteristics.