In It To Quit: Commitment Contracts for Smoking Cessation

When patients arrive at the enrollment meeting, research staff will walk them through the
informed consent form to explain and answer questions about the study. Patients who sign the
consent form enroll in the study. Those who choose not to enroll are thanked for their time
and encouraged to use CHCI smoking cessation services, regardless.

After providing written consent to participate in the study, patients will complete a short
(15 minute) baseline survey assessing their smoking habits. Patients will complete the survey
on their own or with the assistance of a research staff member. See Appendix B for the survey
instrument.

Immediately following the survey, randomization will occur, corresponding to the two phases
of the intervention. Patients will be blinded to randomization. Randomization is done offsite
using Stata. The research staff will enter basic, unidentifiable information about the
patient into a web interface designed specifically for the purpose of this study and receive
a treatment assignment for that participant. In this way, the enrollment staff does not deal
directly with the randomization process. Patients are assigned to one of four study arms:
Control, Treatment 1: Rewards Only, Treatment 2: Rewards w/ pre-commitment for deposit
contract, Treatment 3: Rewards w/ commitment for deposit contract at 2 months.

Soon after enrollment, patients will receive an automated call verifying participation.

Phase I runs from study enrollment through the first biochemical verification of abstinence
from smoking ("biochemical test"), at 2 months. Study participants assigned to the treatment
group, but not the control, will receive rewards in the form of gift cards for engaging in
the smoking cessation activities ("process") and for a negative result on the biochemical
test ("outcome").

Process:

Five process activities will be rewarded for treatment group members:

1. One-time sign up reward for stickK.com

2. submitting a weekly self-report of smoking abstinence on stickK

3. writing a stickK journal entry

4. enlisting family and friends to register as stickK "Supporters" to track progress and
provide positive reinforcement,

5. utilizing CHCI group or individual counseling services provided by a nurse or behavioral
health provider

When possible, initial appointments with counseling services will be offered on the same day
as the enrollment visit using CHCI's "warm handoff" behavioral health appointments.
Participants will be encouraged to log their completion of these visits on stickK, and
research staff will verify on stickK that the patient attended and completed a valid smoking
cessation clinic visit.

For each completed and verified process activity, treatment group participants accrue points
on stickK that can be redeemed for a gift card to a retail store at Phase I end, conditional
on biochemical verification of smoking cessation. If the participant fails to demonstrate
abstinence, s/he forfeits all accrued process points.

Members of the control group will not receive information about stickK or a stickK account
associated with the study, though they may sign up for the online service independently. The
control group will receive information about and have access to CHCI's full menu of smoking
cessation services.

Biochemical verification:

The biochemical tests will be conducted two months after study enrollment. Research staff
will contact patients via phone and/or email to schedule visits to complete these tests.
Investigators will ask all control group members to take the test and compensate them for
doing so, regardless of test result ("measurement incentive"). Only treatment group members
who self-report not smoking during the last week, or from whom investigators were unable to
procure a self-report, will be asked to take the test. This group will not receive a
measurement incentive.

All patients will first complete a CO breathalyzer test. Those that test positive will have
no further testing. Those testing negative will have a urine verification test at the
in-house Quest Diagnostics. Test results will be sent to the EHR.

Process and outcome changes are rewarded according to the following schedule:

Phase I end: redemption of rewards or adoption of deposit contract. The majority of
participants will receive confirmation of their smoking status at the clinic within a few
minutes of taking the test. Research staff will verify the confirmatory test result on stickK
and assist participants as they adopt the deposit contract or redeem their rewards. The
deposit contract is a commitment device that allows users to voluntarily "deposit" rewards
that they can only recover if they succeed in achieving a predetermined goal, which, in this
case, is maintaining smoking abstinence over the four-month Phase II period. In other words,
participants who elect to use the deposit contract risk losing some or all of the rewards
they accrued during the "rewards phase" if they fail to test negative for smoking at Phase II
end.

Protocol by biochemical test result, randomized assignment, and take-up decision:

- Test positive for smoking -> lose accrued process rewards; not eligible for deposit
contract

- Test negative for smoking, and

- No deposit contract -> redeem process and outcome rewards

- Deposit contract-pre-commitment and pre-committed -> confirm, adjust, or opt-out of
commitment

- Deposit contract-pre-commitment and did not pre-commit -> receive deposit contract offer
one final time

- Deposit contract- No pre-commitment -> receive deposit contract offer for the first and
final time

Those who are eligible for but decline the deposit contract redeem 100% of their rewards. The
intervention ends after Phase I for these individuals.

Those who adopt the deposit contract redeem the percentage of their rewards that they did not
invest in the deposit contract. The rest is automatically rolled into the deposit contract,
and the contract period, i.e. Phase II of the intervention, begins immediately.

Phase II: Deposit contract, months 3 through 6. Phase II lasts 4 months, from month 3 through
6. The majority of study participants won't hold a deposit contract and thus won't experience
an active intervention during this time. Participants who do hold a deposit contract will be
free to engage with stickK as they like (e.g. write journal entries, share progress on social
media), but will not receive rewards for doing so.

At 6 months, investigators will ask all study participants to take the second confirmatory
test. Participants without a deposit contract will receive a measurement incentive to take
the test but no performance incentives contingent on the test result. For deposit contract
holders, recovery of the deposit will be contingent on testing negative for smoking.

Measurement of long-term smoking abstinence:

At month 12, all study participants will be asked to visit the clinic for a final
confirmatory test, and all will receive a measurement incentive. No incentives are contingent
on smoking status.

An endline survey will be administered at this time. The endline survey will be
self-administered by participants either via email, mailing, or in person depending on the
availability of participants.

Inclusion Criteria:

- Must be Community Health Center, Inc. medical patients

- Must have had a clinic visit within the previous 2 years

- Daily smoker, with smoking status verified by self-reports in clinic medical records

- Age 18 or over; 19 or over if pregnant

- Has regular access to internet on computer or smartphone

- Not currently enrolled in R2Q and, if formerly enrolled in R2Q, not assigned to the
intervention group.

- Speaks English and/or Spanish

Exclusion Criteria:

- Illiterate patients that do not have someone who can assist them during the study