Co-design of a Community-based Financial Incentive Scheme for Smoking Cessation Services in Ireland: A Modified Nominal Group Technique

Background Despite the overall decline in smoking prevalence, socioeconomic disparities in smoking quit rates are widening. Financial incentives such as cash or cash-like rewards provided conditional on performance of healthy behaviours, are effective tools to enhance smoking cessation, yet are complex and often designed without community input or theoretical rationale. Hence, we aimed to co-design a theoretically driven and contextually-relevant financial incentive scheme for implementation, with key stakeholder groups including community members and health professionals, in Irish primary care and community services. Methods A mixed-methods approach was utilised with a modified Nominal Group Technique, underpinned by Adams et al.’s (2014) 9-domain incentive framework, over three one-day workshops (n = 59 participants) to elicit ideas and achieve consensus on incentive design. Descriptive statistics were used to identify the highly-ranked ideas, while reflexive thematic analysis was employed to examine the decision-making process focusing on key considerations across various domains of the proposed incentive scheme. Results The incentive design was as follows: 1) Total amount: €400 (Median, IQR: €200–500); 2) Form: voucher; 3) Certainty: definite reward; 4) Target population: adults living in deprived areas who smoke and are in receipt of free primary care services; 5) Target behaviour: validated smoking cessation and clinic attendance; 6,7) Schedule and Frequency: incrementally increasing amount aligned with current services review timepoints; 8) Immediacy: as soon as possible within a week; 9) Provider: smoking cessation advisors. Participants’ key considerations in reaching consensus on each incentive domain were represented by five themes including: acceptability, potential of gaming, operational and administrative demands, fit with existing services workflows, maintaining organisational image, and public scrutiny. Conclusion This is the first study to co-design a stakeholder-informed, and theory-aligned incentive-based scheme to support smoking cessation for people living in deprived areas. A pilot is now underway to test real-life implementation feasibility on smoking cessation outcomes.