What's the best way to get members to stop smoking? A financial nudge and a pinch show some promise, for a range of health and wellness choices.
In one of the largest trial of financial incentives for health behaviors to date, a group of researchers led by Scott Halpern, MD, of the University of Pennsylvania, followed two smoking cessation interventions deployed by CVS Caremark for its employees and dependents.
One, a deposit program, required smokers to pay $150, which they would get back along with another $650 from the company if and when they quit smoking. The other, a reward program, offered $800 if they quit.
More than 2,500 participants enrolled, with 90 percent of those assigned to the $800 reward program opting in, and less than 14 percent of those assigned to the deposit program opting in.
The study, published in the New England Journal of Medicine, found that although more smokers opted into the reward program, those in the deposit-based program--who stood to lose $150 that they already paid--were more successful in quitting.
Six months after the intervention, 52 percent of those enrolled in the deposit program had sustained abstinence, compared to just 17 percent of those in the reward program.
While more smokers opted into the deposit program than the reward program, the fact that more in the deposit cohort suggests that the "deposit-based incentives were substantially more efficacious than reward-based incentives among people who would have accepted either," Halpern and colleagues said.
"The robustness of this result to reasonably large potential selection effects suggests that incentives that build on participants' loss aversion may meaningfully change behavior."
Another finding was significant, Halpern argued. Both of the rewards, valued at $800, nearly tripled the rate of smoking cessation compared to the usual counseling and medication therapy. "In addition to the public health effects of such smoking reductions, these findings are important for employers. Because employing a smoker is estimated to cost $5,816 more each year than employing a nonsmoker, even an $800 payment borne entirely by employers and paid only to those who quit would be highly cost-saving."
Skeptically, it "is tempting to question" the finding about the deposit cohort being more likely to quit, "on the grounds that those who are willing to enroll in a deposit program are especially determined to quit," wrote Harvard law professor Cass Sunstein, the intellectual father of the "nudge," in a companion piece in the NEJM.
Sunstein, though, argues that the findings about the deposit cohort are valuable for both the promise of the loss-aversion approach and its limitations.
"The more obvious is that smokers are far more likely to quit if they stand to lose money if they fail. The more subtle is that the very prospect of incurring losses makes people far less willing to enter a smoking-cessation program," he wrote. "Despite the greater comparative effectiveness of the deposit program, the reward program is likely to be more successful, because far more people will sign up for it."
In terms of finding what works best across populations, Sunstein thinks it would be valuable to "know whether a smaller deposit might increase participation without reducing efficacy." For public policy, though, deposit programs may actually be "the better way to help people to quit smoking (and perhaps to alter many kinds of health-related behavior)," he argues.
'"The challenge is to find a way to nudge people to enroll in such programs. If that challenge cannot be met, reward programs are much better bets."
Considering how much employers are spending on workplace wellness programs--some $693 per person on average these days--and the prevalence of the chronic disease burden associated with poor lifestyle choices, there are both high stakes and many opportunities.