title: Use of personal trainers and financial incentives to increase exercise in a behavioral weight-loss program. Patients as Mercenaries?: The Ethics of Using Financial Incentives in the War on Unhealthy Behaviors A randomized, controlled trial of financial incentives for smoking cessation. A systematic review of the use of financial incentives and penalties to encourage uptake of healthy behaviors: protocol Cost-effective primary care-based strategies to improve smoking cessation: more value for money. Cash value of voucher reinforcers in pregnant drug-dependent women. The use of contingency management and motivational/skills-building therapy to treat young adults with marijuana dependence. Results of a year-long incentives-based worksite smoking-cessation program. Tuberculosis screening and compliance with return for skin test reading among active drug users. A randomized study of financial incentives to increase physical activity among sedentary older adults. Improving influenza vaccination rates in the workplace: a randomized trial. A low-cost reinforcement procedure improves short-term weight loss outcomes.
abstract: Exercise is the best predictor of long-term weight loss . This study evaluated two strategies for improving exercise adherence and long-term weight loss in obese out patients . Obese men and women ( N = 193 ) were r and omized to 1 of 5 treatment groups for 18 months : st and ard behavior therapy ( SBT ) ; SBT with supervised walks ( SW ) 3 times per week ; SBT + SW with personal trainers ( PT ) , who walked with participants , made phone reminders , and did make-up SW ; SBT + SW with monetary incentives ( I ) for completing SW ; and SBT + SW + PT + I. Both PT and I enhanced attendance at SWs , the combination producing the best adherence . Increased walk attendance did not result in higher overall energy expenditure , however , and long-term weight loss was also not improved . Post hoc analyses suggest that the level of exercise needed for successful long-term weight loss is much higher than that usually recommended in behavioral treatment programs Consider the following paradox : few people would balk if research ers offered smokers $ 1,000 to participate in a year-long r and omized trial of a smoking cessation intervention , yet many would find it distasteful for a large employer to pay its smoking employees an extra $ 1,000 if they remained smoke-free for one year . Such discrepant judgments are underst and able from the perspective of classical economics . Research participants merit compensation for the risks and opportunity costs they endure in the service of public health , whereas individuals should need no reward for promoting their own well being . However , contrary to traditional theories of rationality , people frequently fail to make health-promoting choices , particularly when such choices require short-term sacrifices to foster long-term goals .1,2 Thus , corporate and government health plan leaders are increasingly applying extrinsic motivations such as financial incentives and other programs to augment health – particularly cardiovascular health – while hopefully increasing productivity and restraining costs.3 , 4 Early evidence suggests that financial incentives can effectively promote the cardioprotective behaviors of smoking cessation,5 , 6 weight loss,7 , 8 and cholesterol reduction.9  Incentives are also currently being studied as a means of promoting warfarin adherence.10 Although the results of these early studies are promising , further research is needed to determine which incentive structures and amounts are optimal , assess the ability of incentives to produce sustained behavior changes , and evaluate the cost-effectiveness of implementing incentive programs  . Ethical dimensions of the incentives themselves are also in need of further analysis . For example , some have charged that financial incentive programs are coercive , inequitable , and inconsistent with shared social values.11 Others have even suggested that implementing incentive programs serves to punish patients for their illnesses.12 In this essay , we outline the rationale for incentive programs to promote cardiovascular health , identify the ethical arguments that have been used to challenge such programs , and assess the merits of these arguments BACKGROUND Smoking is the leading preventable cause of premature death in the United States . Previous studies of financial incentives for smoking cessation in work setting s have not shown that such incentives have significant effects on cessation rates , but these studies have had limited power , and the incentives used may have been insufficient . METHODS We r and omly assigned 878 employees of a multinational company based in the United States to receive information about smoking-cessation programs ( 442 employees ) or to receive information about programs plus financial incentives ( 436 employees ) . The financial incentives were $ 100 for completion of a smoking-cessation program , $ 250 for cessation of smoking within 6 months after study enrollment , as confirmed by a biochemical test , and $ 400 for abstinence for an additional 6 months after the initial cessation , as confirmed by a biochemical test . Individual participants were stratified according to work site , heavy or nonheavy smoking , and income . The primary end point was smoking cessation 9 or 12 months after enrollment , depending on whether initial cessation was reported at 3 or 6 months . Secondary end points were smoking cessation within the first 6 months after enrollment and rates of participation in and completion of smoking-cessation programs . RESULTS The incentive group had significantly higher rates of smoking cessation than did the information-only group 9 or 12 months after enrollment ( 14.7 % vs. 5.0 % , P<0.001 ) and 15 or 18 months after enrollment ( 9.4 % vs. 3.6 % , P<0.001 ) . Incentive-group participants also had significantly higher rates of enrollment in a smoking-cessation program ( 15.4 % vs. 5.4 % , P<0.001 ) , completion of a smoking-cessation program ( 10.8 % vs. 2.5 % , P<0.001 ) , and smoking cessation within the first 6 months after enrollment ( 20.9 % vs. 11.8 % , P<0.001 ) . CONCLUSIONS In this study of employees of one large company , financial incentives for smoking cessation significantly increased the rates of smoking cessation . ( Clinical Trials.gov number , NCT00128375 . Background The use of financial incentives and penalties to encourage uptake of healthy behaviors is increasingly seen as a viable intervention in developed countries . Previous review s of the effectiveness of financial incentives and penalties for encouraging the uptake of healthy behaviors have focused on individual behaviors making it difficult to draw overall conclusions about the effectiveness of such interventions . This systematic review will explore the effectiveness of financial incentives and penalties for encouraging a wide range of behaviors , including : smoking cessation , increased physical activity , healthier dietary intake , sensible patterns of alcohol consumption , safe sun , safe sex , and primary preventive clinical behaviors . Methods Systematic methods will be used to search existing literature and screen studies for inclusion . All studies that meet the following inclusion criteria will be included in the review : participants were 18 years old or older and living in high-income countries ; interventions included cash or cash-like incentives to promote the uptake of healthy behaviors , or cash or cash-like penalties to discourage unhealthy behaviors ; the comparator was usual care or no intervention ; study design was r and omized controlled trial , cluster r and omized controlled trial , controlled before and after study , or interrupted time series analysis . Two review ers will independently screen the publications to ensure they meet the inclusion criteria . Quality will be assessed by two research ers , working independently , using the Cochrane risk of bias tool . Meta- analysis will be conducted , if appropriate . Any studies identified as at ‘ high risk of bias ’ will be excluded from meta- analysis . Discussion This systematic review will provide policy-relevant recommendations for the use of financial incentives and penalties as a method of encouraging uptake of healthy behaviors BACKGROUND Evidence from cost-effective smoking cessation programs is scarce . This study determined the cost-effectiveness of 3 smoking cessation strategies as provided by general practitioners ( GPs ) in Germany . METHODS In a cluster-r and omized smoking cessation trial , rates and intervention costs for 577 smoking patients of 82 GPs were followed up for 12 months . Three smoking cessation treatments were tested : ( 1 ) GP training plus GP remuneration for each abstinent patient , ( 2 ) GP training plus cost-free nicotine replacement medication and /or bupropion hydrochloride for the patient , and ( 3 ) a combination of both strategies .  Smoking abstinence at 12 months was the primary outcome used to calculate incremental cost-effectiveness ratios and net monetary benefits . RESULTS Intervention 1 was not effective compared with treatment as usual ( TAU ) . Interventions 2 and 3 each proved to be cost-effective compared separately with TAU . When applying a 95 % level of certainty of cost-effectiveness against TAU , euro 9.80 or euro 6.96 , respectively , had to be paid for each additional 1 % of patients abstinent at 12 months ( maximum willingness to pay ) . That means that in intervention 2 , euro 92.12 per patient in the program must be invested to gain 1 additional quitter ( as opposed to euro 39.10 paid per patient during the trial ) . In intervention 2 , the cost was euro 82.82 , as opposed to euro 50.04 . Neither of these 2 cost-effective treatments proved to be superior to the other . The cost-effectiveness of both treatments was stable against TAU in sensitivity analyses . ( The exchange rate from October 1 , 2003 , was used ; euro1 = $ 1.17 . ) CONCLUSIONS Both treatments have a high potential to reduce smoking-related morbidity at a low cost . It is highly recommended that they be implemented as a routine service offered by GPs because in many countries , health insurance plans currently do not fund nicotine replacement therapy This study examined the relative reinforcing potency of vouchers and cash in drug-dependent pregnant women ( N = 48 ) across  voucher values ( US 10 dollars , US 50 dollars , and US 100 dollars ) by use of a series of choices to underst and how exchange-delay features of voucher reinforcers influence their reinforcing potency compared with cash . The study also examined a no delay vs. 2-day delay of the cash alternative . Generally , cash was selected at 80%-90 % of voucher face values . Vouchers were also discounted less when a 2-day delay was imposed on the cash option compared to the immediately available cash . These results suggest that voucher discounting does occur among patients in drug treatment . However , vouchers retain 80%-90 % of their cash value and thus remain relatively potent reinforcers Marijuana-dependent young adults ( N = 136 ) , all referred by the criminal justice system , were r and omized to 1 of 4 treatment conditions : a motivational/skills-building intervention ( motivational enhancement therapy/cognitive-behavioral therapy ; MET/CBT ) plus incentives contingent on session attendance or su bmi ssion of marijuana-free urine specimens ( contingency management ; CM ) , MET/CBT without CM , individual drug counseling ( DC ) plus CM , and DC without CM . There was a significant main effect of  CM on treatment retention and marijuana-free urine specimens . Moreover , the combination of MET/CBT plus CM was significantly more effective than MET/CBT without CM or DC plus CM , which were in turn more effective than DC without CM for treatment attendance and percentage of marijuana-free urine specimens . Participants assigned to MET/CBT continued to reduce the frequency of their marijuana use through a 6-month follow-up This study evaluated the impact of a year-long incentives-based worksite smoking-cessation program .  Nineteen moderate-sized worksites , employing a total of approximately 1100 smokers , were r and omized to Incentive or No Incentive conditions .  All identified smokers in the worksite were considered as subjects , whether or not they participated in the intervention . Analyses were conducted at both the worksite and individual level , and using both self-reported and biochemically vali date d cessation as endpoints . The incentive program did not significantly improve cessation rates at either the 1-year or 2-year follow-up assessment s. We conclude that more broadly focused interventions that also address worksite smoking policies , skills training , and cessation re sources , or programs that target additional risk factors are needed to substantially enhance quit rates OBJECTIVES This study assessed the independent and combined effects of different levels of monetary incentives and a theory-based educational intervention on return for tuberculosis ( TB ) skin test reading in a sample of active injection drug and crack cocaine users . Prevalence of TB infection in this sample was also determined . METHODS Active or recent drug users ( n = 1004 ) , recruited via street outreach techniques , were skin tested for TB . They were r and omly assigned to 1 of 2 levels of monetary incentive ( $ 5 and $ 10 ) provided at return for skin test reading , alone or in combination with a brief motivational education session . RESULTS More than 90 % of those who received $ 10 returned for skin test reading , in comparison with 85 % of those who received $ 5 and 33 % of those who received no monetary incentive . The education session had no impact on return for skin test reading . The prevalence of a positive tuberculin test was 18.3 % . CONCLUSIONS Monetary incentives dramatically increase the return rate for TB skin test reading among drug users who are at high risk of TB infection OBJECTIVE Less than half of all U.S. adults meet public health recommendations for physical activity , and even fewer older adults ( aged 50 years and over ) are sufficiently active . Because inactivity increases the risk of costly medical complications , successful efforts to increase physical activity among older adults may potentially be cost-effective . We sought to test if financial incentives for walking could increase physical activity among sedentary older adults . METHODS We conducted a 4-week r and omized controlled study using pedometers .  A total of 51 adults age 50 + from the Raleigh-Durham area of North Carolina participated in the study in April-May 2007 . Individuals were r and omized into one of two arms . The control group received a fixed payment of $ 75 ; the intervention group received a fixed payment of $ 50 plus up to $ 25 more per week depending on the number of weekly aerobic minutes  , defined as 10 + minutes of continuous walking or jogging . RESULTS The control group logged 2.3 h per week , on average . The intervention group logged 4.1 h per week and received an additional weekly payment of $ 17.50 , on average . CONCLUSION Modest financial incentives tied to aerobic minutes are an effective , and potentially cost-effective , approach for increasing physical activity among sedentary older adults BACKGROUND To minimize absenteeism result ing from influenza , employers frequently offer on-site  influenza vaccination to employees . Yet the level of uptake of vaccine is low among working adults . This study was design ed to increase workplace influenza vaccination rates by offering both a choice of intranasal ( LAIV ) and injectable ( TIV ) influenza vaccines to eligible employees , and an incentive for being vaccinated , and by increasing awareness of the vaccine clinic . DESIGN This study used a stratified r and omized cluster trial . SETTING / PARTICIPANTS A total of 12,222 employees in 53 U.S. companies with previous influenza vaccine clinics were examined . INTERVENTIONS Control sites advertised and offered vaccine clinics as previously done . Choice sites offered LAIV or TIV and maintained their previous advertising level but promoted the choice of vaccines . Choice Plus sites increased advertising and promoted and offered a choice of vaccines and a nominal incentive . MAIN OUTCOME MEASURES These included vaccination rates among eligible employees . Hierarchic linear modeling ( HLM ) was used to determine factors associated with vaccination . RESULTS The overall vaccination rate increased from 39 % in 2007 - 2008 to 46 % in 2008 - 2009 ( p<0.001 ) . The difference in vaccination rates for LAIV was 6.5 % for Choice versus Control and 9.9 % for Choice Plus versus Control ( both p<0.001 ) . Rates of TIV increased by 15.9 percentage points in the Choice Plus arm versus Control for workers aged > or = 50 years ( p=0.024 ) . Rates of TIV did not change in workers aged 18 - 49 years in either intervention arm or in workers aged > or = 50 years in the Choice arm . In HLM analyses , factors significantly associated with increased vaccination were older age , female gender , previous company vaccination rate , and the Choice Plus intervention . CONCLUSIONS An incentive for vaccination , an intensified advertising campaign , and offering a choice of influenza vaccines improved vaccination rates in the workplace OBJECTIVE Reinforcement-based treatments , based on behavioral economics models , can improve outcomes of medical conditions with behavioral components . This study evaluated the efficacy of a low-cost reinforcement intervention to produce initial weight loss . METHODS Overweight individuals ( n=56 ) were r and omized to one of two 12-week treatments : Lifestyle , Exercise , Attitudes , Relationships , Nutrition manual with supportive counseling or that same treatment with opportunities to win $ 1 to $ 100 prizes for losing weight and completing weight-loss activities . RESULTS Patients receiving reinforcement  lost significantly more weight ( 6.0 % ± 4.9 % baseline bodyweight ) than patients in the non-reinforcement condition ( 3.5 % ± 4.1 % ; P=.04 ) . Moreover , 64.3 % of patients receiving reinforcement achieved weight loss of ≥ 5 % baseline bodyweight versus 25.0 % of those in the non-reinforcement condition ( P=.003 ) . Proportional weight loss was significantly related to reductions in total cholesterol and 24-hour ambulatory heart rate . CONCLUSION This reinforcement-based intervention  substantially enhances short-term weight loss , and reductions in weight are associated with important changes in clinical biomarkers . Larger-scale evaluation of reinforcement-based treatments  for weight loss is warranted
target: Our framework should help research ers and policy-makers identify the most effective incentive configurations for helping individuals adopt healthy behaviours
background: Financial incentive interventions are increasingly used as a method of encouraging healthy behaviours , from attending for vaccinations to taking part in regular physical activity .
  There is a growing body of research on the effectiveness of financial incentive interventions for health behaviours .
  Wide variations in the nature of these interventions make it difficult to draw firm conclusions about what makes an effective incentive , for whom and under what circumstances .
  Whilst there has been some recognition of the theoretical complexity of financial incentive interventions for health behaviours , there is no framework that categorises these interventions .
  This limits the research community 's ability to clearly establish which components of financial incentives interventions are more and less effective , and how these components might interact to enable behavioural change .
  We propose a framework for describing health-promoting financial incentive interventions .