title: Premium-Based Financial Incentives Did Not Promote Workplace Weight Loss In A 2013-15 Study. Burn and earn: a randomized controlled trial incentivizing exercise during fall semester for college first-year students. Use of personal trainers and financial incentives to increase exercise in a behavioral weight-loss program. Benefits of adding Small Financial Incentives or Optional Group Meetings to a Web-based Statewide Obesity Initiative Financial incentives and purchase restrictions in a food benefit program affect the types of foods and beverages purchased: results from a randomized trial Understanding and Misunderstanding Randomized Controlled Trials Effectiveness of activity trackers with and without incentives to increase physical activity (TRIPPA): a randomised controlled trial. A randomized study of reinforcing ambulatory exercise in older adults. Contingencies for change in complacent smokers. Financial Incentives for Extended Weight Loss: A Randomized, Controlled Trial Healthy habits: efficacy of simple advice on weight control based on a habit-formation model A randomized trial of computer-delivered brief intervention and low-intensity contingency management for smoking during pregnancy. Can Financial Incentives Help People Trying to Establish New Habits? Experimental Evidence with New Gym Members A randomized, controlled trial of financial incentives for smoking cessation. Individual- Versus Group-Based Financial Incentives for Weight Loss Effects of voucher-based incentives on abstinence from cigarette smoking and fetal growth among pregnant women. Effectiveness of Financial Incentives in a Worksite Diabetes Prevention Program Behavioral anti-smoking trial in chronic obstructive pulmonary disease patients A Randomized Controlled Trial of Financial Incentives to Low Income Pregnant Women to Engage in Smoking Cessation Treatment: Effects on Post-Birth Abstinence Individual Versus Team-Based Financial Incentives to Increase Physical Activity: A Randomized, Controlled Trial Prize contingency management for smoking cessation: a randomized trial. A Randomized Trial of Incentives for Smoking Treatment in Medicaid Members. Social norms and financial incentives to promote employees' healthy food choices: A randomized controlled trial. Contingency management for smoking cessation among treatment-seeking patients in a community setting. A Randomized Controlled Trial of Employer Matching of Employees’ Monetary Contributions to Deposit Contracts to Promote Weight Loss Applying economic incentives to increase effectiveness of an outpatient weight loss program (TRIO) - A randomized controlled trial. Financial incentives for abstinence among socioeconomically disadvantaged individuals in smoking cessation treatment. Effects of a personal trainer and financial incentives on exercise adherence in overweight women in a behavioral weight loss program. Who responds to financial incentives for weight loss? Evidence from a randomized controlled trial. A Simple Reinforcement Strategy for Increasing Attendance at a Fitness Facility Effects of Large Financial Incentives for Long-Term Smoking Cessation: A Randomized Trial. Examining two different schedules of financial incentives for smoking cessation among pregnant women. Randomised controlled trial using social support and financial incentives for high risk pregnant smokers: Significant Other Supporter (SOS) program The SUCCESS project: the effect of program format and incentives on participation and cessation in worksite smoking cessation programs. A worksite smoking intervention: a 2 year assessment of groups, incentives and self-help. Enhancing physical activity and reducing obesity through smartcare and financial incentives: A pilot randomized trial. A Pilot Study Testing the Effect of Different Levels of Financial Incentives on Weight Loss Among Overweight Employees A randomized study of financial incentives to increase physical activity among sedentary older adults. A low-cost reinforcement procedure improves short-term weight loss outcomes. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials Financial incentive-based approaches for weight loss: a randomized trial. Randomized trial of four financial-incentive programs for smoking cessation. A Trial of Financial and Social Incentives to Increase Older Adults' Walking. A Mixed-Methods Randomized Controlled Trial of Financial Incentives and Peer Networks to Promote Walking Among Older Adults
abstract: Employers commonly use adjustments to health insurance premiums as incentives to encourage healthy behavior , but the effectiveness of those adjustments is controversial . We gave 197 obese participants in a workplace wellness program a weight loss goal equivalent to 5 percent of their baseline weight . They were r and omly assigned to a control arm , with no financial incentive for achieving the goal , or to one of three intervention arms offering an incentive valued at $ 550 . Two intervention arms used health insurance premium adjustments , beginning the following year ( delayed ) or in the first pay period after achieving the goal ( immediate ) . A third arm used a daily lottery incentive separate from premiums . At twelve months there were no statistically significant differences in mean weight change either between the control group ( whose members had a mean gain of 0.1 pound ) and any of the incentive groups ( delayed premium adjustment , -1.2 pound ; immediate premium adjustment , -1.4 pound ; daily lottery incentive , -1.0 pound ) or among the intervention groups . The apparent failure of the incentives to promote weight loss suggests that employers that encourage weight reduction through workplace wellness programs should test alternatives to the conventional premium adjustment approach by using alternative incentive design s , larger incentives , or both OBJECTIVE To examine the viability of monetary incentives to increase fitness-center use and maintain/improve the Body Mass Indexes ( BMI s ) of first-year students over the fall semester . METHOD R and omized-controlled trial with no-treatment and incentive conditions involving 117 first-year students . For 12 weeks , students in the incentive condition received monetary payments ranging from $ 10 to $ 38.75 for meeting research er-set fitness-center use goals that were identical across conditions . Fitness-center use was monitored through electronic ID-card check-in and check-out records at the campus fitness center . RESULTS 63 % of incentive-condition participants met the weekly fitness-center use goals on average compared to only 13 % of control-condition participants , a significant difference , p<0.001 . Goal achievement significantly decreased over time , p<0.01 and at roughly the same rate in the control and incentive conditions , p=0.23 . Average BMI increases over the fall semester in the control ( 24.2 ( 0.6 ) to 24.6 (0.6)kg/m(2 ) ) versus incentive condition ( 23.1 ( 0.4 ) to 23.5 (0.4)kg/m(2 ) ) were not significantly different ( p=0.70 ) . CONCLUSION Weekly monetary incentives result ed in significantly more first-year students meeting weekly fitness-center use goals . However , the increased fitness-center use by the incentive condition did not prevent an increase in BMI during fall semester 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 Objective To examine whether adding either small , variable financial incentives or optional group sessions improves weight losses in a community-based , Internet behavioral program . Design and methods Participants ( N=268 ) from Shape Up Rhode Isl and 2012 , a 3 month Web-based community wellness initiative , were r and omized to : Shape Up+Internet behavioral program ( SI ) , Shape Up+Internet program+Incentives ( SII ) , or Shape Up+Internet program+Group sessions ( SIG ) . Results At the end of the 3 month program , SII achieved significantly greater weight losses than SI ( SII:6.4 % [ 5.1 - 7.7 ] ; SI:4.2 % [ 3.0 - 5.6 ] ; P=.03 ) ; weight losses in SIG were not significantly different from the other two conditions ( SIG : 5.8 % [ 4.5 - 7.1 ] , P’s≥.10 ) . However , at the 12 month no treatment follow-up visit , both SII and SIG had greater weight losses than SI ( SII : 3.1 % [ 1.8 - 4.4 ] ; SIG : 4.5 % [ 3.2 - 5.8 ] ; SI : 1.2 % [ -0.1 - 2.6 ] ; P’s≤.05 ) . SII was the most cost-effective approach at both 3 ( SII : $ 34/kg ; SI : $ 34/kg ; SIG : $ 87/kg ) and 12 months ( SII : $ 64/kg ; SI : $ 140/kg ; SIG : $ 113/kg ) . Conclusions Modest financial incentives  enhance weight losses during a community campaign and both incentives and optional group meetings improved overall weight loss outcomes during the follow-up period . However , the use of the financial incentives is the most cost-effective approach Background This research evaluated the effects of financial incentives and purchase restrictions on food purchasing in a food benefit program for low income people . Methods Participants ( n=279 ) were r and omized to groups : 1 ) Incentive- 30 % financial incentive for fruits and vegetables purchased with food benefits ; 2 ) Restriction- no purchase of sugar-sweetened beverages , sweet baked goods , or c and ies with food benefits ; 3 ) Incentive plus Restriction ; or 4 ) Control- no incentive or restrictions . Participants received a study -specific debit card where funds were added monthly for 12-weeks . Food purchase receipts were collected over 16 weeks . Total dollars spent on grocery purchases and by targeted food categories were computed from receipts . Group differences were examined using general linear models . Results Weekly purchases of fruit significantly increased in the Incentive plus Restriction ( $ 4.8 ) compared to the Restriction ( $ 1.7 ) and Control ( $ 2.1 ) groups ( p < .01 ) . Sugar-sweetened beverage purchases significantly decreased in the Incentive plus Restriction(−$0.8 per week ) and Restriction ( $ -1.4 per week ) groups compared to the Control group ( + $ 1.5 ; p < .0001 ) . Sweet baked goods purchases significantly decreased in the Restriction ( −$0.70 per week ) compared to the Control group ( + $ 0.82 per week ; p < .01 ) . Conclusions Paired financial incentives and restrictions on foods and beverages purchased with food program funds may support more healthful food purchases compared to no incentives or restrictions . Clinical trial registration Clinical trials.gov Identifier : NCT02643576 RCTs would be more useful if there were more realistic expectations of them and if their pitfalls were better recognized . For example , and contrary to many cl aims in the applied literature , r and omization does not equalize everything but the treatment across treatments and controls , it does not automatically deliver a precise estimate of the average treatment effect ( ATE ) , and it does not relieve us of the need to think about ( observed or unobserved ) confounders . Estimates apply to the trial sample only , sometimes a convenience sample , and usually selected ; justification is required to extend them to other groups , including any population to which the trial sample belongs . Dem and ing “ external validity � ? is unhelpful because it expects too much of an RCT while undervaluing its contribution . Statistical inference on ATEs involves hazards that are not always recognized . RCTs do indeed require minimal assumptions and can operate with little prior knowledge . This is an advantage when persuading distrustful audiences , but it is a disadvantage for cumulative scientific progress , where prior knowledge should be built upon and not discarded . RCTs can play a role in building scientific knowledge and useful predictions but they can only do so as part of a cumulative program , combining with other methods , including conceptual and theoretical development , to discover not “ what works , � ? but “ why things work � ? BACKGROUND Despite the increasing popularity of activity trackers , little evidence exists that they can improve health outcomes . We aim ed to investigate whether use of activity trackers , alone or in combination with cash incentives or charitable donations , lead to increases in physical activity and improvements in health outcomes . METHODS In this r and omised controlled trial , employees from 13 organisations in Singapore were r and omly assigned ( 1:1:1:1 ) with a computer generated assignment schedule to control ( no tracker or incentives ) , Fitbit Zip activity tracker , tracker plus charity incentives , or tracker plus cash incentives .  Participants had to be English speaking , full-time employees , aged 21 - 65 years , able to walk at least ten steps continuously , and non-pregnant . Incentives were tied to weekly steps , and the primary outcome , moderate-to-vigorous physical activity ( MVPA ) bout min per week , was measured via a sealed accelerometer and assessed on an intention-to-treat basis at 6 months ( end of intervention ) and 12 months ( after a 6 month post-intervention follow-up period ) . Other outcome measures included steps , participants meeting 70 000 steps per week target , and health-related outcomes including weight , blood pressure , and quality -of-life measures . This trial is registered at Clinical Trials.gov , number NCT01855776 . FINDINGS Between June 13 , 2013 , and Aug 15 , 2014 , 800 participants were recruited and r and omly assigned to the control ( n=201 ) , Fitbit ( n=203 ) , charity ( n=199 ) , and cash ( n=197 ) groups . At 6 months , compared with control , the cash group logged an additional 29 MVPA bout min per week ( 95 % CI 10 - 47 ; p=0·0024 ) and the charity group an additional 21 MVPA bout min per week ( 2 - 39 ; p=0·0310 ) ; the difference between Fitbit only and control was not significant ( 16 MVPA bout min per week [ -2 to 35 ; p=0·0854 ] ) . Increases in MVPA bout min per week in the cash and charity groups were not significantly greater than that of the Fitbit group . At 12 months , the Fitbit group logged an additional 37 MVPA bout min per week ( 19 - 56 ; p=0·0001 ) and the charity group an additional 32 MVPA bout min per week ( 12 - 51 ; p=0·0013 ) compared with control ; the difference between cash and control was not significant ( 15 MVPA bout min per week [ -5 to 34 ; p=0·1363 ] ) . A decrease in physical activity of -23 MVPA bout min per week ( 95 % CI -42 to -4 ; p=0·0184 ) was seen when comparing the cash group with the Fitbit group . There were no improvements in any health outcomes ( weight , blood pressure , etc ) at either assessment . INTERPRETATION The cash incentive was most effective at increasing MVPA bout min per week at 6 months , but this effect was not sustained 6 months after the incentives were discontinued . At 12 months , the activity tracker with or without charity incentives were effective at stemming the reduction in MVPA bout min per week seen in the control group , but we identified no evidence of improvements in health outcomes , either with or without incentives , calling into question the value of these devices for health promotion . Although other incentive strategies might generate greater increases in step activity and improvements in health outcomes , incentives would probably need to be in place long term to avoid any potential decrease in physical activity result ing from discontinuation . FUNDING Ministry of Health , Singapore Many older adults do not meet physical activity recommendations and suffer from health-related complications . Reinforcement interventions can have pronounced effects on promoting behavior change ; this study evaluated the efficacy of a reinforcement intervention to enhance walking in older adults . Forty-five sedentary adults with mild to moderate hypertension were r and omized to 12-week interventions consisting of pedometers and guidelines to walk 10,000 steps/day or that same intervention with chances to win $ 1-$100 prizes for meeting recommendations . Patients walked an average of about 4,000 steps/day at baseline . Throughout the intervention , participants in the reinforcement intervention  met walking goals on 82.5 % ± 25.8 % of days versus 55.3 % ± 37.1 % of days in the control condition , p < .01 . Even though steps walked increased significantly in both groups relative to baseline , participants in the reinforcement condition walked an average of about 2,000 more steps/day than participants in the control condition , p < .02 . Beneficial effects of the reinforcement condition relative to the control condition persisted at a 24-week follow-up evaluation , p < .02 , although steps/day were lower than during the intervention period in both groups . Participants in the reinforcement intervention also evidence d greater reductions in blood pressure and weight over time and improvements in fitness indices , ps < .05 . This reinforcement-based intervention substantially increased walking and improved clinical parameters , suggesting that larger-scale evaluations of reinforcement-based interventions for enhancing active lifestyles in older adults are warranted . Ultimately , economic analyses may reveal reinforcement interventions to be cost-effective , especially in high-risk population s of older adults The majority of smokers have no plans to quit in the near future . These complacent smokers are less likely to quit than other smokers , and few interventions are known to reduce smoking in this population . Although monetary incentives can reduce complacent smokers ' breath carbon monoxide ( BCO ) levels , it is not clear whether these effects can be sustained beyond the several weeks that past studies have examined . The authors compared complacent smokers r and omly assigned to receive incentives for BCO reductions ( n=18 ) or noncontingent incentives ( n=19 ) for 3 months . Contingent incentives were associated with ( a ) reduced BCO ; ( b ) more BCO sample s indicative of abstinence ; ( c ) fewer cigarettes smoked and more days abstinent at study end ; and ( d ) lower salivary cotinine . These behaviors can predict future cessation , and 2 of the 18 smokers ( 11 % ) receiving BCO-contingent incentives reported quitting as compared with none in the control group . Contingency management procedures , such as those used here , may effectively promote cessation among complacent smokers and provide a model for underst and ing the possible effects of some environmental interventions ( like workplace smoking bans ) on the behavior of complacent smokers ABSTRACT BACKGROUND Previous efforts to use incentives for weight loss have result ed in substantial weight regain after 16 weeks . OBJECTIVE To evaluate a longer term weight loss intervention using financial incentives . DESIGN A 32-week , three-arm r and omized controlled trial of financial incentives for weight loss consisting of a 24-week weight loss phase during which all participants were given a weight loss goal of 1 pound per week , followed by an 8-week maintenance phase . PARTICIPANTS Veterans who were patients at the Philadelphia Veterans Affairs Medical Center with BMI s of 30–40.INTERVENTION Participants were r and omly assigned to participate in either a weight-monitoring program involving a consultation with a dietician and monthly weigh-ins ( control condition ) , or the same program with one of two financial incentive plans . Both incentive arms used deposit contracts ( DC ) in which participants put their own money at risk ( matched 1:1 ) , which they lost if they failed to lose weight . In one incentive arm participants were told that the period after 24 weeks was for weight-loss maintenance ; in the other , no such distinction was made . MAIN MEASUREWeight loss after 32 weeks . KEY RESULTS Results were analyzed using intention-to-treat . There was no difference in weight loss between the incentive arms ( P = 0.80 ) . Incentive participants lost more weight than control participants [ mean DC = 8.70 pounds , mean control = 1.17 , P = 0.04 , 95 % CI of the difference in means ( 0.56 , 14.50 ) ] . Follow-up data 36 weeks after the 32-week intervention had ended indicated weight regain ; the net weight loss between the incentive and control groups was no longer significant ( mean DC = 1.2 pounds , 95 % CI , -2.58–5.00 ; mean control = 0.27 , 95 % CI , -3.77–4.30 , P = 0.76 ) . CONCLUSIONS Financial incentives produced significant weight loss over an 8-month intervention ; however , participants regained weight post-intervention Objective : To evaluate the efficacy of a simple weight loss intervention , based on principles of habit formation . Design : An exploratory trial in which overweight and obese adults were r and omized either to a habit-based intervention condition ( with two subgroups given weekly vs monthly weighing ; n=33 , n=36 ) or to a waiting-list control condition ( n=35 ) over 8 weeks . Intervention participants were followed up for 8 months . Participants : A total of 104 adults ( 35 men , 69 women ) with an average BMI of 30.9 kg m−2.Intervention : Intervention participants were given a leaflet containing advice on habit formation and simple recommendations for eating and activity behaviours promoting negative energy balance , together with a self-monitoring checklist . Main outcome measures : Weight change over 8 weeks in the intervention condition compared with the control condition and weight loss maintenance over 32 weeks in the intervention condition . Results : At 8 weeks , people in the intervention condition had lost significantly more weight ( mean=2.0 kg ) than those in the control condition ( 0.4 kg ) , with no difference between weekly and monthly weighing subgroups . At 32 weeks , those who remained in the study had lost an average of 3.8 kg , with 54 % losing 5 % or more of their body weight . An intention-to-treat analysis ( based on last-observation-carried-forward ) reduced this to 2.6 kg , with 26 % achieving a 5 % weight loss . Conclusions : This easily disseminable , low-cost , simple intervention produced clinical ly significant weight loss . In limited re source setting s it has potential as a tool for obesity management INTRODUCTION Implementation of evidence -based interventions for smoking during pregnancy is challenging . We developed 2 highly replicable interventions for smoking during pregnancy : ( a ) a computer-delivered 5As-based brief intervention ( CD-5As ) and ( b ) a computer-assisted , simplified , and low-intensity contingency management ( CM-Lite ) . METHODS A sample of 110 primarily Black pregnant women reporting smoking in the past week were recruited from prenatal care clinics and r and omly assigned to CD-5As ( n = 26 ) , CM-Lite ( n = 28 ) , CD-5As plus CM-Lite ( n = 30 ) , or treatment as usual ( n = 26 ) . Self-report of smoking , urine cotinine , and breath CO were measured 10 weeks following r and omization . RESULTS Participants rated both interventions highly ( e.g. , 87.5 % of CD-5As participants reported increases in likelihood of quitting ) , but most CM-Lite participants did not initiate reinforcement sessions and did not show increased abstinence .  CD-5As led to increased abstinence as measured by cotinine ( 43.5 % cotinine negative vs. 17.4 % ; odds ratio [ OR ] = 10.1 , p = .02 ) but not for CO-confirmed 7-day point prevalence ( 30.4 % abstinent vs. 8.7 % ; OR = 5.7 , p = .06 ) . Collapsing across CM-Lite status , participants receiving the CD-5As intervention were more likely to talk to a doctor or nurse about their smoking ( 60.5 % vs. 30.8 % ; OR = 3.0 , p = .02 ) . CONCLUSIONS Low-intensity participant-initiated CM did not affect smoking in this sample , but the CD-5As intervention was successful in increasing abstinence during pregnancy . Further research should seek to replicate these results in larger and more diverse sample s. Should CD-5As continue to prove efficacious , it could greatly increase the proportion of pregnant smokers who receive an evidence -based brief intervention We conducted a r and omized controlled trial testing the effect of modest incentives to attend the gym among new members of a fitness facility , a population that is already engaged in trying to change a health behavior . Our experiment r and omized 836 new members of a private gym into a control group , receiving a $ 30 payment unconditionally , or one of 3 incentive groups , receiving a payment if they attended the gym at least 9 times over their first 6 weeks as members . The incentives were a $ 30 payment , a $ 60 payment , and an item costing $ 30 that leveraged the endowment effect . These incentives had only moderate impacts on attendance during members ’ first 6 weeks and no effect on their subsequent visit trajectories . We document substantial overconfidence among new members about their likely visit rates and discuss how overconfidence may undermine the effectiveness of a modest incentive program 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 Data on the effectiveness of employer-sponsored financial incentives for employee weight loss are limited . OBJECTIVE To test the effectiveness of 2 financial incentive design s for promoting weight loss among obese employees . DESIGN R and omized , controlled trial . ( Clinical Trials.gov : NCT01208350 ) SETTING Children 's Hospital of Philadelphia . PARTICIPANTS 105 employees with a body mass index between 30 and 40 kg/m2 . INTERVENTION 24 weeks of monthly weigh-ins ( control group ; n = 35 ) ; individual incentive , design ed as $ 100 per person per month for meeting or exceeding weight-loss goals ( n = 35 ) ; and group incentive , design ed as $ 500 per month split among participants within groups of 5 who met or exceeded weight-loss goals ( n = 35 ) . MEASUREMENTS Weight loss after 24 weeks ( primary outcome ) and 36 weeks and changes in behavioral mediators of weight loss ( secondary outcomes ) . RESULTS Group-incentive participants lost more weight than control participants ( mean between-group difference , 4.4 kg [ 95 % CI , 2.0 to 6.7 kg ] ; P < 0.001 ) and individual-incentive participants ( mean between-group difference , 3.2 kg [ CI , 0.9 to 5.5 kg ] ; P = 0.008 ) . Twelve weeks after incentives ended and after adjustment for 3-group comparisons , group-incentive participants maintained greater weight loss than control group participants ( mean between-group difference , 2.9 kg [ CI , 0.5 to 5.3 kg ] ; P = 0.016 ) but not greater than individual-incentive participants ( mean between-group difference , 2.7 kg [ CI , 0.4 to 5.0 kg ] ; P = 0.024 ) . LIMITATION Single employer and short follow-up . CONCLUSION A group-based financial incentive was more effective than an individual incentive and monthly weigh-ins at promoting weight loss among obese employees at 24 weeks . PRIMARY FUNDING SOURCE National Institute on Aging AIMS This study examined whether voucher-based reinforcement therapy ( VBRT ) contingent upon smoking abstinence during pregnancy is an effective method for decreasing  maternal smoking during pregnancy and improving fetal growth . DESIGN , SETTING AND PARTICIPANTS A two-condition , parallel-groups , r and omized controlled trial was conducted in a university-based research clinic . A total of 82 smokers entering prenatal care participated in the trial . INTERVENTION Participants were assigned r and omly to either contingent or non-contingent voucher conditions . Vouchers exchangeable for retail items were available during pregnancy and for 12 weeks postpartum . In the contingent condition , vouchers were earned for biochemically verified smoking abstinence ; in the non-contingent condition , vouchers were earned independent of smoking status . MEASUREMENTS Smoking outcomes were evaluated using urine-toxicology testing and self-report . Fetal growth outcomes were evaluated using serial ultrasound examinations performed during the third trimester . FINDINGS Contingent vouchers significantly increased point-prevalence abstinence at the end-of-pregnancy ( 41 % versus 10 % ) and at the 12-week postpartum assessment ( 24 % versus 3 % ) . Serial ultrasound examinations indicated significantly greater growth in terms of estimated fetal weight , femur length and abdominal circumference in the contingent compared to the non-contingent conditions . CONCLUSIONS These results provide further evidence that VBRT has a substantive contribution to make to efforts to decrease maternal smoking during pregnancy and provide new evidence of positive effects on fetal health Purpose To evaluate the effect of financial incentive in a diabetes prevention weight loss program at worksites . Design Group-level r and omized intervention study . Setting Four long-term care facilities , r and omly assigned to “ incentive-IG ” or “ non incentive-NIG ” groups . Participants Ninety-nine employees , all overweight or obese ( BMI = mean 34.8±7.4 kg/m2 ) and at risk for type 2 diabetes . Intervention A 16 week weight loss program ( diabetes prevention program ) with a 3 month follow up . IG could either choose a " st and ard incentive " to receive cash award when achieving the projected weight loss or to participate in a " st and ard plus deposit incentive " to get additional money matched with their deposit for projected weight loss . All of the participants received a one-hour consultation for a healthy weight loss at the beginning . Measures Weight-loss , diabetes risk score ( DRS ) , and cardiovascular risk outcomes . Analyses Linear and logistic regressions for completed cases with adjustments for clustering effect at group level . Results IG lost on average more pounds ( p=0.027 ) , reduced BMI ( p=0.04 ) , and reduced in DRS ( p=0.011 ) compared to NIG at week 16 . At the 12-week follow-up period , those in IG plus deposit subgroup had twice the odds ( OR=2.2 , p=0.042 ) and those in the st and ard IG had three times the odds of achieving weight loss goals than NIG ; those in the IG plus deposit group reduced DRS by 0.4 ( p=0.045 ) . Conclusion Monetary incentives appear to be effective in reducing weight and diabetes risk Smoking causes chronic obstructive pulmonary disease ( COPD ) , but few controlled studies have tested anti-smoking treatments in COPD . With procedures likely to attract unmotivated persons we recruited 49 quite-ill , smoking COPD patients . During one or two daily home visits for 85 days , breath carbon monoxide ( CO ) and self-reports of daily smoking were obtained . Patients , given quit date s and nicotine gum ( 2-mg pieces , up to 30 per day ) , were assigned r and omly to three groups : Experimentals were reinforced with lottery tickets for CO < 10 ppm . Cigarette Self Report ( CSR ) patients were reinforced for reporting no smoking that day . Controls received non-contingent payments . Each group 's mean CO level fell at the quit date . Thereafter , reinforced patients maintained significantly lower CO levels than Controls . Although many more 24-h abstentions occurred in the intervention period than in baseline , few patients sustained abstinence ; the groups did not differ in that regard . Outcome was predicted by decisions to throw away cigarettes when intervention began , but not by motivation scales nor Fagerstrom dependence scores . Pay schedules apparently exaggerated self-reports of reduced smoking . Although results are statistically significant , there is still no proven , practical treatment for smoking in advanced COPD Objective : Evaluate the effectiveness of monetary incentives for increasing engagement in smoking  cessation treatment and improving 6-month abstinence in low-income pregnant smokers . Method : Two-group r and omized clinical trial recruiting low-income ( Medicaid-registered ) pregnant smokers receiving assistance through a perinatal support program . Participants were r and omized to either an incentive ( n = 505 ) or control condition  ( n = 509 ) . All participants were offered identical smoking cessation counseling at contacts . Incentive condition participants received incentives for attending pre- and postbirth treatment contacts : $ 25 for each of 6 prebirth provider visits , $ 25–40 for each of 4 postbirth home visits at Weeks 1 , 2 , 4 , and 6 ( total = $ 130 ) , $ 20 for each of 5 postbirth counseling calls and $ 40 for biochemically verified abstinence at the Week 1 and 6-month visits . Control condition participants received only $ 40 for attendance at the Week 1 and 6-month postbirth visits ( $ 40 each ) . Main outcomes : Primary outcome was biochemically confirmed 7-day point-prevalence abstinence at 6-month postbirth follow-up . Secondary outcomes included number of home visits and phone calls taken over the first 6 months postbirth ; biochemically confirmed abstinence at postbirth Week 1 visit ; and self-reported smoking status at 2- and 4-month visits . Results : Incentive condition participants had a higher biochemically confirmed abstinence rate at 6-month postbirth than controls ( 14.7 % vs. 9.2 % , respectively : p < .01 ) . This effect was mediated by incentive condition participants ’ greater acceptance of postbirth home visits and counseling calls . Conclusions : Moderate incentive payments for smoking treatment engagement ( a mean of ≈$214 paid ) increased low-income pregnant smokers ’ engagement and success in smoking cessation treatment ABSTRACT BACKGROUND More than half of adults in the United States do not attain the minimum recommended level of physical activity to achieve health benefits . The optimal design of financial incentives to promote physical activity is unknown . OBJECTIVE To compare the effectiveness of individual versus team-based financial incentives to increase physical activity . DESIGN R and omized , controlled trial comparing three interventions to control . PARTICIPANTS Three hundred and four adult employees from an organization in Philadelphia formed 76 four-member teams . INTERVENTIONS All participants received daily feedback on performance towards achieving a daily 7000 step goal during the intervention ( weeks 1– 13 ) and follow-up ( weeks 14– 26 ) periods . The control arm received no other intervention . In the three financial incentive arms , drawings were held in which one team was selected as the winner every other day during the 13-week intervention . A participant on a winning team was eligible as follows : $ 50 if he or she met the goal ( individual incentive ) , $ 50 only if all four team members met the goal ( team incentive ) , or $ 20 if he or she met the goal individually and $ 10 more for each of three teammates that also met the goal ( combined incentive).MAIN MEASURES Mean proportion of participant-days achieving the 7000 step goal during the intervention . KEY RESULTS Compared to the control group during the intervention period , the mean proportion achieving the 7000 step goal was significantly greater for the combined incentive ( 0.35 vs. 0.18 , difference : 0.17 , 95 % confidence interval [ CI ] : 0.07–0.28 , p < 0.001 ) but not for the individual incentive ( 0.25 vs 0.18 , difference : 0.08 , 95 % CI : -0.02–0.18 , p = 0.13 ) or the team incentive ( 0.17 vs 0.18 , difference : -0.003 , 95 % CI : -0.11–0.10 , p = 0.96 ) . The combined incentive arm participants also achieved the goal at significantly greater rates than the team incentive ( 0.35 vs. 0.17 , difference : 0.18 , 95 % CI : 0.08–0.28 , p < 0.001 ) , but not the individual incentive ( 0.35 vs. 0.25 , difference : 0.10 , 95 % CI : -0.001–0.19 , p = 0.05 ) . Only the combined incentive had greater mean daily steps than control ( difference : 1446 , 95 % CI : 448–2444 , p ≤ 0.005 ) . There were no significant differences between arms during the follow-up period ( weeks 14– 26 ) . CONCLUSIONS Financial incentives rewarded for a combination of individual and team performance were most effective for increasing physical activity . Trial Registration Clinical trials.gov identifier : NCT02001194 BACKGROUND Adjunctive behavioral smoking cessation treatments have the potential to improve outcomes beyond st and ard care . The present study had two aims : ( 1 ) compare st and ard care ( SC ) for smoking ( four weeks of brief counseling and monitoring ) to SC plus prize-based contingency management ( CM ) , involving the chance to earn prizes on days with demonstrated smoking abstinence ( carbon monoxide ( CO ) ≤6 ppm ) ; and ( 2 ) compare the relative efficacy of two prize reinforcement schedules-one a traditional CM schedule , and the second an early enhanced CM schedule providing greater reinforcement magnitude in the initial week of treatment but equal overall reinforcement . METHODS Participants ( N=81 nicotine-dependent cigarette smokers ) were r and omly assigned to one of the three conditions . RESULTS Prize CM result ed in significant reductions in cigarette smoking relative to SC . These reductions were not apparent at follow-up . We found no meaningful differences between the traditional and enhanced CM conditions . CONCLUSIONS Our findings reveal that prize CM leads to significant reductions in smoking during treatment relative to a control intervention , but the benefits did not extend long-term INTRODUCTION Low-income population s are especially likely to smoke and have difficulty quitting . This study evaluated a monetary incentive intended to increase smoking treatment engagement and abstinence among Medicaid recipients who smoke . STUDY DESIGN Two-group r and omized clinical trial of Incentive ( n=948 ) and Control interventions ( n=952 ) for smoking . SETTING / PARTICIPANTS Medicaid recipients recruited from primary care patients ( n=920 ) and callers to the Wisconsin Tobacco Quit Line ( n=980 ) . INTERVENTION Participants were offered five quitline cessation calls and were encouraged to obtain cessation medication ( covered by Medicaid ) . All participants received payment for completing a baseline assessment and a 6-month smoking test . Only Incentive condition participants received compensation for taking counseling calls ( $ 30 per call ) and for biochemically verified abstinence at the 6-month visit ( $ 40 ) . MAIN OUTCOME MEASURES Seven-day point-prevalence smoking abstinence 6-months post study entry and cost/quit . RESULTS Incentive condition participants had significantly higher biochemically determined 7-day point-prevalence smoking abstinence rates 6 months after study induction than did Controls ( 21.6 % vs 13.8 % , respectively , p<0.0001 ) . A positive treatment effect of incentives was present across other abstinence indices , but the size of effects and levels of abstinence varied considerably across indices . Incentive condition participants were also significantly more likely than non-incentivized Control participants to accept Wisconsin Tobacco Quit Line treatment calls and their acceptance of calls mediated their attainment of higher abstinence rates at 6-month follow-up . The cost/quit/participant averaged $ 4,268.26 for the Control participants and $ 3,601.37 for the Incentive participants . CONCLUSIONS This study shows that fairly moderate levels of incentive payments for treatment engagement and abstinence ( a total possible payment of $ 190 ) increased very low-income smokers ' engagement and success in smoking cessation treatment . CLINICAL REGISTRATION This study is registered at www . clinical trials.gov : NCT02713594 OBJECTIVE Population -level strategies to improve healthy food choices are needed for obesity prevention . We conducted a r and omized controlled trial of 2672 employees at the Massachusetts General Hospital who were regular customers of the hospital cafeteria with all items labeled green ( healthy ) , yellow ( less healthy ) , or red ( unhealthy ) to determine if social norm ( peer-comparison ) feedback with or without financial incentives increased employees ' healthy food choices . METHODS Participants were r and omized in 2012 to three arms : 1 ) monthly letter with social norm feedback about healthy food purchases , comparing employee to " all " and to " healthiest " customers ( feedback-only ) ; 2 ) monthly letter with social norm feedback plus small financial incentive for increasing green purchases ( feedback-incentive ) ; or 3 ) no contact ( control ) . The main outcome was change in proportion of green-labeled purchases at the end of 3-month intervention . Post-hoc analyses examined linear trends . RESULTS At baseline , the proportion of green-labeled purchases ( 50 % ) did not differ between arms . At the end of the 3-month intervention , the percentage increase in green-labeled purchases was larger in the feedback-incentive arm compared to control ( 2.2 % vs. 0.1 % , P=0.03 ) , but the two intervention arms were not different . The rate of increase in green-labeled purchases was higher in both feedback-only ( P=0.04 ) and feedback-incentive arms ( P=0.004 ) compared to control . At the end of a 3-month wash-out , there were no differences between control and intervention arms . CONCLUSIONS Social norms plus small financial incentives increased employees ' healthy food choices over the short-term . Future research will be needed to assess the impact of this relatively low-cost intervention on employees ' food choices and weight over the long-term . TRIAL REGISTRATION Clinical Trials.gov : NCT01604499 BACKGROUND Contingency management ( CM ) is an efficacious intervention for reducing cigarette smoking . However , CM is rarely adopted as a smoking cessation treatment in the community . This study analyzed the effectiveness of a CM procedure in combination with a cognitive-behavioral treatment ( CBT ) for smoking cessation among treatment-seeking patients from the general population . METHODS A total of 92 patients were r and omly assigned to one of two treatment conditions : CBT ( N=49 ) or CBT+CM ( N=43 ) . The CM procedure included a voucher program through which nicotine abstinence was reinforced on a schedule of escalating magnitude of reinforcement with a reset contingency .  Self-reported smoking status was confirmed with both carbon monoxide ( CO ) level in expired air and cotinine levels in urine . RESULTS Of the patients who received CBT+CM 97.7 % , completed 6 weeks of treatment , versus 81.6 % of those who received CBT ( p=.03 ) . At the post-treatment assessment , 95.3 % of the patients assigned to the CBT+CM condition achieved abstinence in comparison to the 59.2 % in the CBT group ( p=.000 ) . At the one-month follow-up , 72.1 % of the patients who received CBT+CM  maintained smoking abstinence , versus 34.7 % in the CBT group ( p=.001 ) . At the six-month follow-up , 51.2 % of the patients who received CBT+CM  maintained smoking abstinence in comparison to the 28.6 % in the CBT group ( p=.04 ) . CONCLUSIONS Results from this r and omized clinical trial showed that adding CM to a CBT is effective , and is feasible as an intervention approach with treatment-seeking patients in a community setting Purpose : To test whether employer matching of employees ’ monetary contributions increases employees ’ ( 1 ) participation in deposit contracts to promote weight loss and ( 2 ) weight loss . Design : A 36-week r and omized trial . Setting : Large employer in the northeast United States . Participants : One hundred thirty-two obese employees . Interventions : Over 24 weeks , participants were asked to lose 24 pounds and r and omized to monthly weigh-ins or daily weigh-ins with monthly opportunities to deposit $ 1 to $ 3 per day that was not matched , matched 1:1 , or matched 2:1 . Deposits and matched funds were returned to participants for each day they were below their goal weight . Measures : Rates of making ≥1 deposit , weight loss at 24 weeks ( primary outcome ) , and 36 weeks . Analysis : Deposit rates were compared using χ2 tests . Weight loss was compared using t tests . Results : Among participants eligible to make deposits , 29 % made ≥1 deposit and matching did not increase participation . At 24 weeks , control participants gained an average of 1.0 pound , whereas 1:1 match participants lost an average of 5.3 pounds ( P = .005 ) . After 36 weeks , control participants gained an average of 2.1 pounds , whereas no match participants lost an average of 5.1 pounds ( P = .008 ) . Conclusion : Participation in deposit contracts to promote weight loss was low , and matching deposits did not increase participation . For deposit contracts to impact population health , ongoing participation will need to be higher The prevalence of overweight and obesity has more than doubled in the past three decades , leading to rising rates of non-communicable diseases . This study tests whether adding a payment/rewards ( term reward ) program to an existing evidence -based weight loss program can increase weight loss and weight loss maintenance . We conducted a parallel-group r and omized controlled trial from October 2012 to October 2015 with 161 overweight or obese individuals r and omized to either control or reward arm in a 1:2 ratio . Control and reward arm participants received a four month weight loss program at the LIFE ( Lifestyle Improvement and Fitness Enhancement ) Centre at Singapore General Hospital . Those in the reward arm paid a fee of S$165.00 ( 1 US$ = 1.35S$ ) to access a program that provided rewards of up to S$660 for meeting weight loss and physical activity goals . Participants could choose to receive rewards as guaranteed cash payments or a lottery ticket with a 1 in 10 chance of winning but with the same expected value . The primary outcome was weight loss at months 4 , 8 , and 12 . 161 participants were r and omized to control ( n = 54 ) or reward ( n = 107 ) arms .  Average weight loss was more than twice as great in the reward arm compared to the control arm at month 4 when the program concluded ( 3.4 kg vs 1.4 kg , p < 0.01 ) , month 8 when rewards concluded ( 3.3 kg vs 1.8 kg , p < 0.05 ) , and at month 12 ( 2.3 kg vs 0.8 kg , p < 0.05 ) . These results reveal that a payment/rewards program can be used to improve weight loss and weight loss maintenance when combined with an evidence -based weight loss program . Future efforts should attempt to replicate this approach and identify how to cost effectively exp and these programs to maximize their reach . This study is registered at www . clinical trials.gov ( Identifier : NCT01533454 ) OBJECTIVES We evaluated the effectiveness of offering adjunctive financial incentives for abstinence ( contingency management [ CM ] ) within a safety net hospital smoking cessation program . METHODS We r and omized participants ( n = 146 ) from a Dallas County , Texas , Tobacco Cessation Clinic from 2011 to 2013 to usual care ( UC ; cessation program ; n = 71 ) or CM ( UC + 4 weeks of financial incentives ; n = 75 ) , and followed from 1 week before the quit date through 4 weeks after the quit date . A subset ( n = 128 ) was asked to attend a visit 12 weeks after the scheduled quit date . RESULTS Participants were primarily Black ( 62.3 % ) or White ( 28.1 % ) and female ( 57.5 % ) . Most participants were uninsured ( 52.1 % ) and had an annual household income of less than $ 12 000 ( 55.5 % ) . Abstinence rates were significantly higher for those assigned to CM than UC at all visits following the quit date ( all Ps < .05 ) . Point prevalence abstinence rates in the CM and UC groups were 49.3 % versus 25.4 % at 4 weeks after the quit date and 32.8 % versus 14.1 % at 12 weeks after the quit date . CM participants earned an average of $ 63.40 ( $ 150 possible ) for abstinence during the first 4 weeks after the scheduled quit date . CONCLUSIONS Offering small financial incentives for abstinence might be an effective means to improve abstinence rates among socioeconomically disadvantaged individuals participating in smoking cessation treatment Exercise is important for long-term weight loss , but few studies have examined ways to improve exercise adherence in overweight subjects participating in a behavioral weight loss program . This paper presents two studies , one conducted at the University of Pittsburgh and one at the University of Minnesota , that sought to improve exercise adherence by exerting more direct control over the environmental antecedents and consequences controlling exercise . Study 1 investigated the use of a personal trainer who called participants regularly and met them at their home or office at scheduled times for a walk . Study 2 investigated the effect of a lottery incentive for exercise adherence . In both studies , the effect of these manipulations was examined in the context of a 24-week st and ard behavioral weight control program with three supervised exercise sessions per week . Neither intervention achieved statistically significant improvements in exercise adherence compared to control conditions , perhaps due in part to the limited statistical power of the studies . Future studies should focus on better underst and ing the barriers to exercise and design ing behavioral interventions that address these barriers There is a paucity of evidence on the heterogeneous impacts of financial incentives on weight loss .  Between March 2010 and January 2012 , in a r and omized controlled trial , we assigned 700 obese persons to three experimental arms . We test whether particular subgroups react differently to financial incentives for weight loss . Two treatment groups obtained a cash reward ( € 150 and € 300 with 237 and 229 participants , respectively ) for achieving an individually-assigned target weight within four months ; the control group ( 234 participants ) was not incentivized . Participants and administrators were not blinded to the intervention . We find that monetary rewards effectively induced  obese individuals to reduce weight across all subgroups . However , there is no evidence for treatment-effect heterogeneity for those groups that were incentivized . Among those who were in the € 300 group , statistically significant and large weight losses were observed for women , singles , and those who are not working ( all above 4 kg in four months ) . In addition , the magnitude of the reward matters only for women and migrants . The effectiveness of financial incentives to reduce weight nevertheless raises sensitive ethical issues that should be taken into consideration by policymakers The purpose of the present study was to examine the effect of a previously untested reinforcement strategy ( i.e. , 1 month 's free membership ) on attendance at a  fitness facility . Participants were paying members of a fitness facility r and omly assigned to  control ( n = 100 ) , placebo  ( n = 100 ) , and  reinforcement ( n = 100 ) conditions . The control condition received no intervention ; the placebo condition received a letter by mail ; and the reinforcement condition received the same letter by mail , except that it included an additional paragraph instructing them that they could earn 1 month 's free membership if they attended the fitness facility at least 12 times in the next month . Attendance was monitored for I month baseline and postintervention by using the facility 's computer system . Analysis of variance , t tests , and chi-square analysis all revealed that the reinforcement condition had the best attendance record during the intervention period . These preliminary results shed some light on increasing attendance at a fitness facility . Discussion highlighted the practical implication s of the findings and offered directions for future research BACKGROUND It is not known whether large financial incentives enhance long-term smoking cessation rates outside clinical or workplace setting s. OBJECTIVES The goal of this study was to test whether large financial incentives improved long-term smoking cessation rates in low-income smokers , in a general population setting , without face-to-face or telephone counseling . METHODS This was a 2-arm , parallel group , individually r and omized controlled trial , with follow-up after 3 , 6 , and 18 months . Participants were 805 low-income smokers enrolled between 2011 and 2013 from the general population in Geneva , Switzerl and . We r and omly assigned participants to receive either booklets plus access to a smoking cessation website ( control group , n = 404 ) , or the same intervention plus financial incentives ( intervention group , n = 401 ) . Incremental financial rewards , to a maximum of U.S. $ 1,650 , were offered for biochemically verified abstinence at 1 , 2 , and 3 weeks , and 1 , 3 , and 6 months . No in-person counseling , telephone counseling , or medications were provided . The primary outcome was continuous abstinence between 6 months ( end of incentives ) and 18 months ( 12 months after the incentives ended ) , verified by expired carbon monoxide and salivary cotinine . We also assessed biochemically verified 7-day abstinence at 3 , 6 , and 18 months . RESULTS Rates of continuous abstinence between months 6 and 18 were 9.5 % in the incentive group and 3.7 % in the control group ( p = 0.001 ) . Rates of 7-day abstinence were higher in the incentive group than in the control group at 3 ( 54.9 % vs. 11.9 % ; p < 0.001 ) , 6 ( 44.6 % vs. 11.1 % ; p < 0.001 ) , and 18 months ( 18.2 % vs. 11.4 % ; p = 0.006 ) . CONCLUSIONS In low-income smokers who did not receive face-to-face or telephone smoking cessation counseling , large financial incentives increased long-term rates of smoking cessation .  ( Financial incentives for smoking cessation in low-income smokers ; IS RCT N04019434 ) OBJECTIVE To examine whether an efficacious voucher-based incentives intervention for decreasing smoking during pregnancy and increasing fetal growth could be improved without increasing costs . The strategy was to redistribute the usual incentives so that higher values were available early in the quit attempt . METHOD 118 pregnant smokers in greater Burlington , Vermont ( studied December , 2006-June , 2012 ) were r and omly assigned to the revised contingent voucher ( RCV ) or usual contingent voucher ( CV ) schedule of abstinence-contingent vouchers , or to a non-contingent voucher ( NCV ) control condition wherein vouchers were provided independent of smoking status . Smoking status was biochemically verified ; serial sonographic estimates of fetal growth were obtained at gestational weeks 30 - 34 . RESULTS RCV and CV conditions increased point-prevalence abstinence above NCV levels at early ( RCV : 40 % , CV : 46 % , NCV : 13 % , p=.007 ) and late-pregnancy ( RCV : 45 % ; CV : 36 % ; NCV , 18 % ; p=.04 ) assessment s , but abstinence levels did not differ between the RCV and CV conditions . The RCV intervention did not increase fetal growth above control levels while the CV condition did so ( p<.05 ) . CONCLUSION This trial further supports the efficacy of CV for increasing antepartum abstinence and fetal growth , but other strategies ( e.g. , increasing overall incentive values ) will be necessary to improve outcomes further Smoking  cessation interventions have posed significant challenges for health professionals , particularly when directed at high risk , low income , pregnant smokers . Typical quit rates for pregnant women who receive publicly financed obstetrical care have rarely exceeded 12–16%.1 As many as 70 % of women who quit smoking during pregnancy relapse within one year of delivery.2 Two areas that have received particular attention as possible adjuncts to behaviour change are the use of reinforcements and social supports . Reinforcement in the form of incentives/rewards for positive behaviours has been controversial as an intervention strategy . Some argue that the “ overjustification effect ” of external rewards may cause subjects to lose internal motivation to modify behaviour over the long term.3 However , results of several studies , including two meta-analyses on reinforcement , provide compelling evidence that positive reinforcement provides positive behavioural changes.4 - 8 A second area of study that has been explored in the behaviour change research is the role of social support in motivating and sustaining selected behaviour change . Recent studies have empirically linked tobacco quit rates with daily interaction with a supportive “ other , ” preferably one who did not smoke.9 10 The primary objective of our intervention was to determine whether the combination of bolstered social support and financial incentives had an effect in significantly reducing smoking behaviour among low income , high risk , pregnant and postpartum women who participate in Oregon 's Women , Infants , and Children ( WIC ) program .  The Significant Other Supporter ( SOS ) program was a r and omised , experimentally design ed smoking cessation study implemented in four Oregon WIC program sites . Criteria for entry into the study included the following : age 15 years or older ; self reported smoker ( “ even a puff in the last seven days ” ) ; English speaker/reader ; WIC eligible ; and 28 weeks gestation or less . Eligible subjects were r and omised into one of two groups , and were OBJECTIVES This study examined the effect of program format and incentives on participation and cessation in worksite smoking cessation programs . METHODS Twenty-four worksites were r and omized to 6 conditions that differed in cessation program format and the use of incentives . Programs were offered for 18 months in each worksite . A total of 2402 cigarette smokers identified at baseline were surveyed 12 and 24 months later to assess participation in programs and cessation . RESULTS A total of 407 ( 16.9 % ) of the smoker cohort registered for programs ; on the 12- and 24-month surveys , 15.4 % and 19.4 % of the cohort , respectively , reported that they had not smoked in the previous 7 days . Registration for programs in incentive sites was almost double that of no-incentive sites ( 22.4 % vs 11.9 % ) , but increased registration did not translate into significantly greater cessation rates . Program type did not affect registration or cessation rates . CONCLUSIONS Although incentives increase rates of registration in worksite smoking cessation programs , they do not appear to increase cessation rates .  Phone counseling seems to be at least as effective as group programs for promoting smoking cessation in worksites Sixty-three companies in the Chicago area were recruited to participate in a worksite smoking cessation program . Participants in each worksite received a television program and newspaper supplement ( part of a community-wide media campaign ) , and one of three conditions : ( 1 ) self-help manuals alone ( M ) , ( 2 ) self-help manuals and incentives for 6 months ( IM ) or ( 3 ) maintenance manuals , incentives and cognitive-behavioral support groups for 6 months ( GIM ) . Results at the 2 year assessment are examined using a r and om-effects regression model . In addition , various definitions of quit-rate commonly used in smoking cessation research are explored and the advantages of using a public health approach in the worksite are examined OBJECTIVE A pilot r and omized trial assessed the feasibility and effectiveness of an intervention combining Smartcare ( activity tracker with a smartphone application ) and financial incentives . METHODS A three-arm , open-label r and omized controlled trial design involving traditional education , Smartcare , and Smartcare with financial incentives was involved in this study . The latter group received financial incentives depending on the achievement of daily physical activity goals ( process incentive ) and weight loss targets ( outcome incentive ) . Male university students ( N = 105 ) with body mass index of ≥27 were enrolled . RESULTS The average weight loss in the traditional education , Smartcare , and Smartcare with financial incentives groups was -0.4 , -1.1 , and -3.1 kg , respectively , with significantly greater weight loss in the third group ( both Ps < 0.01 ) . The final weight loss goal was achieved by 0 , 2 , and 10 participants in the traditional education , Smartcare , and Smartcare with financial incentives groups ( odds ratio for the Smartcare with financial incentive vs. Smartcare = 7.27 , 95 % confidence interval : 1.45 - 36.47 ) . Levels of physical activity were significantly higher in this group . CONCLUSIONS The addition of financial incentives to Smartcare was effective in increasing physical activity and reducing obesity Objective : To test the ability of two levels of modest financial incentives to encourage weight loss among overweight employees . Methods : This study used a r and omized design with measurements at baseline , 3 , and 6 months and two levels of financial incentives ( $ 7 and $ 14 per percentage point of weight lost ) . Payments were structured so that all participants had equal ability to obtain the incentives during the study period . Results : At 3 months , participants with no financial incentive lost 2 pounds , those in the $ 7 group lost approximately 3 pounds , and those in the $ 14 group lost 4.7 pounds . Between baseline and 6 months , when the financial gains were equalized , weight losses were similar across groups . Conclusion : This study revealed that modest financial incentives can be effective in motivating overweight employees to lose weight 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 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 The CONSORT statement is used worldwide to improve the reporting of r and omised controlled trials . Kenneth Schulz and colleagues describe the latest version , CONSORT 2010 , which up date s the reporting guideline based on new method ological evidence and accumulating experience . To encourage dissemination of the CONSORT 2010 Statement , this article is freely accessible on bmj.com and will also be published in the Lancet , Obstetrics and Gynecology , PLoS Medicine , Annals of Internal Medicine , Open Medicine , Journal of Clinical Epidemiology , BMC Medicine , and Trials CONTEXT Identifying effective obesity treatment is both a clinical challenge and a public health priority due to the health consequences of obesity . OBJECTIVE To determine whether common decision errors identified by behavioral economists such as prospect theory , loss aversion , and regret could be used to design an effective weight loss intervention . DESIGN , SETTING , AND PARTICIPANTS Fifty-seven healthy participants aged 30 - 70 years with a body mass index of 30 - 40 were r and omized to 3 weight loss plans : monthly weigh-ins , a lottery incentive program , or a deposit contract that allowed for participant matching , with a weight loss goal of 1 lb ( 0.45 kg ) a week for 16 weeks . Participants were recruited May-August 2007 at the Philadelphia VA Medical Center in Pennsylvania and were followed up through June 2008 . MAIN OUTCOME MEASURES Weight loss after 16 weeks . RESULTS The incentive groups  lost significantly more weight than the control group ( mean , 3.9 lb ) . Compared with the control group , the lottery group lost a mean of 13.1 lb ( 95 % confidence interval [ CI ] of the difference in means , 1.95 - 16.40 ; P = .02 ) and the deposit contract group lost a mean of 14.0 lb ( 95 % CI of the difference in means , 3.69 - 16.43 ; P = .006 ) . About half of those in both incentive groups met the 16-lb target weight loss : 47.4 % ( 95 % CI , 24.5%-71.1 % ) in the deposit contract group and 52.6 % ( 95 % CI , 28.9%-75.6 % ) in the lottery group , whereas 10.5 % ( 95 % CI , 1.3%-33.1 % ; P = .01 ) in the control group met the 16-lb target . Although the net weight loss between enrollment in the study and at the end of 7 months was larger in the incentive groups ( 9.2 lb ; t = 1.21 ; 95 % CI , -3.20 to 12.66 ; P = .23 , in the lottery group and 6.2 lb ; t = 0.52 ; 95 % CI , -5.17 to 8.75 ; P = .61 in the deposit contract group ) than in the control group ( 4.4 lb ) , these differences were not statistically significant . However , incentive participants weighed significantly less at 7 months than at the study start ( P = .01 for the lottery group ; P = .03 for the deposit contract group ) whereas controls did not . CONCLUSIONS The use of economic incentives produced significant weight loss during the 16 weeks of intervention that was not fully sustained . The longer-term use of incentives should be evaluated . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00520611 BACKGROUND Financial incentives promote many health behaviors , but effective ways to deliver health incentives remain uncertain . METHODS We r and omly assigned CVS Caremark employees and their relatives and friends to one of four incentive programs or to usual care for smoking cessation . Two of the incentive programs  targeted individuals , and two targeted groups of six participants . One of the individual-oriented programs and one of the group-oriented programs entailed rewards of approximately $ 800 for smoking cessation ; the others entailed refundable deposits of $ 150 plus $ 650 in reward payments for successful participants . Usual care included informational re sources and free smoking-cessation aids . RESULTS Overall , 2538 participants were enrolled . Of those assigned to reward-based programs , 90.0 % accepted the assignment , as compared with 13.7 % of those assigned to deposit-based programs ( P<0.001 ) . In intention-to-treat analyses , rates of sustained abstinence from smoking through 6 months were higher with each of the four incentive programs ( range , 9.4 to 16.0 % ) than with usual care ( 6.0 % ) ( P<0.05 for all comparisons ) ; the superiority of reward-based programs was sustained through 12 months . Group-oriented and individual-oriented programs were associated with similar 6-month abstinence rates ( 13.7 % and 12.1 % , respectively ; P=0.29 ) . Reward-based programs were associated with higher abstinence rates than deposit-based programs ( 15.7 % vs. 10.2 % , P<0.001 ) . However , in instrumental-variable analyses that accounted for differential acceptance , the rate of abstinence at 6 months was 13.2 percentage points ( 95 % confidence interval , 3.1 to 22.8 ) higher in the deposit-based programs than in the reward-based programs among the estimated 13.7 % of the participants who would accept participation in either type of program . CONCLUSIONS Reward-based programs were much more commonly accepted than deposit-based programs , leading to higher rates of sustained abstinence from smoking .  Group-oriented incentive programs were no more effective than individual-oriented programs . ( Funded by the National Institutes of Health and CVS Caremark ; Clinical Trials.gov number , NCT01526265 . ) INTRODUCTION Despite evidence that regular physical activity confers health benefits , physical activity rates among older adults remain low . Both personal and social goals may enhance older adults ' motivation to become active . This study tested the effects of financial incentives , donations to charity , and the combined effects of both interventions on older adults ' uptake and retention of increased levels of walking . STUDY DESIGN RCT comparing three interventions to control . Data collection occurred from 2012 to 2013 . Analyses were conducted in 2013 - 2016 . PARTICIPANTS Ninety-four adults aged ≥65 years from Philadelphia-area retirement communities . INTERVENTION All participants received digital pedometers , walking goals of a 50 % increase in daily steps , and weekly feedback on goal attainment . Participants were r and omized to one of four groups : ( 1 ) Control : received weekly feedback only ; ( 2 ) Financial Incentives : received payment of $ 20 each week walking goals were met ; ( 3 ) Social Goals : received donation of $ 20 to a charity of choice each week walking goals were met ; and ( 4 ) Combined : received $ 20 each week walking goals were met that could be received by participant , donated to a charity of choice , or divided between the participant and charity . MAIN OUTCOME MEASURES Mean proportion of days walking goals were met during the 16-week intervention and 4-week follow-up period . RESULTS After adjusting for baseline walking , the proportion of days step goals were met during the 16-week intervention period was higher in all intervention groups versus controls ( relative risk , 3.71 ; 95 % CI=1.37 , 10.01 ) . During the 4-week follow up period , the proportion of days step goals were met did not differ in intervention groups compared to control ( relative risk , 2.91 ; 95 % CI=0.62 , 13.64 ) . CONCLUSIONS Incentive schemes that use donations to a charity of choice , personal financial incentives , or a combination of the two can each increase older adults ' initial uptake of increased levels of walking . TRIAL REGISTRATION This study is registered at www . clinical trials.gov NCT01643538 Background . Financial incentives and peer networks could be delivered through eHealth technologies to encourage older adults to walk more . Methods . We conducted a 24-week r and omized trial in which 92 older adults with a computer and Internet access received a pedometer , daily walking goals , and weekly feedback on goal achievement .  Participants were r and omized to  weekly feedback only ( Comparison ) , entry into a lottery with potential to earn up to $ 200 each week walking goals were met ( Financial Incentive ) , linkage to four other participants through an online message board ( Peer Network ) , or both interventions ( Combined ) . Main outcomes were the proportion of days walking goals were met during the 16-week intervention and 8-week follow-up . We conducted a content analysis of messages posted by Peer Network and Combined arm participants . Results . During the 16-week intervention , there were no differences in the proportion of days walking goals were met in the Financial Incentive ( 39.7 % ; p = .78 ) , Peer Network ( 24.9 % ; p = .08 ) , and Combined ( 36.0 % ; p = .77 ) arms compared with the Comparison arm ( 36.0 % ) . During 8 weeks of follow-up , the proportion of days walking goals were met was lower in the Peer Network arm ( 18.7 % ; p = .025 ) but not in the Financial Incentive ( 29.3 % ; p = .50 ) or Combined ( 24.8 % ; p = .37 ) arms , relative to the Comparison arm ( 34.5 % ) . Messages posted by participants focused on barriers to walking and provision of social support . Conclusions . Financial incentives and peer networks delivered through eHealth technologies did not result in older adults  walking more
target: Our primary conclusion is that there is a lack of compelling evidence that incentives of any form represent a compelling NCD reduction strategy .
background: The rising epidemic of non-communicable diseases ( NCDs ) poses substantial health and economic challenges to both individuals and society .
  Application of incentive-based strategies based on traditional and behavioural economic theory has emerged as a potential strategy to address rising rates of NCDs .
  Yet , whether or not incentives truly represent a promising strategy for addressing NCDs has not been systematic ally addressed nor is it clear whether certain behavioural economic strategies outperform others or simply offering a cash-based incentive for meeting a goal .
  In this systematic review we aim to determine whether there is an evidence base for any of these strategies .