Many of the major public health issues currently threatening our population, including smoking and obesity, require lifestyle and behavioral changes. Effecting these changes in patients has been challenging, but a deeper understanding of the forces that drive human behavior could inspire the design of better programs leading to behavioral change. For example, behavioral scientists have found that individuals seek more to minimize losses than to maximize gains, a phenomenon called “loss aversion.” Many of us have experienced the feeling of loss aversion personally; for some reason losing a $20 bill often feels more annoying than the satisfaction we get from finding a $20 bill. Further, individuals can be motivated by social dynamics and, in some cases, may be more likely to perform a certain task if they feel part of a group that is performing that task.
With these principles in mind, Halpern and colleagues designed a randomized clinical trial to assess the efficacy of different financial incentive programs for smoking cessation. Just over 2,500 active smokers were randomized to one of three interventions: a rewards program, a deposit program, or a usual care program (involving information and smoking cessation aids). In the rewards programs, participants could receive a total of $800 if they quit smoking, while in the deposit program an up-front deposit of $150 would be returned to the participants upon quitting smoking after 6 months, along with a total $650 reward. In addition, the authors tested the efficacy of the rewards and deposit programs in both an individual and group context.
Both the reward and deposit programs were significantly more effective than usual care (sustained abstinence rates for each program at 6 months were 6% for usual care, 15-16% for the rewards program, and 9-11% for the deposit program). Further, the deposit program had much lower enrollment rates than the reward program (13.7% vs. 90%) but much higher rates of smoking cessation amongst those who chose to do the programs (52.3% for the deposit program vs. 17.1% for the rewards program). Despite this difference, including all patients randomized to either program, the rewards program was more effective than the deposit program, given the low enrollment rate in the deposit program. Interestingly, the authors found no difference between the individual or group based programs with either incentive.
These results have exciting implications for how to help smokers quit. First, as behavioral scientists would have predicted, the risk of losing money is better for inspiring cessation behavior than the potential to make money. However, as Cass R. Sunstein, a lawyer at Harvard University and a leader in the field of behavioral economics points out in an accompanying editorial, the challenge with deposit programs will be finding a way to encourage smokers to enroll. More work is needed to decipher if a smaller deposit will stimulate larger enrollments in deposit programs.
View the NEJM Quick Take video summary of the results of the study, and join a discussion with authors and experts on the NEJM Group Open Forum.