Patients as Mercenaries?: The Ethics of Using Financial Incentives in the War on Unhealthy Behaviors Reducing risk behaviors linked to noncommunicable diseases in Mongolia: a randomized controlled trial. A systematic review of the use of financial incentives and penalties to encourage uptake of healthy behaviors: protocol An Empirical Evaluation of the Effectiveness of Tangible Incentives in Increasing Participation and Behavior Change in a Worksite Health Promotion Program Improving diet, physical activity and other lifestyle behaviours using computer-tailored advice in general practice: a randomised controlled trial Examining the ``Matthew Effect'' on the motivation and ability to make lifestyle changes in 217 heart rehabilitation patients Design and baseline characteristics of participants in the TRial of Economic Incentives to Promote Physical Activity (TRIPPA): a randomized controlled trial of a six month pedometer program with financial incentives. Financial incentives for smoking cessation in low-income smokers: study protocol for a randomized controlled trial Effects of Large Financial Incentives for Long-Term Smoking Cessation: A Randomized Trial. Randomized controlled trial of a computer-tailored multiple health behaviour intervention in general practice: 12-month follow-up results Effectiveness of Financial Incentives in a Worksite Diabetes Prevention Program Effects of a Web-Based Tailored Multiple-Lifestyle Intervention for Adults: A Two-Year Randomized Controlled Trial Comparing Sequential and Simultaneous Delivery Modes Evaluation of intrinsic and extrinsic motivation interventions with a self-help smoking cessation program. Randomised controlled trial using social support and financial incentives for high risk pregnant smokers: Significant Other Supporter (SOS) program Goal Setting and Health Risk Reduction Randomized trial of four financial-incentive programs for smoking cessation. The impact of financial incentives and a patient registry on preventive care quality: increasing provider adherence to evidence-based smoking cessation practice guidelines.
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 OBJECTIVES We tested the efficacy of a 6-session , evidence -based health promotion intervention aim ed at reducing noncommunicable disease ( NCD ) risk behaviors . METHODS Two hundred male and female factory workers in Ulaanbaatar , Mongolia were r and omly assigned to groups receiving either the health promotion intervention or a time-matched financial literacy control intervention . RESULTS The health promotion intervention increased daily fruit and vegetable intake and physical activity , increased readiness for NCD risk behavior reduction and health promotion knowledge , and reduced the number of daily alcoholic drinks and diabetes symptoms 3 months after the intervention . CONCLUSIONS The findings support the efficacy of the intervention to reduce risk behaviors associated with NCDs . Dissemination of the intervention may improve productivity , reduce costs of health services , and better the quality of life for Mongolians 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 The first is that they have value in enhancing the program ’s salience . For participants they serve as a reminder of their commitment and goals . For non participants they may function as a means of making them more aware of the program and thus enhancing the likelihood that they will participate in future program offerings . A second reason for using tangible incentives is for their direct motivational value . To the extent that they are delivered contingent on level of participation or accomplishment , employees may participate at a higher level and change their behavior more in order to earn these rewards . A number of worksite health promotion programs have employed tangible incentives . 4 - 1 ° In the well-known Live for Life program developed by Johnson and Johnson , for example , employees are offered annual risk factor screening as well as a variety of educational classes on diet , exercise , smoking cessation , and stress management . Participants in these classes receive a variety of tangible items , including T-shirts , pens , and caps . This program is reported to have had positive effects on smoking , l~ exercise ] 2 and absenteeism ? " Background The adoption and maintenance of healthy behaviours is essential in the primary prevention of chronic non-communicable diseases . This study evaluated the effectiveness of a minimal intervention on multiple  lifestyle factors such as  diet , physical activity , smoking and alcohol  , delivered through general practice , using computer-tailored feedback . Methods Adult patients visiting 21 general practitioners in Brisbane , Australia , were surveyed about ten health behaviours that are risk factors for chronic , non-communicable diseases . Those who completed the self-administered baseline question naire entered a r and omised controlled trial , with the intervention group receiving computer-tailored printed advice , targeting those health behaviours for which respondents were not meeting current recommendations . The primary outcome was change in summary lifestyle score ( Prudence Score ) and individual health behaviours at three months . A repeated measures analysis compared change in these outcomes in intervention and control groups after adjusting for age and education . Results 2306 patients were r and omised into the trial . 1711 ( 76 % ) returned the follow-up question naire at 3 months . The Prudence Score ( 10 items ) in the intervention group at baseline was 5.88 , improving to 6.25 at 3 months ( improvement = 0.37 ) , compared with 5.84 to 5.96 ( improvement = 0.12 ) in the control group ( F = 13.3 , p = 0.01 ) . The intervention group showed improvement in meeting recommendations for all individual health behaviours compared with the control group . However , these differences were significant only for fish intake ( OR 1.37 , 95 % CI 1.11 - 1.68 ) , salt intake ( OR 1.19 , 95 % CI 1.05 - 1.38 ) , and type of spread used ( OR 1.28 , 95 % CI 1.06 - 1.51 ) . Conclusion A minimal intervention using computer-tailored feedback to address multiple lifestyle behaviours can facilitate change and improve unhealthy behaviours . Although individual behaviour changes were modest , when implemented on a large scale through general practice , this intervention appears to be an effective and practical tool for population -wide primary prevention . Trial Registration The Australian New Zeal and Clinical Trials Registry : Aims : Those who are socioeconomically disadvantaged and people with emotional problems have a poorer prognosis for cardiovascular disease . The authors wanted to examine : ( 1 ) what effect household income , emotional status , high-risk smoking status , and severity of heart disease had on the ability of individuals to make dietary and exercise improvements after heart disease and ( 2 ) to what extent unfavourable lifestyle outcomes among disadvantaged people were mediated by motivational problems . Methods : A two-year follow-up study of the combined cohorts of a r and omized controlled trial .  Level of exercise and present dietary habits were measured at inclusion and after 6 and 24 months . Different motivational factors and  emotional distress  were measured during rehabilitation . Results : Autonomous self-regulation was lowest among smokers ( b=-0.31 , p=0.02 ) and female participants ( b=0.39 , p=0.004 ) . Participants with high scores of emotional distress predicted lower motivation for all the measures . We found no association between socioeconomic status ( household income ) and the ability to perform lifestyle changes . Current smoking status predicted lower ability to obtain lifestyle changes on all measures . Emotional distress was related to lower ability to increase physical activity at 6 months ' but not at 24 months ' follow-up . The mediating effects of motivational factors were insignificant . Conclusions : The results of this study do not support the suspicion that preventive efforts accentuate the socioeconomic differences in cardiovascular health . Health-promotive efforts after heart disease should safeguard that high-risk groups such as smokers are not discouraged from improving their lifestyle in other areas Non-communicable diseases ( NCDs ) are emerging as the predominant global health challenge of this century . Physical inactivity is one of the primary risk factors for NCDs . Therefore , increasing physical activity levels is a public health imperative . The arrival of affordable wearable technologies , such as wireless pedometers , provides one strategy for encouraging walking . However , the effectiveness of these technologies in promoting sustained behavior change has not been established . Insights from economics suggest that incentives may be a useful strategy for increasing maintenance and effectiveness of behavior change interventions , including physical activity interventions that rely on wearable technologies . The aim of this trial is to test the effectiveness of a common wireless pedometer with or without one of two types of incentives ( cash or donations to charity ) for reaching weekly physical activity goals . We present here the design and baseline characteristics of participants of this four arm r and omized controlled trial . 800 full-time employees ( desk-bound office workers ) belonging to 15 different worksites ( on average , 53 ( sd : 37 ) employees at each worksite ) were successfully r and omized to one of four study arms . If shown to be effective , wearable technologies in concert with financial incentives may provide a scalable and affordable health promotion strategy for governments and employers seeking to increase the physical activity levels of their constituents Abstract Background Tobacco smoking is the leading avoidable cause of death in high-income countries . The smoking-related disease burden is borne primarily by the least educated and least affluent groups . Thus , there is a need for effective smoking cessation interventions that reach to , and are effective in this group . Research suggests that modest financial incentives are not very effective in helping smokers quit . What is not known is whether large financial incentives can enhance longer-term ( 1 year ) smoking cessation rates , outside clinical and workplace setting s . Trial design A r and omized , parallel groups , controlled trial . Methods Participants : Eight hundred low-income smokers in Switzerl and ( the less affluent third of the population , based on fiscal taxation ) . Intervention : A smoking cessation program including : ( a ) financial incentives given during 6 months ; and ( b ) Internet-based counseling . Financial rewards will be offered for biochemically verified smoking abstinence after 1 , 2 , and 3 weeks and 1 , 3 , and 6 months , for a maximum of 1,500 CHF ( 1,250 EUR , 1,500 USD ) for those abstinent at all time-points . All participants , including controls , will receive Internet-based , individually-tailored , smoking cessation counseling and self-help booklets , but there will be no in-person or telephone counseling , and participants will not receive medications . The control group will not receive financial incentives . Objective : To increase smoking cessation rates . Outcome : Smoking abstinence after 6 and 18 months , not contradicted by biochemical tests . We will assess relapse after the end of the intervention , to test whether 6-month effects translate into sustained abstinence 12 months after the incentives are withdrawn . R and omization : Will be done using sealed envelopes drawn by participants . Blinding : Is not possible in this context . Discussion Smoking prevention policies and interventions have been least effective in the least educated , low-income groups . Combining financial incentives and Internet-based counseling is an innovative approach that , if proven acceptable and effective , could be later implemented on a large scale at a reasonable cost , decrease health disparities , and save many lives . Trial registration Current Controlled Trials IS RCT N04019434 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 ) Background Effective strategies to address risk factors of non-communicable diseases are required to curtail the exp and ing costs of health care . This trial tested the effectiveness over one year of a minimal intervention targeting multiple health behaviours ( diet , physical activity , alcohol and smoking ) in a general practice setting , through the provision of personalised , computer-tailored feedback . Methods Patients who had attended a general practice in the previous 6 months were recruited from 21 general practitioners in Brisbane , Australia . Baseline data were collected using self-reports on adherence to ten health behaviours and summarised into a health score from 0 to 10 . This r and omised controlled trial used a 2 × 2 factorial design , with one arm r and omising subjects to the intervention or control group . The other arm was either feedback at baseline ( single contact ) or an additional assessment with feedback at 3 months ( dual contact ) . As such , 4 study groups created were , to which participants were r and omised blindly : A. Intervention with single contact ; B. Intervention with dual contact ; C. Control with single contact and D. Control with dual contact . All participants were assessed again at 12 months . Results Of the 4676 participants r and omised , 3065 completed question naires at 12 months . Both single and dual contact groups improved their 10 item health scores ( + 0.31 and + 0.49 respectively ) relative to control group outcomes ( + 0.02 ; p < 0.01 ) . Improvement in adherence to guidelines for fish intake , type of milk consumed , vegetable and fruit intake , and alcohol intake were observed in single and dual contact intervention groups ( p < 0.01 ) . Both intervention groups showed greater improvement than controls for individual health behaviours , apart from red meat intake , smoking behaviour , physical activity and body weight . Interestingly , there was an improvement in reported non-smoking rates in both intervention and control groups ( 3 % single contact ; 4.5 % dual contact ) . Conclusions Small but meaningful long-term changes in health behaviours can be achieved with a low-intensity intervention , which may reduce health care costs if implemented on a large scale . Further research is needed to better underst and the mechanism by which maintenance of behaviour change can be achieved . Trial Registration The Australian New Zeal and Clinical Trials Registry : ACTRN12611001213932 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 Background Web-based computer-tailored interventions for multiple health behaviors can have a significant public health impact . Yet , few r and omized controlled trials have tested this assumption . Objective The objective of this paper was to test the effects of a sequential and simultaneous Web-based tailored intervention on  multiple lifestyle behaviors . Methods A r and omized controlled trial was conducted with 3 tailoring conditions ( ie , sequential , simultaneous , and control conditions ) in the Netherl and s in 2009 - 2012 . Follow-up measurements took place after 12 and 24 months . The intervention content was based on the I-Change model . In a health risk appraisal , all respondents ( N=5055 )  received feedback on their lifestyle behaviors that indicated whether they complied with the Dutch guidelines for physical activity , vegetable consumption , fruit consumption , alcohol intake , and smoking .  Participants in the sequential ( n=1736 ) and simultaneous ( n=1638 ) conditions received tailored motivational feedback to change unhealthy behaviors one at a time ( sequential ) or all at the same time ( simultaneous ) . Mixed model analyses were performed as primary analyses ; regression analyses were done as sensitivity analyses . An overall risk score was used as outcome measure , then effects on the 5 individual lifestyle behaviors were assessed and a process evaluation was performed regarding exposure to and appreciation of the intervention . Results Both tailoring strategies were associated with small self-reported behavioral changes . The sequential condition had the most significant effects compared to the control condition after 12 months ( T1 , effect size=0.28 ) . After 24 months ( T2 ) , the simultaneous condition was most effective ( effect size=0.18 ) . All 5 individual lifestyle behaviors changed over time , but few effects differed significantly between the conditions . At both follow-ups , the sequential condition had significant changes in smoking abstinence compared to the simultaneous condition ( T1 effect size=0.31 ; T2 effect size=0.41 ) . The sequential condition was more effective in decreasing alcohol consumption than the control condition at 24 months ( effect size=0.27 ) . Change was predicted by the amount of exposure to the intervention ( total visiting time : beta=–.06 ; P=.01 ; total number of visits : beta=–.11 ; P<.001 ) . Both interventions were appreciated well by respondents without significant differences between conditions . Conclusions Although evidence was found for the effectiveness of both programs , no simple conclusive finding could be drawn about which intervention mode was more effective . The best kind of intervention may depend on the behavior that is targeted or on personal preferences and motivation . Further research is needed to identify moderators of intervention effectiveness . The results need to be interpreted in view of the high and selective dropout rates , multiple comparisons , and modest effect sizes . However , a large number of people were reached at low cost and behavioral change was achieved after 2 years . Trial Registration Nederl and s Trial Register : NTR 2168 ; http://www.trialregister.nl/trialreg/admin/ rct view.asp?TC=2168 ( Archived by WebCite at http://www.webcitation.org/6MbUqttYB ) Personalized feedback and a financial incentive , developed from an intrinsic/extrinsic motivation framework , were evaluated as adjuncts to self-help material s for  smoking cessation . Ss ( N = 1,217 ) were r and omized to 4 treatment groups and were followed up at 3 and 12 months . Consistent with hypotheses derived from the motivation framework , the financial incentive increased the use of self-help material s , did not increase cessation rates among program users , and was associated with higher relapse rates among those who did manage to quit . The personalized feedback increased both smoking cessation and use of the material s 3 months after distribution of the material s. Continuous abstinence ( abstinence at 3 and 12 months ) in the group that received the personalized feedback alone was twice the rate of the other groups 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 The effectiveness of client participation in goal selection aim ed at health risk reduction was compared with the effectiveness of provider-selected goals and of no goal setting . No difference in goal attainment was found between the two groups with goals . However , analyses of covariance for selected sub sample s of individuals at risk revealed a significant difference between goal - setting groups for weight reduction , with the collaborative goal - setting group being more effective . Covariance analyses for other sub sample s at risk showed significant differences between the goal - setting groups for current health age and potential for life expectancy increase ; the provider goal - setting group proved to be more effective . Paired t tests within groups revealed that the provider goal - setting group made significant change in alcohol intake , seat belt use , and exercise as well as in global measures of current health age , estimated life expectancy , and potential for life expectancy increase . For the collaborative goal - setting group , significant change was found in weight reduction , exercise levels , and the global measures of estimated life expectancy and potential for life expectancy increase . The control group made a significant change in exercise , but not in any of the global measures of risk reduction 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 . ) BACKGROUND This study tested the effects of two organizational support processes , the provision of financial incentives for superior clinical performance and the availability of a  patient ( smoker ) registry and proactive telephone support system for smoking cessation , on provider adherence to accepted practice guidelines and associated patient outcomes . METHODS Forty clinics of a large multispecialty medical group practice providing primary care services were r and omly allocated to study conditions . Fifteen clinics each were assigned to the experimental conditions " control " ( distribution of printed versions of smoking cessation guidelines ) and " incentive " ( financial incentive pay-out for reaching preset clinical performance targets ) .  Ten clinics were r and omized to receive financial incentives combined with access to a central ized patient registry and intervention system ( " registry " ) . Main outcome measures were adherence to smoking cessation clinical practice guidelines and patients ' smoking cessation behaviors . RESULTS  Patients ' tobacco use status  was statistically significant ( P < 0.01 ) more frequently identified in clinics with the opportunity for incentives and access to a registry than in clinics in the control condition . Patients visiting registry clinics accessed counseling programs statistically significantly more often ( P < 0.001 ) than patients receiving care in the control condition . Other endpoints did not statistically significantly differ between the experimental conditions . CONCLUSIONS The impact of financial incentives and a patient registry/intervention system in improving smoking cessation clinical practice s and patient behaviors was mixed . Additional research is needed to identify conditions under which such organizational support processes result in significant health care quality improvement and warrant the investment
Personal financial incentives can change habitual health-related behaviors and help reduce health inequalities .
However , their role in reducing disease burden is potentially limited given current evidence that effects dissipate beyond three months post-incentive removal
OBJECTIVES Uncertainty remains about whether personal financial incentives could achieve sustained changes in health-related behaviors that would reduce the fast-growing global non-communicable disease burden .
This review aims to estimate whether : i. financial incentives achieve sustained changes in smoking , eating , alcohol consumption and physical activity ; ii .
effectiveness is modified by ( a ) the target behavior , ( b ) incentive value and attainment certainty , ( c ) recipients ' deprivation level .