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. Design and baseline characteristics of participants in the Enhancing Physical Activity and Reducing Obesity through Smartcare and Financial Incentives (EPAROSFI): A pilot randomized controlled trial. Patients as Mercenaries?: The Ethics of Using Financial Incentives in the War on Unhealthy Behaviors A systematic review of the use of financial incentives and penalties to encourage uptake of healthy behaviors: protocol Randomized trial of four financial-incentive programs for smoking cessation. Loss‐Framed Financial Incentives and Personalized Goal‐Setting to Increase Physical Activity Among Ischemic Heart Disease Patients Using Wearable Devices: The ACTIVE REWARD Randomized Trial Enhancing physical activity and reducing obesity through smartcare and financial incentives: A pilot randomized trial. Multiple behavior changes in diet and activity: a randomized controlled trial using mobile technology. Effects of financial incentives for the purchase of healthy groceries on dietary intake and weight outcomes among older adults: A randomized pilot study Financial incentives for smoking cessation in low-income smokers: study protocol for a randomized controlled trial Individual Versus Team-Based Financial Incentives to Increase Physical Activity: A Randomized, Controlled Trial Premium-Based Financial Incentives Did Not Promote Workplace Weight Loss In A 2013-15 Study. Some Recent Developments on Financial Incentives for Smoking Cessation Among Pregnant and Newly Postpartum Women Are financial incentives cost-effective to support smoking cessation during pregnancy? An RCT protocol of varying financial incentive amounts for smoking cessation among pregnant women Coupling Financial Incentives With Direct Mail in Population-Based Practice The impact of financial incentives and a patient registry on preventive care quality: increasing provider adherence to evidence-based smoking cessation practice guidelines. Long-term effects of interventions for weight loss using food provision and monetary incentives. A Randomized Controlled Trial of Financial Incentives for Smoking Cessation Financial incentives for smoking cessation in pregnancy: randomised controlled trial Paying Low-Income Smokers to Quit? The Cost-Effectiveness of Incentivizing Tobacco Quit Line Engagement for Medicaid Recipients Who Smoke. A Pilot Randomized Trial of Financial Incentives or Coaching to Lower Serum Phosphorus in Dialysis Patients. You can't pay me to quit: the failure of financial incentives for smoking cessation in head and neck cancer patients.
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 BACKGROUND An activity tracker combined with a smartphone application ( smartcare ) may help people track and receive feedback on their own activities . However , activity trackers themselves generally fail to drive long-term sustained engagement for a majority of users . One potential strategy for increasing the effectiveness of smartcare is through the use of incentives . The purpose of this pilot r and omized trial is to test the feasibility of our intervention and to assess the extent to which smartcare with or without financial incentives can increase physical activity levels and reduce weight over a 12-week period . METHODS / DESIGN This study employs a three-arm , open-label r and omized controlled trial design : control ( st and ard basic education ) , smartcare , and smartcare plus financial incentives .  Male university students with body mass index ≥ 27 are enrolled . Our primary and secondary endpoints are the amount of weight loss and the level of physical activity respectively . The weight loss goal is 3 % of baseline at week 4 , 5 % at week 8 , and 7 % at week 12 . The daily physical activity goal was individualized according to the participants ' weight . Process incentives are accumulated when participants met daily physical activity goals , and outcome incentives are provided when they met weight reduction goals . DISCUSSION Given the global increase in physical inactivity and obesity , there is a growing need for effective , scalable , and affordable health promotion strategies . Our proof-of-concept study will provide the evidence for the combination of rising health promotion technology of activity trackers and smartphone applications with the modern concept of behavioral economics using financial incentives Consider the following paradox : few people would balk if research ers offered smokers $ 1,000 to participate in a year-long r and omized trial of a smoking cessation intervention , yet many would find it distasteful for a large employer to pay its smoking employees an extra $ 1,000 if they remained smoke-free for one year . Such discrepant judgments are underst and able from the perspective of classical economics . Research participants merit compensation for the risks and opportunity costs they endure in the service of public health , whereas individuals should need no reward for promoting their own well being . However , contrary to traditional theories of rationality , people frequently fail to make health-promoting choices , particularly when such choices require short-term sacrifices to foster long-term goals .1,2 Thus , corporate and government health plan leaders are increasingly applying extrinsic motivations such as financial incentives and other programs to augment health – particularly cardiovascular health – while hopefully increasing productivity and restraining costs.3 , 4 Early evidence suggests that financial incentives can effectively promote the cardioprotective behaviors of smoking cessation,5 , 6 weight loss,7 , 8 and cholesterol reduction.9  Incentives are also currently being studied as a means of promoting warfarin adherence.10 Although the results of these early studies are promising , further research is needed to determine which incentive structures and amounts are optimal , assess the ability of incentives to produce sustained behavior changes , and evaluate the cost-effectiveness of implementing incentive programs  . Ethical dimensions of the incentives themselves are also in need of further analysis . For example , some have charged that financial incentive programs are coercive , inequitable , and inconsistent with shared social values.11 Others have even suggested that implementing incentive programs serves to punish patients for their illnesses.12 In this essay , we outline the rationale for incentive programs to promote cardiovascular health , identify the ethical arguments that have been used to challenge such programs , and assess the merits of these arguments Background The use of financial incentives and penalties to encourage uptake of healthy behaviors is increasingly seen as a viable intervention in developed countries . Previous review s of the effectiveness of financial incentives and penalties for encouraging the uptake of healthy behaviors have focused on individual behaviors making it difficult to draw overall conclusions about the effectiveness of such interventions . This systematic review will explore the effectiveness of financial incentives and penalties for encouraging a wide range of behaviors , including : smoking cessation , increased physical activity , healthier dietary intake , sensible patterns of alcohol consumption , safe sun , safe sex , and primary preventive clinical behaviors . Methods Systematic methods will be used to search existing literature and screen studies for inclusion . All studies that meet the following inclusion criteria will be included in the review : participants were 18 years old or older and living in high-income countries ; interventions included cash or cash-like incentives to promote the uptake of healthy behaviors , or cash or cash-like penalties to discourage unhealthy behaviors ; the comparator was usual care or no intervention ; study design was r and omized controlled trial , cluster r and omized controlled trial , controlled before and after study , or interrupted time series analysis . Two review ers will independently screen the publications to ensure they meet the inclusion criteria . Quality will be assessed by two research ers , working independently , using the Cochrane risk of bias tool . Meta- analysis will be conducted , if appropriate . Any studies identified as at ‘ high risk of bias ’ will be excluded from meta- analysis . Discussion This systematic review will provide policy-relevant recommendations for the use of financial incentives and penalties as a method of encouraging uptake of healthy behaviors BACKGROUND 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 Regular physical activity reduces the risk of cardiovascular events , but most ischemic heart disease ( IHD ) patients do not obtain enough . Methods and Results ACTIVE REWARD ( A Clinical Trial Investigating Effects of a R and omized Evaluation of Wearable Activity Trackers with Financial Rewards ) was a 24‐week home‐based , remotely monitored , r and omized trial with a 16‐week intervention ( 8‐week ramp‐up incentive phase and 8‐week maintenance incentive phase ) and an 8‐week follow‐up . Patients used wearable devices to track step counts and establish a baseline . Patients in control received no other interventions . Patients in the incentive arm received personalized step goals and daily feedback for all 24 weeks . In the ramp‐up incentive phase , daily step goals increased weekly by 15 % from baseline with a maximum of 10 000 steps and then remained fixed . Each week , $ 14 was allocated to a virtual account ; $ 2 could be lost per day for not achieving step goals . The primary outcome was change in mean daily steps from baseline to the maintenance incentive phase . Ischemic heart disease patients had a mean ( SD ) age of 60 ( 11 ) years and 70 % were male . Compared with control , patients in the incentive arm had a significantly greater increase in mean daily steps from baseline during ramp‐up ( 1388 versus 385 ; adjusted difference , 1061 [ 95 % confidence interval , 386–1736 ] ; P<0.01 ) , maintenance ( 1501 versus 264 ; adjusted difference , 1368 [ 95 % confidence interval , 571–2164 ] ; P<0.001 ) , and follow‐up ( 1066 versus 92 ; adjusted difference , 1154 [ 95 % confidence interval , 282–2027 ] ; P<0.01 ) . Conclusions Loss‐framed financial incentives with personalized goal setting significantly increased physical activity among ischemic heart disease patients using wearable devices during the 16‐week intervention , and effects were sustained during the 8‐week follow‐up . Clinical Trial Registration URL : https://www . clinical trials.gov . Unique identifier : NCT02531022 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 BACKGROUND Many patients exhibit multiple chronic disease risk behaviors . Research provides little information about advice that can maximize simultaneous health behavior changes . METHODS To test which combination of diet and activity advice maximizes healthy change , we r and omized 204 adults with elevated saturated fat and low fruit and vegetable intake , high sedentary leisure time , and low physical activity to 1 of 4 treatments :  increase fruit/vegetable intake and physical activity , decrease fat and sedentary leisure , decrease fat and increase physical activity , and increase fruit/vegetable intake and decrease sedentary leisure .  Treatments provided 3 weeks of remote coaching supported by mobile decision support technology and financial incentives . During treatment , incentives were contingent on using the mobile device to self-monitor and attain behavioral targets ; during follow-up , incentives were contingent only on recording . The outcome was st and ardized , composite improvement on the 4 diet and activity behaviors at the end of treatment and at 5-month follow-up . RESULTS Of the 204 individuals r and omized , 200 ( 98.0 % ) completed follow-up . The increase fruits/vegetables and decrease sedentary leisure treatments improved more than the other 3 treatments ( P < .001 ) . Specifically , daily fruit/vegetable intake increased from 1.2 servings to 5.5 servings , sedentary leisure decreased from 219.2 minutes to 89.3 minutes , and saturated fat decreased from 12.0 % to 9.5 % of calories consumed . Differences between treatment groups were maintained through follow-up . Traditional dieting ( decrease fat and increase physical activity ) improved less than the other 3 treatments ( P < .001 ) . CONCLUSIONS Remote coaching supported by mobile technology and financial incentives holds promise to improve diet and activity . Targeting fruits/vegetables and sedentary leisure together maximizes overall adoption and maintenance of multiple healthy behavior changes Providing financial incentives can be a useful behavioral economics strategy for increasing fruit and vegetable intake among consumers . It remains to be determined whether financial incentives can promote intake of other low energy-dense foods and if consumers who are already using promotional tools for their grocery purchases may be especially responsive to receiving incentives . This r and omized controlled trial tested the effects of offering financial incentives for the purchase of healthy groceries on 3-month changes in dietary intake , weight outcomes , and the home food environment among older adults . A secondary aim was to compare frequent coupon users ( FCU ) and non-coupon users ( NCU ) on weight status , home food environment , and grocery shopping behavior .  FCU ( n = 28 ) and NCU ( n = 26 ) were r and omly assigned to either an incentive or a control group . Participants in the incentive group received $ 1 for every healthy food or beverage they purchased . All participants completed 3-day food records and a home food inventory and had their height , weight , and waist circumference measured at baseline and after 3 months . Participants who were responsive to the intervention and received financial incentives significantly increased their daily vegetable intake ( P = 0.04 ) . Participants in both groups showed significant improvements in their home food environment ( P = 0.0003 ) . No significant changes were observed in daily energy intake or weight-related outcomes across groups ( P < 0.12 ) . FCU and NCU did not differ significantly in any anthropometric variables or the level at which their home food environment may be considered ' obesogenic ' ( P > 0.73 ) . Increased consumption of vegetables did not replace intake of more energy-dense foods . Incentivizing consumers to make healthy food choices while simultaneously reducing less healthy food choices may be important 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 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 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 Smoking during pregnancy is a leading preventable cause of poor pregnancy outcomes and immediate and longer-term adverse health outcomes among exposed offspring . Developing more effective smoking cessation interventions for pregnant women has been a public health priority for more than 30 years . We review developments over the past 3 years ( 2012–2015 ) on the use of financial incentives to promote smoking cessation among pregnant women . We search ed the literature for reports on primary and secondary analyses and review s of controlled trials on this topic published in peer- review ed journals using the search engine PubMed , review ed bibliographies of published articles , and consulted expert colleagues . The search revealed several important developments , with the following three being especially noteworthy . First , the review identified four new r and omized controlled trials , three of which further supported the efficacy of this treatment approach . One of the three trials supporting efficacy also included the first econometric analysis of this treatment approach showing financial incentives with pregnant smokers to be highly cost-effective . Second , two Cochrane review s were published during this 3-year period covering the more recent and earlier efficacy trials . Meta-analyses in both review s supported the efficacy of the approach . Lastly , the first effectiveness trial was reported demonstrating that  financial incentives increased abstinence rates above control levels when implemented by obstetrical clinic staff in a large urban hospital working with community tobacco interventionists . Overall , there is a growing and compelling body of evidence supporting the efficacy and cost-effectiveness of  financial incentives for smoking cessation among pregnant women AIMS To investigate the cost-effectiveness of up to £ 400 worth of financial incentives for smoking cessation in pregnancy as an adjunct to routine health care . DESIGN Cost-effectiveness analysis based on a Phase II r and omized controlled trial ( RCT ) and a cost-utility analysis using a life-time Markov model . SETTING The RCT was undertaken in Glasgow , Scotl and . The economic analysis was undertaken from the UK National Health Service ( NHS ) perspective . PARTICIPANTS A total of 612 pregnant women r and omized to receive usual cessation support plus or minus financial incentives of up to £ 400 vouchers ( US $ 609 ) , contingent upon smoking cessation . MEASUREMENTS Comparison of usual support and incentive interventions in terms of cotinine-vali date d quitters , quality -adjusted life years ( QALYs ) and direct costs to the NHS . FINDINGS The incremental cost per quitter at 34 - 38 weeks pregnant was £ 1127 ($1716).This is similar to the st and ard look-up value derived from Stapleton & West 's published ICER tables , £ 1390 per quitter , by looking up the Cessation in Pregnancy Incentives Trial ( CIPT ) incremental cost ( £ 157 ) and incremental 6-month quit outcome ( 0.14 ) . The life-time model result ed in an incremental cost of £ 17 [ 95 % confidence interval ( CI ) = -£93 , £ 107 ] and a gain of 0.04 QALYs ( 95 % CI = -0.058 , 0.145 ) , giving an ICER of £ 482/QALY ( $ 734/QALY ) . Probabilistic sensitivity analysis indicates uncertainty in these results , particularly regarding relapse after birth . The expected value of perfect information was £ 30 million ( at a willingness to pay of £ 30 000/QALY ) , so given current uncertainty , additional research is potentially worthwhile . CONCLUSION Financial incentives for smoking cessation in pregnancy are highly cost-effective , with an incremental cost per quality -adjusted life years of £ 482 , which is well below recommended decision thresholds Background Smoking during pregnancy is harmful to the unborn child . Few smoking cessation interventions have been successfully incorporated into st and ard antenatal care . The main aim of this study is to determine the feasibility of a personal financial incentive scheme for encouraging smoking cessation among pregnant women . Design A pilot r and omised control trial will be conducted to assess the feasibility and potential effectiveness of two varying financial incentives that increase incrementally in magnitude ( $ 20 vs. $ 40AUD ) , compared to no incentive in reducing smoking in pregnant women attending an Australian public hospital antenatal clinic . Method Ninety ( 90 ) pregnant women who self-report smoking in the last 7 days and whose smoking status is biochemically verified , will be block r and omised into one of three groups : a. No incentive control group ( n=30 ) , b. $ 20 incremental incentive group ( n=30 ) , and c. $ 40 incremental incentive group ( n=30 ) . Smoking status will be assessed via a self-report computer based survey in nine study sessions with saliva cotinine analysis used as biochemical validation . Women in the two incentive groups will be eligible to receive a cash reward at each of eight measurement points during pregnancy if 7-day smoking cessation is achieved . Cash rewards will increase incrementally for each period of smoking abstinence . Discussion Identifying strategies that are effective in reducing the number of women smoking during pregnancy and are easily adopted into st and ard antenatal practice is of utmost importance . A personal financial incentive scheme is a potential antenatal smoking cessation strategy that warrants further investigation . Trial registration Australian New Zeal and Clinical Trials Registry ( ANZCTR ) number : Financial incentives are being used increasingly to encourage a wide array of health behaviors because of their well-established efficacy . However , little is known about how to translate incentive-based strategies to public health practice geared toward improving population -level health , and a dearth of research exists on how individuals respond to incentives through public health communication strategies such as direct mail . This study reports results of a population -based r and omized controlled trial testing a direct mail , incentive-based intervention for promoting mammography uptake . The study population was composed of a r and om sample of Minnesota women enrolled in Medicare fee-for-service and overdue for breast cancer screening . Participants ( N = 18,939 ) were r and omized into three groups : ( 1 ) Direct Mail only , ( 2 ) Direct Mail plus Incentive , and ( 3 ) Control . Both direct mail groups received two mailers with a message about the importance of mammography ; however , Mail plus Incentive mailers also offered a $ 25 incentive for getting a mammogram . Logistic regression analyses measured intervention effects . Results showed the odds for receiving mammography were significantly higher for the Direct Mail plus Incentive group compared with both Direct Mail only and Control groups . The use of incentives also proved to be cost-effective . Additionally , the Direct Mail only group was more likely to receive mammography than the Control group . Findings offer experimental evidence on how the population -based strategy of direct mail coupled with a financial incentive can encourage healthy behavior , as well as how incentive-based programs can be translated into health promotion practice aim ed at achieving population -level impact 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 One hundred seventy-seven men and women who had participated in an 18-month trial of behavioral interventions involving food provision and financial incentives  were examined 12 months later . Food provision , but not financial incentives , led to better weight loss than st and ard behavioral treatment during the 18-month trial , but over 12 additional months of no-treatment follow-up , all treated groups gained weight , maintained only slightly better weight losses than a no-treatment control group , and did not differ from each other . Weight loss success during both active treatment and maintenance was associated with increase in exercise , decrease in percentage of energy from fat , increase in nutrition knowledge , and decrease in perceived barriers to adherence . Obesity treatment research should focus on developing better ways to maintain changes in the diet and exercise behaviors needed for sustained weight loss Background : Although 435,000 Americans die each year of tobacco-related illness , only ∼3 % of smokers quit each year . Financial incentives have been shown to be effective in modifying behavior within highly structured setting s , such as drug treatment programs , but this has not been shown in treating chronic disease in less structured setting s. The objective of this study was to determine whether modest financial incentives increase the rate of smoking cessation program enrollment , completion , and quit rates in a outpatient clinical setting . Methods : 179 smokers at the Philadelphia Veterans Affairs Medical Center who reported smoking at least 10 cigarettes per day were r and omized into incentive and nonincentive groups . Both groups were offered a free five-class smoking cessation program at the Philadelphia Veterans Affairs Medical Center . The incentive group was also offered $ 20 for each class attended and $ 100 if they quit smoking 30 days post program completion . Self-reported smoking cessation was confirmed with urine cotinine tests . Results : The incentive group had higher rates of program enrollment ( 43.3 % versus 20.2 % ; P < 0.001 ) and completion ( 25.8 % versus 12.2 % ; P = 0.02 ) . Quit rates at 75 days were 16.3 % in the incentive group versus 4.6 % in the control group ( P = 0.01 ) . At 6 months , quit rates in the incentive group were not significantly higher ( 6.5 % ) than in the control group ( 4.6 % ; P > 0.20 ) . Conclusion : Modest financial incentives are associated with significantly higher rates of smoking cessation program enrollment and completion and short-term quit rates . Future studies should consider including an incentive for longer-term cessation . ( Cancer Epidemiol Biomarkers Prev 2006;15(1):12–8 Objective To assess the efficacy of a financial incentive added to routine specialist pregnancy stop smoking services versus routine care to help pregnant smokers quit . Design Phase II therapeutic exploratory single centre , individually r and omised controlled parallel group superiority trial . Setting One large health board area with a material ly deprived , inner city population in the west of Scotl and , United Kingdom . Participants 612 self reported pregnant smokers in NHS Greater Glasgow and Clyde who were English speaking , at least 16 years of age , less than 24 weeks pregnant , and had an exhaled carbon monoxide breath test result of 7 ppm or more . 306 women were r and omised to incentives and 306 to control . Interventions The control group received routine care , which was the offer of a face to face appointment to discuss smoking and cessation and , for those who attended and set a quit date , the offer of free nicotine replacement therapy for 10 weeks provided by pharmacy services , and four , weekly support phone calls . The intervention group received routine care plus the offer of up to £ 400 of shopping vouchers : £ 50 for attending a face to face appointment and setting a quit date ; then another £ 50 if at four weeks ’ post-quit date exhaled carbon monoxide confirmed quitting ; a further £ 100 was provided for continued vali date d abstinence of exhaled carbon monoxide after 12 weeks ; a final £ 200 voucher was provided for vali date d abstinence of exhaled carbon monoxide at 34 - 38 weeks ’ gestation . Main outcome measure The primary outcome was cotinine verified cessation at 34 - 38 weeks ’ gestation through saliva ( < 14.2 ng/mL ) or urine ( < 44.7 ng/mL ) . Secondary outcomes included birth weight , engagement , and self reported quit at four weeks . Results Recruitment was extended from 12 to 15 months to achieve the target sample size . Follow-up continued until September 2013 . Of the 306 women r and omised , three controls opted out soon after enrolment ; these women did not want their data to be used , leaving 306 intervention and 303 control group participants in the intention to treat analysis . No harms of  financial  incentives were documented . Significantly more smokers in the incentives group than control group stopped smoking : 69 ( 22.5 % ) versus 26 ( 8.6 % ) . The relative risk of not smoking at the end of pregnancy was 2.63 ( 95 % confidence interval 1.73 to 4.01 ) P<0.001 . The absolute risk difference was 14.0 % ( 95 % confidence interval 8.2 % to 19.7 % ) . The number needed to treat ( where financial incentives need to be offered to achieve one extra quitter in late pregnancy ) was 7.2 ( 95 % confidence interval 5.1 to 12.2 ) . The mean birth weight was 3140 g ( SD 600 g ) in the incentives group and 3120 ( SD 590 ) g in the control group ( P=0.67 ) . Conclusion This phase II r and omised controlled trial provides substantial evidence for the efficacy of incentives for smoking cessation in pregnancy ; as this was only a single centre trial , incentives should now be tested in different types of pregnancy cessation services and in different parts of the United Kingdom . Trial registration Current Controlled Trials IS RCT N87508788 OBJECTIVES To determine the cost-effectiveness of an incentive-based stop-smoking intervention that paid Medicaid recipients who smoke to take calls from a tobacco quit line . METHODS A cost-effectiveness analysis was conducted alongside a r and omized controlled trial . The analysis was conducted from a health care systems perspective on the basis of costs and effectiveness over a 6-month follow-up . Participants ( n = 1900 ) were recruited from May 2013 to June 2015 through quit line ( n = 980 ) , clinic-based ( n = 444 ) , or community-based ( n = 476 ) referrals .  Incentive group participants ( n = 948 ) received $ 30 a call for taking up to five tobacco quit line calls and $ 40 for biochemically verified tobacco abstinence at 6 months . Control group participants ( n = 952 ) did not receive financial incentives for taking quit line calls . Intervention re source costs included incentive payments to participants , counselor and administrative staff time , and smoking cessation medications . Smoking status at baseline and 6 months was determined for all study participants via carbon monoxide ( CO ) breath tests ( abstinence : CO < 7 ppm ) . Cost-effectiveness analysis calculated the incremental cost-effectiveness ratio ( ICER ) . RESULTS Incentive treatment produced higher 6-month CO-confirmed 7-day point-prevalence abstinence than did the control treatment ( 21.6 vs. 13.8 % ; P < 0.001 ) . The ICER of the financial incentives intervention was $ 2316 ( 95 % confidence interval $ 1582-$4270 ) per additional person who quit . The study ICER compares favorably with other smoking treatments , such as varenicline combined with proactive telephone counseling , whose ICER has been estimated at $ 2600 per additional smoker who quits . CONCLUSIONS Use of financial incentives to engage with tobacco quit line treatment is a cost-effective option to enhance smoking cessation rates for low-income smokers OBJECTIVE Among chronic hemodialysis patients , hyperphosphatemia is common and associated with mortality . Behavioral economics and complementary behavior-change theories may offer valuable approaches to achieving phosphorus ( PO4 ) control . The aim was to determine feasibility of implementing financial incentives and structured coaching to improve PO4 in the hemodialysis setting . DESIGN AND METHODS This pilot r and omized controlled trial was conducted in 3 urban dialysis units for 10 weeks among 36 adults with elevated serum PO4 ( median > 5.5 mg/dL over 3 months ) . INTERVENTIONS Twelve participants each were r and omized to : ( 1 ) financial incentives for lowering PO4 , ( 2 ) coaching about dietary and medication adherence , or ( 3 ) usual care . PO4 was measured during routine clinic operations . Each incentives arm participant received the equivalent of $ 1.50/day if the PO4 was ≤5.5 mg/dL or > 5.5 mg/dL but decreased ≥0.5 mg/dL since the prior measurement . The coach was instructed to contact coaching arm participants at least 3 times per week . MAIN OUTCOME MEASURES The outcome measures included : ( 1 ) enrollment rate , ( 2 ) dropout rate , and ( 3 ) change in PO4 from beginning to end of 10-week intervention period . RESULTS Of 66 eligible patients , 36 ( 55 % ) enrolled . Median age was 53 years , 83 % were black race , and 78 % were male . Median baseline PO4 was 6.0 ( interquartile range 5.6 , 7.5 ) . Using stratified generalized estimation equation analyses , the monthly decline in PO4 was -0.32 mg/dL ( 95 % CI -0.60 , -0.04 ) in the incentives arm , -0.40 mg/dL ( -0.60 , -0.20 ) in the coaching arm , and -0.24 mg/dL ( -0.60 , 0.08 ) in the usual care arm . No patients dropped out . All intervention arm participants expressed interest in receiving similar support in the future . CONCLUSIONS This pilot trial demonstrated good feasibility in enrollment and implementation of novel behavioral health strategies to reduce PO4 in dialysis patients OBJECTIVE A prospect i ve r and omised study was conducted at a tertiary care hospital to evaluate the effects of financial incentives for smoking cessation targeted at a high-risk population . METHODS Patients with a past history of head and neck cancer were voluntarily enrolled over a two-year period . They were r and omised to a cash incentives or no incentive group . Subjects were offered enrolment in smoking cessation courses .  Smoking by-product levels were assessed at 30 days , 3 months and 6 months . Subjects in the incentive group received $ 150 if smoking cessation was confirmed . RESULTS Over 2 years , 114 patients with an established diagnosis of head and neck cancer were offered enrolment . Twenty-four enrolled and 14 attended the smoking cessation classes . Only two successfully quit smoking at six months . Both these patients were in the financially incentivised group and received $ 150 at each test visit . CONCLUSION Providing a financial incentive for smoking cessation to a population already carrying a diagnosis of head and neck cancer in order to promote a positive behaviour change was unsuccessful
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 .