Methods to maximize retention in weight loss studies. A work-site weight control program using financial incentives collected through payroll deduction. Nationwide access to an internet‐based contingency management intervention to promote smoking cessation: a randomized controlled trial Effectiveness of Financial Incentives in a Worksite Diabetes Prevention Program Correspondence programs for smoking cessation and weight control: a comparison of two strategies in the Minnesota Heart Health Program. Promoting weight control at the worksite: a pilot program of self-motivation using payroll-based incentives. Behavioral treatment of obesity with monetary contracting: two-year follow-up. Financial Incentives for Extended Weight Loss: A Randomized, Controlled Trial Who responds to financial incentives for weight loss? Evidence from a randomized controlled trial. Does It Pay to Pay?: A Randomized Trial of Prepaid Financial Incentives and Lottery Incentives in Surveys of Nonphysician Healthcare Professionals The effects of a deposit contract as a component in a behavioural programme for stopping smoking. Predictive Validity of a Cigarette Purchase Task in a Randomized Controlled Trial of Contingent Vouchers for Smoking in Individuals With Substance Use Disorders. 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. Toward the development of self-help health behaviour change programs: weight loss by correspondence. Financial incentive-based approaches for weight loss: a randomized trial. Treating overweight children through parental training and contingency contracting. Remote Alcohol Monitoring to Facilitate Incentive‐Based Treatment for Alcohol Use Disorder: A Randomized Trial Incentive-based Intervention to Maintain Breastfeeding Among Low-income Puerto Rican Mothers Monetary incentives promote smoking abstinence in adults with attention deficit hyperactivity disorder (ADHD). Patients as Mercenaries?: The Ethics of Using Financial Incentives in the War on Unhealthy Behaviors A Randomized Controlled Trial of Employer Matching of Employees’ Monetary Contributions to Deposit Contracts to Promote Weight Loss Use of contingency management incentives to improve completion of hepatitis B vaccination in people undergoing treatment for heroin dependence: a cluster randomised trial A comparison of the effects of external control and self-control on the modification and maintenance of weight.
OBJECTIVE Dropouts from clinical trials  decrease quality and increase costs .  Free participation , paid participation , and contingency contracting are three study retention methods . Contingency contracting , or depositing a fee to be refunded contingent upon attendance in a clinical trial , has been reported to decrease dropouts without affecting weight loss . These three methods of retention were compared with a commercial weight loss clinic 's practice of charging nonrefundable fees . METHODS AND PROCEDURES  Dropouts  were compared in two studies testing mazindol , with one study using free care  and the other using contingency contracting ; two studies testing phenylpropanolamine , one using free care  and the other using  contingency contracting ;  and in studies with phenylpropanolamine on file with Thompson Medical Company using free care , paid participation , and contingency contracting . RESULTS The dropout rate was 50 % at 8 weeks in a trial of mazindol with free care vs. 7 % for contingency contracting ( p<0.001 ) . The two phenylpropanolamine studies gave the same weight losses , but the dropouts were 37 % at 8 weeks for free care vs. 11 % for contingency contracting ( p<0.001 ) . The studies of phenylpropanolamine on file at the Thompson Medical Company had 28 % dropouts at 8 weeks using free care vs. 19 % for paid participation ( p<0.001 ) , and 11 % for contingency contracting ( p<0.005 ) . Dropouts with contingency contracting ( 11 % ) were not different from the commercial weight loss program ( 13 % ) . DISCUSSION Contingency contracting can decrease dropouts , improve quality , and decrease costs without affecting weight loss in clinical trials for obesity In a work-site weight control program using a self-motivational program of financial incentives implemented through payroll deduction , 131 university employees chose weight loss goals ( 0 to 60 lb ) and incentives ( + 5 to + 30 ) to be deducted from each paycheck for six months . Return of incentive money was contingent on progress toward weight goals . Participants were assigned r and omly to one of four protocol s , involving group educational sessions v self-instruction only and required v optional attendance at weigh-ins and sessions . Overall , dropout rates ( 21.4 % ) and mean weight loss ( 12.2 lb ) were encouraging , especially compared with those of other work-site programs . Weight loss was positively associated with attendance at weigh-ins and educational sessions . However , requiring attendance did not increase program effectiveness and seemed also to discourage enrollment among men . The weight control program was equally effective when offered with professionally led educational sessions or when accompanied by self-instructional material s only Background and aims Contingency management ( CM ) is one of the most effective behavioral interventions to promote drug abstinence , but availability of this treatment is limited . We evaluated the efficacy and acceptability of internet‐based CM relative to an internet‐based monitoring and goal ‐ setting control group in a nationwide sample of cigarette smokers . Design R and omized controlled trial with 3‐ and 6‐month follow‐ups . Setting United States . Participants Smokers ( n = 94 ) from 26 states were enrolled ( mean age 36 , 56 % female ) . Intervention and comparator Participants were r and omized to earn financial incentives ( up to $ 480 over 7 weeks ) based on video‐verified abstinence using breath carbon monoxide ( CO ) output ( n = 48 ; abstinent contingent group , AC ) , or based on su bmi tting CO sample s ( n = 46 , su bmi ssion contingent , SC ) . Both groups also received the same CO‐based goals . A $ 50 deposit was required in both groups that could be recouped from initial earnings . Measures The primary outcome was point prevalence at week 4 . Secondary outcomes were point prevalence at the 3‐ and 6‐month follow‐ups , percentages of negative CO sample s , adherence to the CO sampling protocol , and treatment acceptability ratings on a 0–100‐mm visual analog scale . Findings Abstinence rates differed at 4 weeks between the AC ( 39.6 % ) and SC ( 13.0 % ) groups [ odds ratio ( OR ) = 4.4 , 95 % confidence interval ( CI ) = 1.6–12.3 ] , but not at the 3‐ ( 29.2 % AC and 19.6 % SC , OR = 1.7 , 95 % CI = 0.6–4.4 ) or 6‐ ( 22.9 % AC and 13.0 % SC , OR = 2.0 , 95 % CI = 0.7–5.9 ) month follow‐ups . During the two main treatment phases , there were significant differences in negative COs ( 53.9 % AC and 24.8 % SC , OR = 3.5 , 95 % CI = 3.1–4.0 ; 43.4 % AC and 24.6 % SC , OR = 2.3 , 95 % CI = 1.6–3.4 ) . Adherence to the CO su bmi ssion protocol was equivalent ( 78 % AC and 85 % SC , difference = 7.0 % , 95 % CI = −10.3 to 23.8 % , F < 1 , P = 0.39 ) . The lowest acceptability ratings were for the items assessing the deposit , whereas the highest ratings concerned the ease of the intervention , the graph of CO results , and earning money . Conclusions A contingency management/financial incentive program delivered via the internet improved short‐term abstinence rates compared with an internet program without the incentives 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 Mailed invitations to participate in weight loss and /or smoking cessation correspondence programs to 31,400 households in a suburban community . Two programs were offered to r and omized subsets of households , a 6-month correspondence program costing + 5 and the same program for free but requiring a + 60 deposit to be refunded based on success in weight loss or smoking cessation . Overall , sign-up included 1,304 people for weight loss and 142 for smoking cessation . The + 5 program was about 5 times as popular as the incentive program .  Vali date d weight change after 6 months averaged about 4 lb for the + 5 program and 8 lb for the incentive program . Corresponding rates of smoking cessation were about 9 % and 20 % , respectively . We conclude that correspondence programs for the promotion of weight control and smoking cessation are potentially cost-effective methods for reaching individuals in the community at large , many of whom would not be interested in clinic-based programs . Issues meriting further research include recruitment , especially of smokers , and evaluation of the relative trade-offs in recruitment success versus efficacy of differing treatment approaches Thirty-six individuals participated in a worksite weight-loss program  in which the central component was a self-motivation program of biweekly payroll deductions refunded contingent on meeting self-selected weight-loss goals . Half were assigned to early treatment and the remainder to a delayed treatment control group .  Nine additional individuals also enrolled at the time of  delayed treatment  and were included in descriptive analyses of factors associated with weight loss . Results showed low program attrition over 6 months ( 6 % ) and mean weight losses ( 12.3 lb ) that are competitive with those obtained in clinical setting s. Although not different at baseline , participants in the delayed treatment group lost more than twice as much weight as those in the early treatment condition . This difference was interpreted as either a strong seasonal effect or a critical mass effect related to the proportion of employees at the worksite participating in the program . We conclude that self-motivation programs for health behavior change using the payroll system as an organization framework offer a promising new methodology for promoting healthful behaviors in work setting Reported is a 2-year follow-up of a behavioral weight reduction program  for men using monetary contracts of varying size and group versus individual contingencies . Although initial weight losses were large , in the absence of an effective maintenance program weight losses at two years were modest , similar to those obtained with less effective initial weight loss procedures . Group contracts were significantly more effective in producing long term loss than individual contracts . Reported behaviors associated with weight loss at 2 years are presented 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 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 Background Monetary incentives in survey research may provide important gains from a method ological perspective in the control and reduction of survey error associated with potential nonresponse of participants . However , few studies have systematic ally investigated the use of monetary incentives or other methods to improve the response rates in the nonphysician clinician population . Objective To investigate differences in response rates to a mailed self-administered survey of nonphysician clinicians who were r and omized to receive a prepaid monetary incentive , a postsurvey prize drawing , or no incentive . Methods A r and omized controlled trial of financial incentives was conducted from November 2002 to February 2003 . Nonphysician clinicians ( nurse practitioners [ NPs ] and physician assistants [ PAs ] ; N = 3,900 ) r and omly selected to participate in a national ethics-related study were assigned r and omly in equal allocations ( n = 1,300 [ 650 NPs , 650 PAs ] ) to three incentive groups : ( a ) no incentive ; ( b ) a $ 5 prepaid token incentive in the initial mailing ; or ( c ) a chance to win one of ten $ 100 prize drawings upon completion and return of a self-administered survey . Results A $ 5 cash incentive increased survey response rates to an adjusted 64.2 % : a 19.5 percentage point increase over the lottery group ( 44.7 % response rate ) , and a 22 percentage point increase over the control group ( 42.2 % response rate ) . Discussion A nominal cash incentive of $ 5 yields a significantly higher response rate from nonphysician providers than receiving either a lottery option or no incentive Abstract A contract procedure is described in which a money deposit provided by cigarette smokers at the time of stopping smoking is returned at set intervals contingent on their having not smoked . Outcome results up to 6 months after the stop smoking date are presented for 33 smokers who used this procedure as a component in a behavioural programme , and for 27 smokers who received the same treatment package but without the deposit component .  The results for both groups are encouraging , and in the short term the deposit group did significantly better than the no-deposit group . Reasons for the failure of this difference to be maintained are discussed , and it is suggested that long term results would be improved by holding deposits over a longer interval . Other evidence is presented to show that the deposit procedure had a specific effect on smoking rather than a more general effect on attendance rates .  Deposit contracts also appear acceptable to smokers . Urinary nicotine analysis appeared effective in deterring as well as detecting faking INTRODUCTION A cigarette purchase task ( CPT ) is a behavioral economic measure of the reinforcing value of smoking in monetary terms ( ie , cigarette dem and ) . This study investigated whether cigarette dem and predicted response to contingent monetary rewards for abstinence among individuals with substance use disorders . It also sought to replicate evidence for greater price sensitivity at whole-dollar pack price transitions ( ie , left-digit effects ) . METHODS Participants ( N = 338 ) were individuals in residential substance use disorder treatment who participated in a r and omized controlled trial that compared contingent vouchers to noncontingent vouchers for smoking abstinence . Baseline dem and indices were used to predict number of abstinent days during the 14-day voucher period ( after the reduction lead-in ) and at 1 and 3 months afterward . RESULTS Dem and indices correlated with measures of smoking and nicotine dependence . As measured by elasticity , intensity and O max , higher dem and significantly predicted fewer abstinent exhaled carbon monoxide readings during voucher period for individuals in the noncontingent vouchers condition . Breakpoint exhibited a trend-level association with abstinent exhaled carbon monoxide readings . Dem and indices did not predict abstinence in the contingent vouchers group , and did not predict abstinence at 1- and 3-month follow-ups . Left-digit price transitions were associated with significantly greater reductions in consumption . CONCLUSIONS The association of cigarette dem and with smoking behavior only in the group for whom abstinence was not incentivized indicates that CPT assesses the value of smoking more than the value of money per se and that vouchers counteract the effects of the intrinsic reinforcing value of cigarettes . Results provide initial short-term evidence of predictive validity for the CPT indices . IMPLICATION S This study provides the first evidence of the validity of the CPT for predicting early response to brief advice for smoking cessation plus nicotine replacement in smokers with substance dependence . However , dem and for cigarettes did not predict voucher-based treatment response , indicating that incentives serve as a powerful motivator not to smoke that acts in opposition to the intrinsic reinforcing value of cigarettes and that the indices reflect the value of smoking more than the value of money per se 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 The goal of this study was to evaluate a correspondence weight control program , and to assess the impact of three program elements ( weekly homework , interim weigh-ins , and participation deposits ) individually and in combination . All treated participants received 15 weekly st and ard lessons by mail . Three program features were varied factorially : a ) homework assignments , b ) interim weigh-ins and c ) a deposit refunded contingent on returning homework and /or attending interim weigh-ins . Participants were assigned r and omly to active treatment conditions or a delayed treatment control group .  Among treated males ( N = 14 ) , initial average weight loss and BMI reduction were 9.6 kg and 3.1 respectively ; average net weight loss and BMI reduction at one year follow-up were 5.8 kg and 1.9 respectively . Among treated females ( N = 128 ) , initial average weight loss and BMI reduction were 3.1 kg and 1.2 respectively ; average net weight loss and BMI reduction at one year were 2.3 kg and .88 respectively . Women in all treated groups , except lessons only , showed a greater BMI reduction than untreated controls at the end of treatment . Women in conditions including both homework and interim weigh-ins had greater initial BMI reductions ( M = 1.6 ) than those who received lessons only ( M = .76 ) . At one year , net BMI reductions were comparable across all treated groups . Of the 42 women initially registered in conditions that included both homework and weigh-ins , 12 who denied joining other programs lost at least 4.5 kg ( M = 7.1 ) during treatment , and 7 had a net loss of at least 4.5 kg ( M = 8.0 ) at one year without apparent involvement in any other program 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 Fifteen overweight girls aged 5 to 11 yr were r and omly assigned to one of two weight-reduction treatments : response-cost plus reinforcement , response-cost only , or a no-treatment control group . In the response-cost plus reinforcement group , parents contracted to facilitate their child 's weight loss by carrying out reinforcement and stimulus control techniques , completing weekly charts and graphs , and encouraging their child to exercise . The response-cost only group parents did not contract to reinforce their child 's performance . The response-cost program applied to both experimental groups was conducted in weekly meetings in which parents lost previously deposited sums of money . Twenty-five per cent was deducted for missing the weekly meeting , 25 % for failing to fill out charts and graphs , and 50 % if their child failed to meet her specified weekly weight-loss goal . At the end of the 12-week treatment period , both experimental groups had lost significantly more weight than the control group . After an eight-week , no-contact follow-up , some of the lost weight was regained . The response-cost plus reinforcement group was still significantly below the controls . The response-cost group just missed significance . A 31-week , no-contact follow-up failed to show a treatment effect , but did show a trend towards slower weight gain by the response-cost plus reinforcement group Background The delivery of monetary incentives contingent on verified abstinence is an effective treatment for alcohol use disorder . However , technological barriers to accurate , frequent biochemical verification of alcohol abstinence have limited the dissemination of this technique . Methods In the present r and omized parallel trial , we employed a breathalyzer that allows remote , user‐verified collection of a breath alcohol sample , text messaging , and reloadable debit cards for remote delivery of incentives to evaluate a contingency management treatment for alcohol use disorder that can be delivered with no in‐person contact . Treatment‐seeking participants with alcohol use disorder ( n = 40 ) were recruited from the community and r and omized to either a contingent or a noncontingent group ( n = 20 each ) . The contingent group received nearly immediate monetary incentives each day they remotely provided negative breathalyzer sample s. The noncontingent group received matched monetary payments each day they successfully provided sample s independent of alcohol content . Groups were not masked as awareness of group contingencies was an essential intervention component . Results The primary outcome of the intent‐to‐treat analyses ( analyzed n = 40 ) was percent days abstinent as measured by the remote breathalyzer sample s. Abstinence rates in the contingent group were 85 % , which was significantly higher than the 38 % recorded in the noncontingent group , corresponding to an odds ratio of 9.4 ( 95 % CI = 4.0 to 22.2 ) . Breathalyzer collection adherence rates were over 95 % , and participant ratings of acceptability were also high . Conclusions These results support the efficacy , acceptability , and feasibility of this remotely deliverable abstinence reinforcement incentive intervention for the initiation and near‐term maintenance of abstinence from alcohol in adults with alcohol use disorder . Due to low provider and participant burden , this procedure has the potential for broad dissemination The study provides a proof-of-concept that monthly financial incentives contingent on observed breastfeeding increased breastfeeding rates through 6-month postpartum among low-income Puerto Rican mothers . BACKGROUND AND OBJECTIVE : Despite maternal and child health benefits , breastfeeding rates are relatively low among low-income Puerto Rican mothers . This study examined the hypothesis that monthly financial incentives would significantly increase the proportion of breastfeeding mothers at 6 months postpartum compared with Supplemental Nutrition Program for Women , Infants , and Children ( WIC ) services only among Puerto Rican mothers . METHODS : A r and omized , 2-arm parallel-group design , from February 2015 through February 2016 . Half of the r and omized participants received monthly financial incentives contingent on observed breastfeeding for 6 months ( Incentive ) , and the other half received usual WIC services only ( Control ) . Thirty-six self-identified Puerto Rican women who initiated breastfeeding were enrolled .  Monthly cash incentives were contingent on observed breastfeeding increasing the amount given at each month from $ 20 to $ 70 for a total possible of $ 270 . RESULTS : The intent-to-treat analysis showed significantly higher percentages of breastfeeding mothers in the incentive group at each time point compared with those in the control group ( 89 % vs 44 % , P = .01 at 1 month ; 89 % vs 17 % , P < .001 at 3 months ; 72 % vs 0 % , P < .001 at 6 months ) . No significant differences were detected at any time point between study groups for self-reported exclusive breastfeeding rate and infant outcomes ( ie , weight , emergency department visits ) . CONCLUSIONS : Contingent cash incentives significantly increased breastfeeding through 6-month postpartum among WIC-enrolled Puerto Rican mothers ; however , no significant differences between the study groups were observed on exclusive breastfeeding rate and infant outcomes . Larger-scale studies are warranted to examine efficacy , implementation potential , and cost-effectiveness Individuals with attention deficit hyperactivity disorder ( ADHD ) smoke at rates significantly higher than the general population and have more difficulty quitting than nondiagnosed individuals . Currently , there are no evidence -based approaches for reducing smoking specifically in individuals with ADHD . Adult regular smokers with or without ADHD participated in a study of extended smoking withdrawal where monetary incentives were used to promote abstinence . Participants were paid according to an escalating schedule for maintaining abstinence measured as self-report of no smoking and an expired air carbon monoxide ( CO ) level of < or=4 parts per million . Sixty-four percent ( 14/22 ) of smokers with ADHD and 50 % ( 11/22 ) of smokers without ADHD maintained complete abstinence for the 2-week duration of the study . Twenty-two percent ( 5/22 ) and 9 % ( 2/22 ) of smokers with ADHD and without ADHD , respectively , maintained continued abstinence for up to 10 days following the removal of the contingencies . Though abstinence rates were higher for the smokers with ADHD , the group differences were not statistically significant . Results suggest that monetary incentives may be a useful approach for promoting abstinence in adult smokers with ADHD , perhaps owing to altered reinforcement processes in these individuals 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 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 BACKGROUND Poor adherence to treatment diminishes its individual and public health benefit . Financial incentives , provided on the condition of treatment attendance , could address this problem . Injecting drug users are a high-risk group for hepatitis B virus ( HBV ) infection and transmission , but adherence to vaccination programmes is poor . We aim ed to assess whether contingency management delivered in routine clinical practice increased the completion of HBV vaccination in individuals receiving opioid substitution therapy . METHODS In our cluster r and omised controlled trial , we enrolled participants at 12 National Health Service drug treatment services in the UK that provided opioid substitution therapy and nurse-led HBV vaccination with a super-accelerated schedule ( vaccination days 0 , 7 , and 21 ) . Clusters were r and omly allocated 1:1:1 to provide vaccination without incentive ( treatment as usual ) , with fixed value contingency management ( three £ 10 vouchers ) , or escalating value contingency management ( £ 5 , £ 10 , and £ 15 vouchers ) . Both contingency management schedules rewarded on-time attendance at appointments . The primary outcome was completion of clinical ly appropriate HBV vaccination within 28 days . We also did sensitivity analyses that examined vaccination completion with full adherence to appointment times and within a 3 month window . The trial is registered with Current Controlled Trials , number IS RCT N72794493 . FINDINGS Between March 16 , 2011 , and April 26 , 2012 , we enrolled 210 eligible participants . Compared with six ( 9 % ) of 67 participants treated as usual , 35 ( 45 % ) of 78 participants in the fixed value contingency management group met the primary outcome measure ( odds ratio 12·1 , 95 % CI 3·7 - 39·9 ; p<0·0001 ) , as did 32 ( 49 % ) of 65 participants in the escalating value contingency management group ( 14·0 , 4·2 - 46·2 ; p<0·0001 ) . These differences remained significant with sensitivity analyses . INTERPRETATION Modest financial incentives delivered in routine clinical practice significantly improve adherence to , and completion of , HBV vaccination programmes in patients receiving opioid substitution therapy . Achievement of this improvement in routine clinical practice should now prompt actual implementation . Drug treatment providers should employ contingency management to promote adherence to vaccination programmes . The effectiveness of routine use of contingency management to achieve long-term behaviour change remains unknown . FUNDING National Institute for Health Research ( RP-PG-0707 - 10149 ) In an experimental study of weight reduction , 62 obese men and women were administered a pretreatment question naire and r and omly assigned to three experimental treatment groups : ( a ) an external control group with a nonrefundable contingency ; ( 6 ) a self-control group with a refundable contingency ; and ( c ) a self-control group with a nonrefundable contingency . The results indicated that the self-control and external-control treatments were equally effective in producing reduction in weight . However , both self-control interventions were more effective than the external-control intervention in promoting maintenance of weight loss
Group refunds , deposit not paid as lump sum , participants setting their own deposit size and additional behaviour change techniques were associated with greater weight loss during treatment .
Post-treatment , there was no significant effect of MCCs on weight loss .
There was a significant small-to-medium effect of MCCs on participant retention during treatment .
Research er-set deposits paid as one lump sum , refunds delivered on an all-or-nothing basis and refunds contingent on attendance at classes were associated with greater retention during treatment .
Post-treatment , there was no significant effect of MCCs on participant retention .
The results support the use of MCCs to promote weight loss and participant retention up to the point that the incentive is removed and identifies the conditions under which MCCs work best
Financial incentives to improve health have received increasing attention , but are subject to ethical concerns .
Monetary Contingency Contracts ( MCCs ) , which require individuals to deposit money that is refunded contingent on reaching a goal , are a potential alternative strategy .
This review evaluates systematic ally the evidence for weight loss – related MCCs .