August 19, 2011
By Harvey B. Simon, M.D.
Harvard Medical School
In an ideal world, virtue would be its own reward. In our world, though, virtue often benefits from a little help. For example:
- Many of us learned to make our own beds for a small allowance.
- As teens, we picked up a few bucks mowing the lawn or shoveling snow for an elderly neighbor.
- When we finally joined the work force, we hoped to earn a raise (if not a super-sized bonus) for a job well done.
The same goes for health. As a reward, good health often falls short in its ability to motivate prudent health behavior.
Smoking and obesity are two of the most pressing and hard to change lifestyle problems in America. Smoking rates have come down, but quit rates are slowing. Despite lots of attention to the problem, obesity rates continue to grow.
Can financial incentives help when common sense and medical advice have failed? Two interesting studies suggest the answer is a qualified "yes."
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Smoking is the leading preventable cause of death in the United States. Each year about 440,000 people die of causes related to smoking. Quitting remains difficult even with the help of counseling, nicotine replacement therapy and prescription drugs.
To find out if financial incentives could boost quit rates, researchers studied 878 employees of a large company based in the United States. All were current smokers who wanted to quit. Half of the volunteers were randomly assigned to receive information about smoking cessation programs. The other half received the same information plus a series of financial incentives. They would get $100 for completing a smoking cessation program, $250 for kicking the habit within 6 months, and another $400 for staying off cigarettes for another 6 months.
The two groups were similar in age, years of education, income, general health, number of cigarettes smoked per day and number of previous attempts to quit. Two-thirds of each group was male. To verify that people weren't smoking, their urine was tested for cotinine, a chemical produced when the body metabolizes nicotine.
The results show that paying can pay off. Members of the incentive group were more likely to enroll in a smoking cessation program than members of the information-only group. They were also more likely to quit within 6 months and to stay quit at 9 to 12 months and 15 to 18 months.
The financial incentive program cost the company $700 for each successful participant. That's a bargain considering that quitting saves the boss $3,400 a year due to workers who are more productive, miss fewer days of work and have fewer illnesses. But even though money talks, it does not talk loud enough to solve the smoking problem. Nicotine addiction proved stronger than money: 90% of the volunteers started smoking again.
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Between 1960 and 2008, the rate of obesity in the United States skyrocketed from about 13% to 33%. In all, over two-thirds of Americans are overweight or obese. The consequences include an increased risk of diabetes, hypertension, heart disease, erectile dysfunction, arthritis, depression and premature death.
If present trends continue, obesity and lack of exercise will overtake smoking as the number one preventable cause of death.
A popular reality TV show uses rewards to induce weight loss. But will money motivate weight loss in the real world?
To answer this question, researchers studied 57 volunteers between the ages of 30 and 70. All were obese. They had body mass indexes between 30 and 40. But they were otherwise healthy. Ninety-five percent were male.
Each person had a one-hour private session with a nutritionist at the start of the study; each person got an accurate scale. The subjects were then randomly assigned to one of three groups. People in the first group were offered no financial incentive. (This was the comparison group.) People in the second group agreed to a contract where they could get up to $252 a month depending on how much weight they lost. And people in the third group were eligible to win up to $100 a day through a lottery if they lost weight, although most prizes were lower.
By the end of the 16-week trial, the members of the contract and lottery groups had lost significantly more weight (14.0 and 13.1 pounds, respectively) than members in the comparison group (3.9 pounds). The volunteers were on their own after the study ended, but the scientists still followed their progress. Without the financial incentives, members of the contract and lottery groups gained weight. But after 7 months, they had still lost slightly more weight (9.2 and 6.2 pounds, respectively) than the members of the comparison group (4.0 pounds).
Bottom line? Money talks, but people listen only while they're being paid.
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Money Has Limits
Smoking cessation and weight loss are two of the most important lifestyle changes people can make. They are also among the most difficult.
These two studies show that financial incentives can help some people reach their goals. But money alone can't solve difficult health problems any more than money can solve the world's other woes.
The Roman orator Cicero said, "Nothing is so strongly fortified that it cannot be taken by money." Mark Twain wrote, "Virtue has never been as respectable as money." But money can only go so far towards achieving good health habits. Perhaps, though, American novelist James Allen got it right when he said, "If your real desire is to be good, there is no reason to wait for the money; you can do it now, this very moment, just where you are."
For virtue, for money or for health itself, lifestyle changes are worth the effort. Listen up, guys!
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Harvey B. Simon, M.D., is an Associate Professor of Medicine at Harvard Medical School and a member of the Health Sciences Technology Faculty at Massachusetts Institute of Technology. He is the founding editor of the Harvard Men's Health Watch newsletter and author of six consumer health books, including The Harvard Medical School Guide to Men's Health (Simon and Schuster, 2002) and The No Sweat Exercise Plan, Lose Weight, Get Healthy and Live Longer (McGraw-Hill, 2006). Dr. Simon practices at the Massachusetts General Hospital; he received the London Prize for Excellence in Teaching from Harvard and MIT.