Qaseem: Incentives could prevent health care policy contention


Yaqoob Qaseem, Columnist

Last Wednesday, The New York Times published an article discussing a research trial recently described in the New England Journal of Medicine contrasting two different smoking cessation programs. Both programs provided an $800 incentive to participants who were able to successfully quit smoking in six months. However, one program required an initial $150 deposit that was returned upon successful completion of the program. Although the success rate of the penalty program was about three times greater than that of the pure rewards program, the higher enrollment in the pure rewards program made it more effective overall. Moreover, both programs were shown to be significantly more effective than traditional treatment methods.

Although the web headline of the Times article — “Study Asks if Carrot or Stick Can Better Help Smokers Quit” — may initially seem to effectively capture the essence of the study, the exact phrasing of the headline misrepresents the true nature of the smoking cessation programs examined. The Times quoted Dr. Scott Halpern of the University of Pennsylvania School of Medicine, the primary author of the study: “Adding a bit of stick was much better than pure carrot.” The study did not consider the difference between a “stick” and a “carrot.” Rather, the study compared a small penalty coupled with a financial incentive to a financial incentive alone.

The print headline of the article, “Stick Beats Carrot in Anti-Smoking Efforts, Study Says,” is potentially even more misleading. Although skewing the distinction between the programs as in the web title, this headline also belies the greater overall effect in the pure rewards group. Cass Sunstein, a Harvard law professor, wrote an editorial for NEJM explaining the greater likelihood of smokers to quit when confronted with a penalty is more obvious while the aversion of participants to penalty programs is more subtle. Thus, Sunstein concludes the greater enrollment of the pure rewards program is likely to make it more successful unless people can be “nudged” into penalty programs. The pure carrot actually defeats the stick with carrot when the larger picture is considered.

My aim is not to critique the Times but rather to bring the more elusive aspects of the study into the spotlight. Both groups of participants received financial rewards for quitting smoking. Although loss aversion in the penalty program elevated the rate of success, the pure rewards program showed greater overall promise due to an increased desire for participation. These subtleties suggest a new direction for public policy, an evolution from a focus on punishment to a focus on reward.

Traditional healthcare policies, particularly those related to smoking, bring only penalties to mind. Taxes are placed on cigarettes and fines are charged for smoking in inappropriate locations. Although implemented with good intentions, these policies often generate grievances among the general population, largely due to their removal of autonomy from the decision-making process. For instance, in the case of taxes, governments effectively force citizens to pay more for cigarettes. Some view this act as an attempt to force individuals into adopting healthy behavior.

Last week, I wrote a column about “junk food” taxes. Although such policies have their place due to their potential to save a significant number of lives, they require delicate and sensitive implementation. Moreover, policies based on penalties inevitably invite controversy due to the reasons noted above.

In contrast, the implementation of either of the types of rewards programs discussed in the NEJM study would have little cause for criticism. Both programs preserve autonomy by allowing program invitees to choose whether they would like to enroll. Even in the penalty program, the participant enrolls with conscious acknowledgement of the potential to lose money.

Moreover, the current strategy for implementation is highly valuable in effectively benefitting all parties involved. CVS Health, which conducted the study with the University of Pennsylvania School of Medicine, will launch a smoking cessation program for its colleagues next month. The program, named 700 Good Reasons, offers a $700 reward and requires a $50 deposit. According to the Times, large employers bear a great portion of rising healthcare costs and thus offer incentives for healthy behaviors. By providing valuable data about the efficacy of such incentive programs, the NEJM study opens the door for a new range of benefits for employees.

Smoking causes 480,000 deaths per year in the United States, making it the leading cause of preventable death. The innovative findings presented in NEJM, however, carry implications for all domains of health. The expansion of research-proven incentive programs represents an innovative new direction for healthcare policy, one with the potential to save lives with little dispute.

Yaqoob Qaseem is a Weinberg freshman. He can be reached at [email protected]. If you would like to respond publicly to this column, send a Letter to the Editor to [email protected].