Special Report - In austere times, can bribery be healthy?

DUNDEE, Scotland (Reuters) - Moira Christie has to ring the doorbell when she goes to visit friends these days. That’s a new thing for her. Until a few months ago, everyone knew she was coming because they could hear her hacking smoker’s cough from far down the street.

Audrey Mackenzie (L), an NHS Tayside 'Quit 4 U' smoking cessation incentive scheme co-ordinator, holds a carbon monoxide breath tester in front of participant Moira Christie during a weekly class at the Royal Victoria Hospital in Dundee, Scotland June 24, 2010. REUTERS/David Moir

“My cough was my calling card,” the tiny 54-year-old Scot says with a laugh. “But not any more. I’m not coughing now. My friends and relatives can’t believe it. They say ‘You’ve never given up! You? Never!’ -- but I have, I’ve done it, and I feel so much healthier already.”

Christie is not only quieter and healthier, she’s a little richer too. That’s because the local health authority paid her to quit. The scheme is one of a clutch of experiments cropping up across Europe, the United States and parts of Latin America which use financial incentives -- cash payments, gift cards, shopping vouchers and the like -- to encourage or cajole people to drop their bad habits and live more healthily. “The underlying rationale of incentives is that healthier people are less costly to the system than sick ones,” says Harald Schmidt at the Harvard School of Public Health.

The experiments have grown out of studies in the relatively new discipline of behavioural economics, which examines how emotional factors affect economic choices. Some public health experts are yet to be convinced that bribing people can work. But as healthcare costs keep rising in such heavyweight nations as the United States and heavy-smoking locations as Dundee, and as governments move to cut huge budget deficits, hundreds of local authorities, employers and health insurers -- even the occasional former investment banker -- are dabbling with health incentive schemes.


The idea is simple: pay people to act now and governments will reap the rewards later in lower healthcare costs. Statistically speaking, people who shun harmful habits are more productive and have less need for expensive hospitals, doctors and medicines. By changing “habitual health-related behaviours,” says Theresa Marteau, director of the Centre for the Study of Incentives in Health and a psychology professor at King’s College London, those behind the schemes aim to make more people healthier for longer. Specifically, “they’re trying to tackle the big four that are responsible for most of the world’s premature deaths and illnesses -- excessive eating, smoking, drinking and lack of exercise,” says Marteau.

Many in Dundee are at risk from all four. Moira Christie had smoked for around 35 years by the time she joined her incentive programme, which is called Quit 4 U. The scheme is backed by the National Health Service and was born out of a similar project, Give It Up For Baby, which aims to reduce shockingly high rates of smoking among mums-to-be in Dundee. In some of the poorest areas of the city up to 40 percent of pregnant women and half of all adults smoke, while rates of obesity and alcohol-related illness are among the highest in Europe.

“What we have here is a cocktail of influences on our most deprived communities who have the worst health -- a cocktail which ensures that trying to change their behaviour through simplistic messages is just not going to work,” says Andrew Radley, a public health expert who along with colleague Paul Ballard has championed Quit 4 U and is now overseeing its expansion into other areas. “You therefore have to work with them to come up with motivators that are actually part of their way of thinking.”

Participants get 12.50 pounds on a grocery store card every week they stay off tobacco, building to a potential total of 150 pounds after three months. For mums-to-be who stay off cigarettes, the payments continue until the baby is three months old. Anyone who gets that far would take home 650 pounds. Participants in both schemes commit to regular carbon monoxide breath tests to prove they’re not cheating.

The lure of extra cash has so far proved enough to get even some of the most die-hard tobacco addicts to quit. Margaret Robertson, a former 40-a-day smoker who attends the weekly breath test and support group sessions alongside Christie, is proud of the little nest egg she’s nurturing. “I’m letting it build up until Christmas. That’s when it’ll really help,” says Robertson, 61, who started smoking when she was 11 years old and has just completed her sixth smoke-free week in 50 years.


When Dundee’s first pilot project started in 2007, critics condemned the idea of incentives as little more than state bribery. So far, though, the results have been impressive: 12-week quit rates are more than double those achieved in any previous years.

By the end of the first year, 55 mothers in the city of Dundee, which has a population of 140,000, had quit smoking using the incentive scheme, and 140 had quit across the coastal Tayside region of eastern Scotland. The year before, just six pregnant women had made contact with Tayside’s stop smoking services -- and none of them stayed in touch beyond four weeks.

Even these pilots can be cost-effective, argue Ballard and Radley. They put the overall cost per quitter at 1,700 pounds, which might sound a lot until you consider that smoking costs Britain’s taxpayer-funded health system some 5 billion pounds a year according to a 2009 study by Oxford University researchers. Globally, the World Lung Foundation estimates the annual cost of smoking is $500 billion (325.8 billion pound) in medical expenses, lost productivity and environmental harm.

“The whole methodology of this incentive scheme is defined by community-based research. It is driven by what is of most value to the target audience,” says Ballard. If you get it right, it can be “an approach that can really deliver results.”

There is no doubt Scotland can do with the help. It is known, after all, as the land whose citizens don’t just eat Mars Bars and pizza in perilously large amounts, but deep-fry them first. A study published last month found that almost the entire adult population of Scotland -- 97.5 percent -- have habits that are deemed “dangerous to health” including smoking, heavy drinking, taking no exercise, being overweight and eating a poor diet.

Ballard calls Dundee an “incredibly unhealthy” city in a “mega unhealthy” nation. In truth, the rest of the developed world is not much better. Obesity, smoking, alcohol and lack of exercise are causing more protracted and expensive diseases, and killing more residents of the rich world earlier, than anything else. The World Health Organisation (WHO) predicts that by 2015, around 2.3 billion adults worldwide will be overweight and more than 700 million will be obese.

In Europe, the WHO reckons obesity alone is already responsible for up to 8 percent of all health costs and between 10 and 13 percent of deaths. Experts predict that in Britain almost nine out of 10 adults and two thirds of children will be overweight or obese by 2050. By then the medical bill and loss of productivity could top 50 billion pounds a year.

Little wonder that drug companies are spending billions of dollars searching for treatments and cures for cancers, diabetes and heart disease. But why develop drugs when the best thing we could do to improve our health is quit smoking, stop eating so much fat, salt and sugar, exercise more and cut back on alcohol? And if getting more people to do that is difficult, which of course it is, then why not pay them?

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Former investment banker Winton Rossiter is convinced paying people to get healthier is the next big thing. Rossiter, a 55-year-old American-born businessman who’s lived in England for 20 years, has become one of the pioneers of British incentive schemes. Three years ago he founded a company called WeightWins which now promotes a scheme called “pounds for pounds”.

“We earn incentives from shopping in certain places, flying certain airlines -- so why not get financially rewarded for doing something that’s positive?” he says. “We’re in an incentives culture where people need a reason to even think about getting healthy.”

Rossiter’s firm has been running a pilot scheme in Kent, southern England, where the taxpayer-funded local health authority asked him to help cut a 24 percent adult obesity rate. The programme works by adding up how much weight each participant has lost and how long it remains off. A sliding scale of payments is applied; those who lose the most and keep it off earn the most money.

Rossiter says his programme is already working. By last month, of the 402 people who started a “pounds for pounds” plan in the Kent scheme, 321, or 80 percent, had lost weight, while just 20 percent either stayed the same or gained weight. Less encouragingly, more than three-quarters of participants had dropped out by 12 months, meaning their progress, or lack of it, could not be counted in the final results.

Rossiter makes his money through a joining fee, which starts at 45 pounds sterling and goes up to 135 pounds, plus a monthly subscription fee of between 10 and 30 pounds. Participants can earn rewards of up to 3,000 pounds. To get that, they’d have to lose 150 pounds of weight over 21 months and keep it all off for at least three months.

“You get paid to lose weight -- two things people definitely want to do,” he says.

In the Kent scheme, taxpayers footed the subscription bills via the local health authority. But Rossiter says the cost to local governments could be returned many times over. He’s broken down British government data that estimated the annual cost of obesity at between 3.3 billion pounds sterling and 3.7 billion pounds. For every pound of obesity weight that is removed permanently, he says, the government saves 170 pounds in medical expenses and 1,200 pounds in lifetime economic costs. Kent paid Weight Wins around 12 pounds for every pound of fat lost.


Public health scientists are less enthusiastic. “I think they can be useful in some instances, but it depends very much on how they’re implemented,” says Harvard’s Schmidt. Both King’s College’s Marteau and Tammy Boyce, an expert at the King’s Fund healthcare think-tank in London, say the Kent pilot was “not a proper trial” because it lacked the proper scientific procedures needed to evaluate the outcomes.

Marteau’s sense is that the best evidence to support the use of incentives schemes can be found not in large, cross-societal groups, but in specific niches of unhealthy behaviour where all the usual health messages have failed. Here, it seems, an immediate and relatively large reward may be enough to change a pattern. “The two places where incentives really have been found to be effective are in drug addict abstinence programmes, and in smoking cessation in pregnancy,” she says. “And when you think about it, these are outliers” -- extreme, addictive behaviours generally shown by people on the margins.

Former banker Rossiter is undeterred. Frustrated by what he sees as dithering among public health officials, he is planning to take “pounds for pounds” direct to the public via the internet, where anyone can pay a joining fee and sign up to win cash rewards for slimming down.

“If obesity really is the public health crisis and the ticking timebomb that we keep hearing about, then we need to throw out some of our scepticism and prejudices and really push this thing forward,” he says.

So sure is Rossiter that his scheme will work, he’s ready to guarantee “long-term results” for any government in Europe prepared to back the scheme. “If Scotland wanted to put a million overweight people into my programme, I would guarantee long-term behaviour change and weight loss or they would get their money back. But I’m still waiting for the call.”

Perhaps he should meet Gianluca Buonanno, the flamboyant mayor of the small north-western Italian town of Varallo, and another big enthusiast of using health incentive schemes to make whole nations healthier.

A few years ago, Buonanno set up a plan which promised to pay oversized residents 50 euros for losing 3 to 4 kilograms in a month, a further 200 euros if they kept the weight off for 5 months, and yet more if they managed to keep their weight down for a year. The scheme, he says, was a great success, particularly for one 42-year-old woman who said she had become so fat that her husband “would not even look at her any more”.

“Sixty percent of participants reached their objectives,” Buonanno told Reuters. He’s now lobbying in Italy’s parliament for the plan to be scaled up across the nation. The results, “can’t be measured only in prizes. If a person feels better, consumes less medicine, then the nation’s entire health system gains.”


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The notion of health incentives has been popularised in the past few years by books like ‘Nudge’ and ‘Freakonomics’, which describe how such concepts as “behavioural economics” and “choice architecture” can be used to engineer people towards healthier habits. It’s no coincidence that as the Obama administration started to show an interest in behavioural economics, one of the authors of Nudge, Cass Sunstein, joined the White House staff.

“Incentives are definitely becoming a very trendy method,” says public health specialist Boyce, who has watched with dismay as governments have become excited by the idea of old-fashioned bribery. The idea, she says, allows politicians to cosy up to the powerful food and drinks industry lobby and duck out of writing tough legislation for better health. It satisfies many governments’ desires to be libertarian and business-friendly and avoid slapping taxes on high-fat or high-sugar junk foods.

Britain’s health minister, Andrew Lansley, said last week that the country’s new coalition government does not believe in “lecturing or nannying” people to change their behaviour, preferring a “non-regulatory approach”. It has not indicated whether incentives may be a part of that.

Mike Kelly, director of public health at Britain’s National Institute for Health and Clinical Excellence, which advises government on cost-effective health policies, says incentive schemes are popping up all over the place. So far, though, there isn’t much in the way of hard scientific evidence about incentivising people for health. “If these things are going to go forward it ought to be on a proper evidence-based set of principles. And we desperately need to know whether it is a cost-effective option.”

The London-based Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) published a review last year that found there were studies underway on around 130 incentives schemes globally. More than half were in the United States, with Britain, Germany and Mexico among active countries. It found around half the schemes were aimed at getting people to stop smoking, with healthy eating next and obesity targeted by a minority.


In the United States, where healthcare is largely handled through private insurance companies, major employers such as Safeway and General Electric are also getting into incentives in a big way. In recent years they have begun paying bonuses or offering health insurance discounts to employees who give up bad habits or keep their weight and cholesterol levels in check. That, in turn, has spawned a clutch of new companies such as VirginHealthMiles and RedBrick Health, who sell “pay for prevention schemes” to big corporations.

In Germany, Barmer Ersatzkasse, a large sickness fund which insures around 6.8 million people, offers incentives to members who take part in any or all of 17 named healthy activities -- from turning up for immunisations to giving up smoking or going regularly to the gym. Members get a bonus card on which points are credited; anyone earning 500 or more points over two years can redeem them against such “healthy” prizes as cycle helmets or sports watches. Families can pool their points and trade them in for a bigger reward such as a Nintendo Wiifit console (1500 points) or even swap them for hard cash rewards of up to 30 euros a year per person.

The fund also offers schemes giving discounts on premiums to people who don’t use health services that much -- a bit like a “no claims” bonus on a house or car insurance policy.


The German plan highlights one of the potential disadvantages in such schemes: they may prove self-selecting. Harvard’s Schmidt, who has studied health incentives in the United States and Germany, says incentives may not only improve insurance plan members’ health -- so their costs go down -- but may also attract more healthy people in the first place. That risks leaving those in the poorest health, who are often also society’s poorest financially, facing higher costs for the healthcare they urgently need.

That’s just one of a broader set of problems that Schmidt sees as inherent in the incentives idea. Why should fat people get paid to do what thin people are doing already? Why should smokers who quit now get a bonus when those who quit last year didn’t? If regular gym-goers were already quite happy to pay for it, why should taxpayers’ money be used to subsidise others just in the hope a few more may be nudged in the same direction? Won’t some people become adept at gaming the system?

Schmidt breaks those affected by incentive schemes into groups:

* the “lucky ones” -- those who already go to the gym regularly and will now get extra cash or prizes for doing so;

* the “yes I can” group, who find the incentive gives them exactly the nudge they needed;

* the “I’ll do it tomorrow” group who never quite get around to it and feel punished by not being able to get the reward;

* the “unlucky ones” who have no hope of getting to a gym because of their work or family life or disability;

* and the “leave me alone” group which is self-explanatory.

For all but one or two of these groups, incentives would likely fail, Schmidt says, so using taxpayers’ money to fund them doesn’t look like much of a deal. “I don’t have a problem with incentives if they work. But...” His voice trails off and he gives a shrug of the shoulders.


What evidence there is from scientific assessments is not that encouraging either. Marteau cites a so-called Cochrane review -- a systematic analysis of previous peer-reviewed studies -- conducted in 2008 on using incentives to help people stop smoking. It found that none of the 17 trials it analysed had higher quit rates at six months when incentives were used.

On obesity, the findings are similar. A 2008 systematic review looking at eight weight-loss trials which were followed up for at least a year found that incentives had no positive effect on weight loss or weight maintenance at 12 or 18 months.

The King’s Fund’s Boyce worries that governments are starting up incentives plans before any proper scientific analysis has been done. “You wouldn’t do this with a drug,” she says, pointing out that many years, even decades, of trials and tests are conducted on medicines before they are distributed to the general public. “But for some reason we allow ourselves to get caught up in the moment and attach ourselves to ideas like this that don’t really have a big evidence base.”


But such scepticism doesn’t cut it with Rebecca Garside, who is 28 and just a few weeks off giving birth to her first baby. As part of Dundee’s scheme to stop pregnant mums smoking, she’s at her local pharmacy blowing into a carbon monoxide monitor to prove that despite 11 years as a smoker, she has finally given up.

As the blinking green light officially confirms her as a non-smoker, she strokes her swollen belly. Health statistics suggest her baby will now be a healthier weight and less likely to need intensive care after birth, and that both Garside and her child will be less likely to develop a range of costly chronic diseases like asthma, heart disease and cancer.

But Garside is thinking of the more immediate future. She is saving the “quit” credits on her supermarket gift card, she says, for “all those things I know I’ll have to buy when the baby comes along.”

“Buggies, nappies, and even my weekly food shopping. It’ll definitely be a help.”

Additional reporting by Philip Pullella in Rome, editing by Simon Robinson and Sara Ledwith