When he was growing up, Gerry Weitz's dad smoked three packs of cigarettes a day. After a health scare at age 40, his father quit, but years of toxic smoke had taken a toll on his body. A few years later, while hiking in Israel, the elder Weitz died from a heart attack.
That was over 20 years ago, but Gerry Weitz still mourns his father. "This was a preventable death," he said.
After his father died, Weitz decided to do everything in his power to help others quit smoking. But he didn't know what he could do exactly. Weitz isn't a doctor or a health coach. He owns Hearts Pest Management, a pest control company in Southern California.
As he thought about the problem, he realized that one group of people he might have some influence over were his employees. “My people are blue-collar workers. A lot of them don’t have healthy habits, and a lot of them struggle with money.
"I started thinking, maybe I could pay them to quit [smoking]," said Weitz. So he did. Weitz pays any employee who goes smoke-free for six months $500. To ensure would-be quitters get the support they need, he also pays for them to participate in smoking-cessation support groups.
Since starting the program, Weitz has paid two of his 16 employees for successfully quitting. Several others are working towards being six months smoke free. "That money is a big motivator for a lot of them," he said.
While smoking has declined for the last 50 years, there are still 40 million Americans who smoke, according to data from the United States Centers for Disease Control and Prevention (CDC). The CDC estimates that the country spends nearly $170 billion on health care for smokers and gives up about $150 billion in lost productivity due to premature deaths related to secondhand smoke. Given the staggering human and financial cost associated with smoking, “we have to figure out the most effective and efficient ways to deliver smoking cessation treatment," said Dr. Norman Edelman, senior scientific adviser for the American Lung Association.
Studies suggest that paying people to quit smoking not only promotes healthy behavior, but also saves a lot of money. However, some people believe there may be unseen risks in making a marketplace out of personal decisions.
Paid to quit
Dr. Scott Halpern's 2015 study on smoking has two central questions. First, are people more likely to quit smoking if they are paid? Second, assuming people are more likely to quit if they receive a reward, what is the best reward structure?
To test these questions, Halpern divided study participants, all smokers and all employees of the national drugstore chain CVS, into one of several groups. In the first group, participants received $800 if they quit smoking. In the second, participants had to deposit $150 of their own money. If they were able to quit smoking, they'd get their deposit plus $650 back. If weren't sucessful quitting, they'd lose their deposit.
Third was a control group. The control group was not offered any financial reward for quitting smoking, but they were given smoking cessation aids, like nicotine gum. Once participants were presented with the rules and conditions of the group they had been assigned to, they were free to accept them and take part, or reject them and not participate in the study.
When Halpern tabulated the results, published in the May 2015 edition of New England Journal of Medicine, he found that offering a reward increased the likelihood of a participant quitting smoking by about 130 percent. While only 6 percent of participants who received counseling and free nicotine gum were able to quit smoking, about 14 percent of participants in the rewards groups were able to quit smoking for at least six months.
Skin in the game
Halpern also found major differences in the success rates between the two rewards groups. People who put down a $150 deposit were twice as likely to quit smoking as people who did not have to make a deposit. Halpern thinks asking people to put down some of their own money works better because it leverages our natural aversion to losing money as well as the desire to collect money.
The problem, from Halpern’s perspective, is that few people want to put their own money down. When presented with the incentive group they had been assigned to, 90 percent of people in the rewards program accepted the challenge. By contrast, only 14 percent of participants in the deposit-reward program decided to participate.
"The study is interesting because it demonstrates the importance of loss aversion in two different ways," wrote Cass Sunstein, professor at Harvard Law School and a former member of the Obama administration, in a commentary published in the New England Journal of Medicine. "The more obvious is that smokers are far more likely to quit if they stand to lose money if they fail. The more subtle is that the very prospect of incurring losses makes people far less willing to enter a smoking-cessation program. Despite the greater comparative effectiveness of the deposit program, the reward program is likely to be more successful, because far more people will sign up for it."
Employers spend between $4,000 and $6,000 more to employ smokers than nonsmokers, according to Halpern (on health care and on lost productivity). “An incentive program that pays $800 to those who succeed in quitting is obviously a win-win situation," he said. "It's cost-saving for the employer and it's health-promoting for the employee.”
Halpern notes that many employers also have programs designed to encourage healthy lifestyles, including eating well, exercising and quitting smoking. “Large companies spend $800-900 a year per employee on wellness programs,” said Halpern, “but that money is spent in ways that are blind to human psychology. Employers can do more to curb smoking and other wellness behaviors by recognizing that how you spend money is as important and how much you spend.”
A moral hazard
While financial incentives motivate people to act, that may not always be a good thing, according to some economists. "Monetary rewards can sometimes backfire if the activity in question is or should be valued intrinsically for its own sake," said Jonathan Wight, professor of economics at the University of Richmond. So for example, "paying a child for good grades may lead that child to focus on a short-term motivation but corrupt a long-term love of learning," he said.
It's not clear that intrinsic values are corrupted by monetary rewards in the case of paying people to quit smoking. "There might be a moral hazard created if people take up risky behaviors on the belief that society will then pay them to stop those activities," said Wight. Or perhaps people will be more successful quitting smoking if they are "motivated to improve [their] health solely to honor and respect the body that God created," he said.
Ultimately, Wight isn't concerned. "I do not think [there is a] plausible moral hazard worth worrying about in this context," he said. In fact, he's in favor of paying people to quit smoking, at least the way Halpern set the conditions up.