A Spicy Debate – “Resolved: Employers, the Government, and Third Party Payors Should Incentivize Smokers to Quit”

AMERSA 35th Annual National Conference

Nov 3rd 2011

Kevin Volpp MD, PhD Affirmative

Geoffrey C. Williams MD, PhD Negative Center for Community Health

Healthy Living Research Center

University of Rochester

1

I AM LYING TO YOU NOW!

I WILL EXPLAIN SHORTLY

I WILL STOP LYING WHEN I FINISH THIS SLIDE

How did you feel when I tried to buy your vote?

Did any of you feel reactive?

That is what Kevin Volpp’s program wants to do with smokers- simply pay people to not smoke because we know better then them.

If you had a negative reaction to my buying your vote think twice about the effects of this program as it does the same thing.

Definition of MaintenanceWe need to agree on the definition of

maintenance of abstinence from tobacco a minimum of 6 mo., better to be 12 mo. From the end of the Intervention. About 33% of smokers relapse after not smoking for

12 mo. (SRNT Hughes et al., 2003, Gilpin & Pierce 2002, West et al. 2005).

There is a 50% reduction in heart attack with 12 months abstinence

Tobacco use is a free choice, so smokers can start again if desired.

4

Affirmative’s burden is to answer all these questions

1. Do smokers paid to stop maintain abstinence?

2. How much do we need to pay smokers to stop? Needs to be both realistic (politically & financially) and to determine if we can afford it and if it is cost-beneficial or not.

- Health care costs 21% of GDP - Kevin already admitted in his presentation he doesn’t know how much smokers

need to be paid

3. Does paying smokers to stop cause problems (directly AND indirectly) that potentially offset any benefits?

- Teens and poor starting smoking to get reward- Undermining effect for those not paid- Smokers can start again to get paid again- Money used by smokers goes to tobacco industry

4. Are alternatives we have now less effective than to paying to stop?- SDT models for health behavior, and tobacco dependence treatment

5

Do smokers really stop smoking for 6 -12 months with incentives? Competitions and incentives for smoking cessation.

Cochrane Review – concluded “no effect on long term cessation.”

“Nineteen studies met our inclusion criteria, covering >4500 participants….. the exception of one recent trial, incentives and competitions have not been shown to enhance long-term cessation rates. Early success tended to dissipate when the rewards were no longer offered”

Cahill, K., Perera., R. (April 2011) Competitions and Incentives for Smoking Cessation. Department of Primary Health Care, University of Oxford.

Behavioral Theory and Economic Theory offer no mechanism for a maintenance effect of rewards or punishments. (SDT does)-Even though Dr. Volpp indicates higher rates for those paid in one study-he needs to demonstrate a mechanism by which that is expected to be sustained before we spend $1 billion a year on payments to smokers

6

Intrinsic Vs Extrinsic Intervention for Self Help Cessation

1,217 smokers randomized to 4 groupsIntrinsic –Personal Analysis of Reasons for Quitting Extrinsic- lottery drawing for trips, secret giftBothNeither

Averaged 25 cigarettes per day for 24 years

Curry et al. Jour Consult Clin Psych 1991:59:318-3247

Intrinsic Vs Extrinsic Intervention for Self Help Cessation

Outcome Intrinsic

(304)

Extrinsic

(304)

Both

(304)

Control

(304)

p

7 day abs.

3 mo.

13% 8% 9% 8% .06

7 day abs

3 & 12 mo

10% 4% 4% 5% .004

Curry et al., JCCP 1991;59:318-324

8

Intrinsic Vs Extrinsic Intervention for Self Help Cessation

Continuous abstinence over 3 to 12 months was increased by personalized feedback on intrinsic reasons for quit

Financial incentive :increased use of self-help materialsno increase in cessation among prog. usershigher relapse in those who had quit suggesting that

motivation had been undermined

Curry et al., JCCP 1991;59:318-3249

Do smokers really stop smoking for 6 -12 months with incentives? NO

Conclusion: Payment does not work for maintenance!

-Across 19 studies, only 1 study supported paying smokers,

-Curry et al 1991 showed an undermining effect of rewards.

Behavioral Theory and Economic Theory offer no mechanism for a maintenance effect of rewards or punishments. (SDT does)

10

Overview of Self-Determination Theory and HealthSelf Determination Theory Overview

Define Motivation as energy directed toward a goalAssumptions: innate aspects of self, needs InternalizationSDT Model for Health Behavior ChangeMeta-analysis

Randomized controlled trials - SDT Dental outcomes Physical activity, weight loss Tobacco abstinence

11

Psychological Needs: Supporting Optimal Motivation

AutonomyThe need to feel choiceful and volitional in one’s

behavior

CompetenceThe need to feel optimally challenged and capable of

achieving outcomes

RelatednessThe need to feel connected to and understood by

important others

Deci & Ryan, 2000Deci & Ryan, 2000Ryan & Deci, 2000Ryan & Deci, 2000

12

InternalizationAn inherent, proactive process by which autonomous

and competence motivations are increased naturally over time

13

SDT Model of Health Behavior Change

Personality Differences in

Autonomy

Intrinsic vs. Extrinsic Values

Autonomy

Competence

Relatedness

Mental HealthDepression

SomatizationAnxiety

Quality of lifeSuicidality

* RCT of Intervention to increase autonomy* RCT of Intervention to increase autonomy

Needs Support

Health Care Climate Important others

Physical HealthNot Smoking*

Physical activity*

Weight Loss*

Diabetes Control

Medication Use*

Healthier Diet*

Dental Health*14

Does paying to stop cause problems? Yes

Direct problems 1. Teens & poor may start smoking to get money.

A. Research needs to be done to show vulnerable populations (teens, poor, severe and persistent mental illness) don’t increase smoking rate for the $750 reward to stop.

B. Most smokers relapse several times before stopping even when not paid for stopping. Now, they can make money from relapsing.

2. Too costly in real-world environment we live in.- 45 million adult smokers x $750 x 11% = 3.7 billion dollars per year - Health care is already 21% of GDP ($14.7 T) = $3 trillion- This program could cost 1% of the total US health care budget- Much of this money will go to the tobacco industry!

3. Payments undermine intrinsic motivation (autonomy). - It is reasonable these payments may undermine motivation for health. - That violates biomedical ethics. - All interventions need to assess autonomy as an outcome.

15

ABIM Foundation. Ann Intern Med. 2002;136:243-246Beauchamp & Childress. Biomedical Ethics 2009.

Medical Professionalism – A Physician Charter & Biomedical Ethics

Primacy of patient welfare: a dedication to serving patients’ interests

Patient autonomy: to empower patients to make informed decisions

Social justice: to eliminate discrimination

1616

Does paying to stop cause problems?Indirect problems that may be caused1. A precedent may be set that results in having to pay for other health

behaviors.

- SDT meta-analysis shows large effect for undermining intrinsic motivation for others not paid the reward. Cohen’s d = -0.95

- Smokers may not do other health behaviors unless paid.

- Non-smokers may want to be paid for (I know I want this if smokers paid to stop):1. Regular Physical Activity2. Keeping a healthy body weight3. Immunizations4. Mammograms and pap smears5. Colonscopy

Conclusion: Much more research is needed before payment for cessation is adopted. Vulnerable populations may start, costs are prohibitive, unethical to reduce autonomy, people will want payment for all health behaviors.17

Are Intrinsic and Extrinsic Motivation Additive?

When a person’s intrinsically motivated for an activity will adding extrinsic reward

enhance the person’s motivation?

18

Summary of Meta-analytic Results of the Effects of Extrinsic Rewards on Free-Choice Intrinsic Motivation

(32)-0.28*

(7)

(92)-0.36*Expected

(9)0.01Unexpected

Tangible Rewards

Verbal Rewards

(101)-0.24*All rewards

kd

Deci, Koestner, and Ryan (1999)

0.33* (21)-0.34* (92)

Task non-contingent

Engagement contingent

Completion contingentPerformance contingent

-0.40*

-0.44*

(55)

(19)

-0.14

19

When all people got the expected rewards -0.36

When people got lessthan maximal rewards -0.88

When some people gotno rewards -0.95

numbers are Cohen’s d effect size, all are significant

Deci, Koestner, and Ryan (1999)

Summary of effectsAcross 92 studies, there is a moderate negative

effect on intrinsic motivation when subjects are paid for the specific behavior.

When some people got no reward there is a large undermining effect (d = -0.95) suggesting that people may need to be paid for other health behaviors!Smokers may need to be paid for other behaviorsNon-smokers may need to be paid for health behav.Not ethical to undermine autonomy

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Are their reasonable alternatives to paying for health? YESMotivation Based Treatments Are Sustained

1. Self-Determination Theory Interventions have shown initiation and maintenance of cessation for 12 months is as good as paying the incentive for smokers that want to stop and for those that don’t want to stop

- RCT 1 N=1,006 6.2 vs 2.4% SDT – PHS vs CC- RCT 2 N=808 8% vs 2.4% SDT – PHS vs Historical Control- Translational pilot Insuran. (N=300) 29% 6 month abstinence- Translational pilot NYS (N=500) 28% 6 month abstinence

2. Motivation Enhancement interventions result in greater patient autonomy, (self-regulation) , perceived competence, and have greater personal value or their health in 5RCTs. These ‘motivations’ improve quality of life, sustained behavior change and improved health.

Williams et a., JGIM 2006; Ryan et al., EJHP, 200822

Smoker’s Health Study Design

Randomized controlled trial of 30 mo.

Questionnaire assessments: * autonomous motivation * perceived competence * autonomy support

Outcomes:* Took Medication* Tobacco Abstinence at 6, 18, and 30 months* Reduction in % calories from fat, LDL-C

Williams, McGregor et al., Health Psychology. 2006;25(1): 91-101. 23

SDT + Tobacco and Cholesterol GuidelineIntensive Treatment included:4 contacts over 6 months

Need support and information givingExplore barriers and valuesShared decision making used to set planProblem solving/skills buildingPharmacotherapy (smoking only)

Control: Community care, encourage MD visit

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All Patients Odds Ratio PHS Odds Ratio

6-month 7-day Point Prevalence 2.9 2.5

Patients who Did Not Want to Quit Odds Ratio

6-month 7-day Point Prevalence 2.7

All Patients Odds Ratio

12-month Prolonged Abstinence at 18-months 2.6

Patients with Elevated LDL-C Intervention Control p-Value

18-month Change in LDL-C 8.0 mg/dl 4.0 mg/dl < 0.05

Health Outcomes at 6-months and 18-months

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Conclusions: Are their reasonable alternatives to paying for health?Motivation Based Treatments Are Sustained And Are Reasonable

Alternatives

4.These interventions are cost effective.- Cost $350 per participant- Cost-effectiveness is $400 per life year saved- The payments go to clinical programs (e.g. tobacco and substance

abuse counselors) rather than to the tobacco industry

5. Do not undermine long-term motivation, set precedents, or encourage people to start smoking for money

- Teens may be vulnerable to the $750 reward and start- Reward differentially ‘targets’ low SES people to start smoking

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Conclusions: there is little to no positive evidence, there is reason to believe people will be harmed, effective Tx exists.

1. Do smokers paid to stop maintain abstinence? No not in the meta-analysis of 19 studies (Cochrane Review).

2. How much do we need to pay smokers to stop? We can’t afford this.1. This would add 1% to current health care costs2. Rewards need to be increased over time and reinforced3. Smokers are expected to start again and can get paid again

3. Does paying smokers to stop cause problems (directly AND indirectly) that potentially offset any benefits? Quite Possibly!

1. Teens and poor starting smoking to get reward2. Undermining effect for those not paid3. The intervention is likely unethical 4. Money used by smokers goes to tobacco industry rather than to chemical

dependency counselors

4. Are alternatives to paying to stop less effective? No 1. SDT models for health behavior, and tobacco dependence treatment

27

References ABIM Foundation, American Board of Internal Medicine, ACP-ASIM Foundation, American College of

Physicians-American Society of Internal Medicine, European Federation of Internal Medicine. (2002). Medical professionalism in the new millennium: a physician charter. Annals of Internal Medicine, 136, 243-246.

Beauchamp, T., & Childress, J. (2009). Principles of biomedical ethics (6th Ed. ed.). New York: Oxford University Press, Inc.

Cahill, K., & Perera, R. (2011). Competitions and incentives for smoking cessation (Review). The Cochrane Library, 3, 1-37.

Curry, S., Grothaus, L., McAfee, T., & Pabiniak, C. (1998). Use and cost effectiveness of smoking-cessation services under four insurance plans in a Health Maintenance Organization. New England Journal of Medicine, 339, 673-679.

Deci, E., Koestner, R., & Ryan, R. (1999). A meta-analytic review of experiments examining the effects of extrinsic rewards on intrinsic motivation. Psychological Bulletin, 125, 627-668.

Deci, E., & Ryan, R. (2000). The "what" and "why" of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry, 11, 227-268.

Fiore , M.C., Baker, T.B. (2011). Treating smokers in the health care setting. NEJM, 365(13):1222-31 Hughes, J., Keely, J., Niaura, R., Ossip-Klein, D., Richmond, R., & Swan, G. (2003). Measures of

abstinence in clinical trials: Issues and recommendations. Nicotine and Tobacco Research, 5, 13-25.

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References Lévesque, C., Williams, G., Elliot, D., Pickering, M., Bodenhamer, B., & Finley, P. (2007). Validating the

theoretical structure of the Treatment Self-Regulation Questionnaire (TSRQ) across three different health behaviors. Health Education Research, 22(5), 691-702.

Pierce, J., & Gilpin, E. (2003). A minimum 6-month prolonged abstinence should be required for evaluating smoking cessation trials. Nicotine and Tobacco Research, 5, 151-153.

Ryan, R., & Deci, E. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55, 68-78.

Ryan, R. M., Patrick, H., Deci, E. L., & Williams, G. C. (2008). Facilitating health behavior change and its maintenance: Interventions based on Self-Determination Theory. European Health Psychologist, 20, 2-5.

West, R., Hajek, P., Stead, L., & Stapleton, J. (2005). Outcome criteria in smoking cessation trials: Proposal for a common standard. Addiction, 10, 299-303.

Williams, G., McGregor, H., Sharp, D., Kouides, R., Lévesque, C., Ryan, R., & Deci, E. (2006). A self-determination multiple risk intervention trial to improve smokers' health. Journal of General Internal Medicine, 21, 1288-1294.

Williams, G., McGregor, H., Sharp, D., Lévesque, C., Kouides, R., Ryan, R., & Deci, E. (2006). Testing a self-determination theory intervention for motivating tobacco cessation: Supporting autonomy and competence in a clinical trial. Health Psychology, 25, 91-101.

Williams, G., Niemiec, C., Patrick, H., Ryan, R., & Deci, E. (2009). The importance of supporting autonomy and perceived competence in facilitating long-term tobacco abstinence. Annals of Behavioral Medicine, 37, 315-324.

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Self-Determination Theory: Self-Determination Theory: Meta-AnalysisMeta-Analysis

of 186 data sets related to of 186 data sets related to health promotion or clinical health promotion or clinical

settingssettings

SDT META-ANALYSISThese data demonstrate that support for

psychological needs in health domain leads to: better mental health outcomesgreater health behavior changeimproved quality of life

This is in contrast to Paternalism which is controlling and would be expected to worsen peoples quality of life and health outcomes.

InternalizationAn inherent, proactive process by which autonomous

and competence motivations are increased naturally over time

From meta-analysis: “the primary effect of rewards is that they tend to forstall self-regulation”

We need to chose programs that facilitate this and not undermine it.

32Deci Koestner and Ryan 1999

Making rewards less controllingA. Minimize use of authoritarian style and pressuring

B. Acknowledging good performance

C. Providing Choice about how to do the talk

D. Emphasizing the interesting or challenging aspects of the task.

Deci Koestner and Ryan 1999

Conclusions: there is little to no positive evidence, there is reason to believe people will be harmed, effective Tx exists.

1. Do smokers paid to stop maintain abstinence? No not in the meta-analysis of 19 studies (Cochrane Review).

2. How much do we need to pay smokers to stop? We can’t afford this.1. This would add 1% to current health care costs2. Rewards need to be increased over time and reinforced3. Smokers are expected to start again and can get paid again

1. Does paying smokers to stop cause problems (directly AND indirectly) that potentially offset any benefits? Quite Possibly!

1. Teens and poor starting smoking to get reward2. Undermining effect for those not paid3. The intervention is likely unethical 4. Money used by smokers goes to tobacco industry rather than to chemical

dependency counselors

2. Are alternatives to paying to stop less effective? No 1. SDT models for health behavior, and tobacco dependence treatment

34