1. A Spicy Debate – “Resolved: Employers, the Government, and Third Party Payors Should Incentivize Smokers to Quit” AMERSA 35 th Annual National Conference Nov 3 rd 2011 Kevin Volpp MD, PhD Affirmative Geoffrey C. Williams MD, PhD Negative Center for Community Health Healthy Living Research Center University of Rochester 1

2. I AM LYING TO YOU NOW! I WILL EXPLAIN SHORTLY I WILL STOP LYING WHEN I FINISH THIS SLIDE

3. 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.

4. Definition of Maintenance We 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

5. 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

6. 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

7. Intrinsic Vs Extrinsic Intervention for Self Help Cessation 1,217 smokers randomized to 4 groups Intrinsic –Personal Analysis of Reasons for Quitting Extrinsic- lottery drawing for trips, secret gift Both Neither Averaged 25 cigarettes per day for 24 years Curry et al. Jour Consult Clin Psych 1991:59:318-3247

8. Intrinsic Vs Extrinsic Intervention for Self Help Cessation OutcomeIntrinsic (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% 5%.004 Curry et al., JCCP 1991;59:318-324 8

9. 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 materials no increase in cessation among prog. users higher relapse in those who had quit suggesting that motivation had been undermined Curry et al., JCCP 1991;59:318-324 9

10. 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

11. Overview of Self-Determination Theory and Health Self Determination Theory Overview Define Motivation as energy directed toward a goal Assumptions: innate aspects of self, needs Internalization SDT Model for Health Behavior Change Meta-analysis Randomized controlled trials - SDT Dental outcomes Physical activity, weight loss Tobacco abstinence 11

12. Psychological Needs: Supporting Optimal Motivation Autonomy The need to feel choiceful and volitional in one’s behavior Competence The need to feel optimally challenged and capable of achieving outcomes Relatedness The need to feel connected to and understood by important others Deci & Ryan, 2000 Ryan & Deci, 2000 12

13. Internalization An inherent, proactive process by which autonomous and competence motivations are increased naturally over time 13

14. SDT Model of Health Behavior Change Personality Differences in Autonomy Intrinsic vs. Extrinsic Values Autonomy Competence Relatedness Mental Health Depression Somatization Anxiety Quality of life Suicidality * RCT of Intervention to increase autonomy Needs Support Health Care Climate Important others Physical Health Not Smoking* Physical activity* Weight Loss* Diabetes Control Medication Use* Healthier Diet* Dental Health* 14

15. 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

16. ABIM Foundation. Ann Intern Med. 2002;136:243-246 Beauchamp & 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 16

17. Does paying to stop cause problems? Indirect problems that may be caused 1. 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 Activity 2. Keeping a healthy body weight 3. Immunizations 4. Mammograms and pap smears 5. 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

18. 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

19. 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 contingent Performance contingent -0.40* -0.44* (55) (19) -0.14 19

20. When all people got the expected rewards -0.36 When people got less than maximal rewards -0.88 When some people got no rewards -0.95 numbers are Cohen’s d effect size, all are significant Deci, Koestner, and Ryan (1999)

21. Summary of effects Across 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 behaviors Non-smokers may need to be paid for health behav. Not ethical to undermine autonomy 21

22. Are their reasonable alternatives to paying for health? YES Motivation 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, 2008 22

23. 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

24. SDT + Tobacco and Cholesterol Guideline Intensive Treatment included: 4 contacts over 6 months Need support and information giving Explore barriers and values Shared decision making used to set plan Problem solving/skills building Pharmacotherapy (smoking only) Control: Community care, encourage MD visit 24

25. Health Outcomes at 6-months and 18- months 25

26. 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 26

27. 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 costs 2. Rewards need to be increased over time and reinforced 3. 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 reward 2. Undermining effect for those not paid 3. 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

28. 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. 28

29. 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. 29

30. Self-Determination Theory: Meta-Analysis of 186 data sets related to health promotion or clinical settings

31. SDT META-ANALYSIS These data demonstrate that support for psychological needs in health domain leads to: better mental health outcomes greater health behavior change improved 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.

32. Internalization An 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. 32 Deci Koestner and Ryan 1999

33. Making rewards less controlling A. 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

34. 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 costs 2. Rewards need to be increased over time and reinforced 3. 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 reward 2. Undermining effect for those not paid 3. 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