Should incentives be used to encourage healthy living?

Healthy living feature: smokingLast week, NICE's Citizens Council - a group which brings the views of the public to NICE's decision-making - spent two days debating the ins and outs of using incentives as an effective way of encouraging people to make positive lifestyle changes, such as giving up smoking or losing weight.

The 30 members of the Citizens Council, reflecting the age, gender, socioeconomic status and ethnicity of the people of England and Wales, were given a series of presentations on how incentives could be used, before taking part in a number of lively discussions all designed to help them reach a verdict.

NICE has already considered the use of incentives during the development of clinical guidelines on psychosocial interventions for drug misuse, but will take onboard the views of the Citizens Council when exploring the idea within various public health guidance topics.

Encouraging mums-to-be to stop smoking

Such topics include smoking in pregnancy, an issue that was raised at the Citizen's Council meeting by Andrew Radley, a public health pharmacist from NHS Tayside who is leading a smoking cessation incentive scheme for pregnant smokers called Give It Up For Baby.

Tayside is a large region in Scotland which has significant areas of social deprivation concentrated mainly around Dundee. Throughout Dundee there is a strong correlation between deprivation and smoking.

Smoking during pregnancy can cause serious health problems, including increasing the risk of infant mortality by an estimated 40 per cent.

Give It Up For Baby uses financial incentives in the form of grocery vouchers worth £12.50 a week for fresh fruit and vegetables to encourage pregnant smokers from socially deprived communities to quit smoking.

Women who were eligible for the program were identified by midwives, local pharmacists and health visitors, and were recruited if they express a wish to give up smoking.

So far the scheme has helped 55 mothers in Dundee to quit smoking, and a total of 140 women have quit across the Tayside region.

For women who fully engaged with the program, an average payment of about £210 was made. Expenditure indicates a cost per quitter figure of about £1,700. Treating disease directly caused by smoking produces medical bills of more than £5billon a year in the UK, the British Heart Foundation has estimated.

Paying people to lose weight

Following on from Mr Radley's talk, Claire Martin, acting director of public health at Thanet and Dover, NHS Eastern and Costal Kent explained an incentive scheme that offered cash for those who were willing to lose weight.

Tackling obesity is a major problem for the NHS in east Kent with the annual cost of treating diseases related to being overweight and obese, such as Type-2 diabetes, heart disease and cancer, at £200 million. Currently, 24% of adults in east Kent are classified as being obese.

Nationally, the cost to the NHS of obesity is £4 billion.

In response to this growing problem, the Pounds for Pounds programme was set up, in what it is the first public evaluation by the NHS of a weight loss incentive scheme.

Overall, 67 per cent of 401 participants lost weight, an average of 18Ibs, after three months in the programme.

But achieving a longer term change in behaviour proved harder, with only a quarter of the participants staying in the programme for a year, despite the financial incentives on offer.

Claire Martin says: “In conclusion, there were high dropout rates and so it is very difficult to interpret the results to show how successful this would be on a population approach.

“Clearly it works for some people, but more research needs to be undertaken to understand the true effect of incentives on weight loss.”

A lack of evidence

A lack of evidence for the use of incentives for individual behaviour change was also highlighted by Dr Tammy Boyce, a research fellow with the independent health think-tank The King's Fund.

Healthy living feature: crisps“A lot of the research on incentives is done in the US where they operate a different type of healthcare system. Really the research base for the use of incentives is quite small, “says Dr Boyce.

“Sometimes they are effective, and they work for some people but the evidence is mixed. There is more research showing that incentives are less effective for weight loss than for quitting smoking.”

However, a search by the Cochrane Collaboration of all the available evidence looking at whether competitions and incentives help smokers to quit in the medium to long term showed that such incentives do not enhance long term smoking cessation rates, with early success tending to dissipate when the rewards are no longer offered.

Getting children to eat healthily

An area where incentives have proved successful, however, is in encouraging children to eat more fruit and vegetables.

Food Dudes, developed by researchers at the University of Bangor in Wales, is a school-based intervention designed for use in primary schools to encourage children to eat fruit and vegetables that is achieving remarkable results.

By using rewards and positive role-models, the Food Dudes Programme encourages children to repeatedly taste different fruits and vegetables. Repeated tasting of these foods allows children to discover that fruit and vegetables actually taste good.

With increased liking of fruit and vegetables comes the greater likelihood that children will eat these foods simply for their taste rather than for any external reward.

Additionally, the Food Dudes Programme creates a culture, at school and at home, that strongly supports the eating of fruit and vegetables and within this environment children come to think of themselves as “healthy eaters” who eat fruit and vegetables.

In the first year of launching in Wolverhampton, 22 schools and 5,000 children have accessed the programme. Initial research in six participating schools found that children increase their fruit consumption by 54 per cent and vegetable consumption by 48 per cent.

In recognition of the positive results, Food Dudes was recently awarded the Gold medal at the Chief Medical Officer's Public Health Awards 2010.

Dr Adrian Phillips, director of public health for Wolverhampton, says: “Food Dudes helps children to eat healthily and is a really exciting and fun way to encourage them to eat more fruit and vegetables. We're extremely proud of the difference we've made to children in Wolverhampton, and that our efforts have been recognised through this national award.”

Difficult decisions

So having spent two days listening to compelling evidence for and against the use of incentives to change behaviour, the only thing that appears clear cut is that the Citizen's Council face one of their toughest tasks yet in weighing up all the pros and cons of incentives to come to a decision.

When they do, a report on the Council's views will be available on the NICE website for public comment, before the Council submits a report to the Board of NICE setting out its findings.

This page was last updated: 12 July 2010

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.