Seminar Programme 5.30pm Dr Geoff Watts: Welcome and Introductions

1. Seminar Programme 5.30pm Dr Geoff Watts: Welcome and Introductions Professor Theresa Marteau: Impact of Incentives on Health Behaviour (15mins) Professor Paul Dolan:Spill over and Carry-over Effects of Incentives (15mins) Professor Richard AshcroftEthics, Acceptability and Public Perception (15mins) 6.15pm Panel responses 6.30pm Discussion 7.00pm Wine reception

2. Impact of Incentives on Health Behaviour Professor Theresa Marteau

3. What is the impact of incentivising healthy behaviours? I Do incentives change habitual health behaviours? Limited effects that don’t endure; most evidence for smoking cessation in pregnancy II Do incentives increase infrequent health behaviours? At best, modest effects in healthy UK populations III Do incentives have perverse unintended consequences? • crowding out no evidence in health contexevidence • gaming to get an incentive evidence BUT is it sufficient to counter use of a scheme with some benefit?

4. I Do incentives change habitual health behaviours? Review Aim to assess: • whether financial incentives can result in sustained behaviour change for • smoking cessation • healthier eating • reduced alcohol consumption • increased physical activity • the conditions influencing effectiveness Protocol: Mantzari et al 2012

5. Study estimates of financial incentive effects on health behaviours at time-points after incentive removal • >2-3 m 2.11(1.21-3.67) • >3-6 m • >6 m Mantzari, Vogt, Shemilt, Wei, Higgins, Marteau under review

6. Study estimates of financial incentive effects on health behaviours at time-points after incentive removal Donatelle 2002 (A) Donatelle 2002 (B) Heil 2008 Higgins 2004 Higgins 2010 Shoptaw 2002 (A) Shoptaw 2002 (B) • >2-3 m 2.57(2.20-5.54) • >3-6 m • >6 m Mantzari, Vogt, Shemilt, Wei, Higgins, Marteau under review

7. Study estimates of financial incentive effects on health behaviours at time-points after incentive removal Donatelle 2002 (A) Donatelle 2002 (B) Heil 2008 Higgins 2004 Higgins 2010 Shoptaw 2002 (A) Shoptaw 2002 (B) • >2-3 m 2.57(2.20-5.54) • >3-6 m • >6 m Mantzari, Vogt, Shemilt, Wei, Higgins, Marteau under review

8. IDo incentives change habitual health behaviours? The role of financial incentives in changing habitual health behaviours is limited given that effects are not sustained beyond a few months after incentive removal BUT based on a small number of studies Most of the evidence for enduring effects comes from studies assessing smoking cessation in pregnant women (but none conducted in UK).

9. Smoking in Pregnancy • Largest single contributor to poor maternal and fetal outcomes including low birth weight, premature delivery, still birth and neonatal death • Most common in young women, those with low levels of education, and those with mental health problems % women in England smoking throughout pregnancy - 2012

10. Case ExampleBig Change for the Little One: Single Cohort Study in Chesterfield Nov 2011 – Aug 2012 2971 pregnant women 615 smokers (21%) 239 (39%) enrolled in scheme 48 (8%) quit at delivery 25 (4%) quit 6/12 post baby Previous year: 0% quit Ierfino, Mantzari, Hirst, Jones, Aveyard, Marteau under review

11. Media Response Pre Study Post Study

12. What is the impact of incentivising healthy behaviours? I Do incentives change habitual health behaviours? Change does not seem to endure Most evidence for smoking cessation in pregnancy II Do incentives increase infrequent health behaviours? At best, modest effects in healthy UK populations III Do incentives have perverse unintended consequences? • crowding out no evidence in health contextevidence • gaming to get an incentive evidence BUT is it sufficient to counter use of a scheme with some benefit?

13. II Do incentives increase infrequent health behaviours? Financial Incentives to Increase Uptake and Completion of HPV Vaccination: a randomised controlled trial Participants: 1000 girls aged 16-17 not vaccinated for HPV at age 12: either first time invitees or previous non-attenders Randomised to one of two groups: i. Control Group: standard vaccination invitation letter ii. Intervention Groupletter with the offer of £45 voucher for receiving the 3 vaccinations (£20 for 1st £5 for 2nd and £20 for the 3rd) Protocol: Mantzari et al 2013 BMC Public Health

14. Financial Incentives to Increase Uptake and Completion of HPV Vaccination TNational Target (achieved for 12 yr olds) National catch up rate Intervention Intervention Control Control Mantzari, Vogt, Marteau. Health Psychology in press

15. Media Response

16. What is the impact of incentivising healthy behaviours? I Do incentives change habitual health behaviours? Change does not seem to endure Most evidence for smoking cessation in pregnancy II Do incentives increase infrequent health behaviours? At best, modest clinically insignificant effects in healthy UK populations III Do incentives have perverse unintended consequences? • crowding out no evidence in health contexevidence • gaming to get an incentive evidence BUT is it sufficient to counter use of a scheme with some benefit?

17. III Do incentives have perverse unintended consequences? i. Crowding Out = reducing intrinsic motivation for a behaviour when incentive is removed “….we find strong evidence for an undermining effect of tangible rewards on intrinsic motivation for simple tasks when motivation manifest in behavior is initially high.” “…for health related behaviors, baseline levels of incentivized behaviors are usually low …. Correspondingly, we find no evidence for crowding out of incentivized health behaviors.”

18. III Do incentives have perverse unintended consequences? ii. Gaming to get an incentive 0/239 gamed to enroll 10/ 239 (4%)enrolled on the schemehad at least one salivary cotinine or anabasine result compatible with smoking having reported not smoking providing a CO reading compatible with not smoking. Ierfino, Mantzari, Hirst, Jones, Aveyard, Marteauunder review

19. What is the impact of incentivising healthy behaviours? I Do incentives change habitual health behaviours? Change does not seem to endure Most evidence for smoking cessation in pregnancy II Do incentives increase infrequent health behaviours? At best, modest clinically insignificant effects in healthy UK populations III Do incentives have perverse unintended consequences? • crowding out no evidence in health contexts • gaming to get an incentive evidence only amongst those enrolled BUT is it sufficient to counter use of a scheme with some benefit?

20. Spillover and Carry-over Effects of Incentives Professor Paul Dolan

21. Paul Dolan • Behavioural spillovers: review and taxonomy • Behavioural spillovers of financial incentives to exercise: a randomised lab experiment With Matteo Galizzi • Carryover effects of financial incentives to eat/not to eat: a randomised lab experiment With Matteo Galizzi and Daniel Navarro-Martinez

22. Behavioural spillovers

23. Spillovers from incentives to exercise More drinks, fats and sugars in H More fats in L and E Note – 14-17 calories burned in the exercise

24. Carryover effects: treatments

25. Carryover effects: results

26. Ethics, Acceptability and Public Perception Professor Richard Ashcroft

27. Richard Ashcroft • Coercion, pressure, manipulation and inducement • Theoretical review and empirical studies • No strong evidence or robust conceptual argument to suggest coercion, but manipulation remains of concern • Acceptability, efficiency, incentives as tools of public policy • Media analysis, empirical studies, theoretical review • A trade off between concerns about fairness and support for effective interventions • “Money Out of Place” • Work in progress • Is an incentive a payment? A bribe? A reward? Or merely an aid? • Is this dependent on the context, or the behaviour, or the intention of the offeror, or the beliefs of the recipient?

28. Media Response • A consistent pattern of responses • Examples shown throughout this presentation • See also the reports of Weaver’s team’s trial in “contingency management”. • We analysed this in Parke et al. 2011 • A consistent worry about the “undeserving” • A consistent framing around “money out of place” • Trade-offs vs. Principled objections

29. Does the media representation reflect individuals’ attitudes? • We looked at this via online survey work with British and US samples and by discrete choice experiments (Promberger et al. 2011 and 2012) • A marked reluctance to “blame the victim” • A recognition that behaviours can be hard to change • A pragmatism: if nothing else works, and this does, then “pay them if it works”.

30. Is there a consistent “moral story” which coheres with the empirical data? • Although coercion is often mentioned, the real concern appears to be with manipulation • Much turns on • Whether the person wants to change • Whether it is hard for them to do so • If an incentive is an “aid” or a “trade” • If there are wider social benefits • The form of the incentive (cash, vouchers...)

31. An outstanding challenge • The ethical and social acceptability of incentives depends in part on “what works” • But it also depends on framing and narrative • There is a complex cultural story about money and its meanings which tells us what incentives “must” do in terms of influencing behaviour and the moral significance of that • But this doesn’t necessarily fit well with our evidence of what incentives actually do (or fail to do).

32. Summary I Personal financial incentives have at best modest effects in changing behaviour in general populations exceptions include smoking cessation in pregnant women and treatments in those with drug addictions II No evidence of adverse effects III There is moral unease in the public about their use even when there is evidence of effectiveness. This can be allayed when: • there is no safe, effective alternative • behaviour change is acknowledged to be difficult

33. Panel Response Chair: Dr Geoff Watts Panel: Professor Luc Bovens Professor Julian Le Grand Professor Anne Ludbrook Dr Clare Relton