獎勵還是懲罰 更有利於戒菸

What would make a smoker more likely to quit, a big reward for succeeding or a little penalty for failing? That is what researchers wanted to know when they assigned a large group of CVS employees, their relatives and friends to different smoking cessation programs.

想讓吸菸者戒菸，是對戒菸成功大加獎勵還是對戒菸失敗小施懲戒更加有效？爲了搞清楚這個問題，研究人員讓CVS藥店(CVS)的一大羣員工及其親朋好友接受了不同的戒菸方案。

The answer offered a surprising insight into human behavior. Many more people agreed to sign up for the reward program, but once they were in it, only a small share actually quit smoking. A far smaller number agreed to risk the penalty, but those who did were twice as likely to quit.

他們得到的答案展示了人類行爲中令人驚訝的一面。有很多人都願意參加獎勵方案，但在加入之後，真正戒了煙的人寥寥無幾。而在同意冒險嘗試懲罰方案的那一小部分人當中，成功戒菸的可能性卻是前者的兩倍。

The trial, which was described in The New England Journal of Medicine on Wednesday, was the largest yet to test whether offering people financial incentives could lead to better health. It used theories about human decision making that have been developed in psychology and economics departments over several decades and put them into practice with more than 2,500 people who either worked at CVS Caremark, the country’s largest drugstore chain by sales, or were friends or relatives of those employees.

這項試驗於5月13日發表在《新英格蘭醫學雜誌》(The New England Journal of Medicine)上，它是迄今爲止規模最大的一項以測試經濟獎勵能否改善人們健康爲目的的研究。該試驗採用了心理學和經濟學部門在近幾十年來建立起來的人類決策理論，並將其應用於美國最大的連鎖藥店CVS Caremark公司的員工及其朋友或親戚。合計參與人數超過了2500人。

Researchers found that offering incentives was far more effective in getting people to stop smoking than the traditional approach of giving free smoking cessation help, such as counseling or nicotine replacement therapy like gum, medication or patches. But they also found that requiring a $150 deposit that would be lost if the person failed to stay off cigarettes for six months nearly doubled the chances of success.

研究人員發現，與傳統的戒菸方法，即通過各種方式免費幫人戒菸（如提供諮詢，使用口香糖、藥物或貼片等尼古丁替代療法）相比，提供獎勵的效果要好得多。但他們也發現，如果要求參與者交150美元保證金，且告知他們在6個月內無法戒菸就拿不回保證金，戒菸的成功率幾乎可以翻一番。

“Adding a bit of a stick was much better than a pure carrot,” said Dr. Scott Halpern, deputy director of the Center for Health Incentives and Behavioral Economics at the University of Pennsylvania School of Medicine, who led the study.

該研究的負責人，賓夕法尼亞大學醫學院(University of Pennsylvania School of Medicine)健康激勵和行爲經濟學研究中心(Center for Health Incentives and Behavioral Economics)副主任斯科特·哈爾彭(Scott Halpern)博士說：“胡蘿蔔加一點大棒的效果比純用胡蘿蔔更好。”

The finding is likely to get the attention of large companies as they sort out what types of benefits to offer employees in an era of rising health care costs. Most large employers, which bear much of those costs, now offer incentives for health-promoting behavior in the form of employee wellness programs, but until now, they have had little evidence of what types of programs actually work to guide them.

在這個醫療費用不斷上漲的時代，上述發現很可能會引起那些正在考慮該爲自己的員工提供何種福利待遇的大公司的關注。大多數大型用人單位承擔着員工醫療費用的絕大部分，他們現在多以員工保健計劃(employee wellness programs)的形式來激勵促進健康的行爲，但到目前爲止，還沒有多少證據能證實哪種方案可以真正有效地指導他們。

CVS, which helped conduct the study, is using the findings to design a smoking cessation incentive next month for its more than 200,000 employees.

CVS（也就是協助進行該研究的公司）下個月將利用上述研究成果爲其20多萬名員工設計激勵戒菸的方案。

“These large employers are spending an average of $800 to $900 per employee per year, but in ways that are often blind to normal human psychology,” Dr. Halpern said, adding that the spending on wellness had nearly doubled in five years.

“這些大型用人單位每年平均要在每名員工身上花費800到900美元，”哈爾彭博士說，5年內醫療支出增加了近一倍，“但他們花錢時卻往往對人員心理層面上的因素視而不見。”

The trial was intended to change that. Researchers randomly assigned the participants to a number of program options and let them decide whether they wanted to participate. About 14 percent of people assigned to the penalty program accepted it, compared with about 90 percent of people assigned to the reward program.

這項試驗就是爲了要改變這一現狀。研究人員向參與者們隨機分配了多種戒菸方案，並讓他們自己決定是否參加。分配入懲罰方案組的參與者中約有14%表示接受，相比之下，分配入獎勵方案組的參與者中接受者高達90%。

The penalty program required participants to deposit $150; six months later, those who had quit smoking would get the deposit back, along with a $650 reward. In the reward-only program, participants were simply offered an $800 payment if they stayed off cigarettes for six months.

懲罰方案要求參與者繳納150美元保證金；6個月後，成功戒菸者不但得以退還保證金，還將獲得650美元的獎勵。而在純獎勵方案中，參加者戒菸6個月就可以獲得800美元的獎勵。

The success rate for those who joined the pure rewards group was low, about 17 percent, compared with more than 50 percent for the penalty program, though the figures had to be adjusted to account for the possibility that those who opted for the penalty might have been more motivated to quit to begin with.

純獎勵方案組的參與者中戒菸成功率很低，約爲17%；相比之下，在懲罰方案組中成功率則超過了50%。不過，考慮到願意接受懲罰方案的參與者有可能從一開始就有較高的戒菸積極性，仍需對上述數字加以校正。

Even after that adjustment, those who signed up for the penalty were nearly twice as likely to quit as those who opted for pure rewards, and five times as likely to quit as those who just got free counseling or nicotine replacement therapy. Even so, the largest overall effect was among the group that was assigned to pure rewards, simply because so many more people took part.

但即使經過這麼一番校正，願意接受懲罰方案的參與者戒菸的可能性仍是選擇單純獎勵方案者的近兩倍，是隻接受免費諮詢或尼古丁替代療法者的五倍。縱然如此，整體效果最好的仍要數純獎勵組，因爲這組的參與者人數要多得多。

“This is an original set of findings,” said Cass R. Sunstein, a Harvard law professor who helped develop some influential ideas in the field of behavioral economics, notably that if the social environment can be changed — for example, by posting simple warnings — people can be nudged into better behavior. “They could be applied to many health issues, like alcoholism, or whenever people face serious self-control problems.”

哈佛大學法學院的教授卡斯·R·桑斯坦( Cass R. Sunstein)說：“這些發現很有獨創性，可以應用於酗酒等很多健康問題，或是人面臨嚴重自我控制問題的時候。”桑斯坦教授曾幫助建立起行爲經濟學領域的某些深具影響力的觀點，其中特別值得一提的是：改變社會環境（例如，張貼簡單的警告）可以敦促人們改善自己的行爲。

Professor Sunstein, who oversaw regulatory policy for the Obama administration from 2009 to 2012 and now directs the Program on Behavioral Economics and Public Policy at Harvard, wrote an opinion article on the study, but was not involved in it.

2009年至2012年期間，他負責了奧巴馬政府的管控政策，現在是哈佛大學行爲經濟學和公共政策項目(Program on Behavioral Economics and Public Policy)負責人。他爲上文介紹的研究撰寫過評論文章，但並沒有實際參與其中。

Over all, success eluded most of the study participants. More than 80 percent of smokers in the most popular pure rewards group were still smoking at the end of the study. Even so, researchers say, their success rate was far greater than for those who got the traditional treatment, signaling that there could be substantial public health benefits in offering financial incentives.

總體而言，大多數研究參與者都沒能成功戒菸。在研究結束時，最受歡迎的純獎勵組中有超過80%的吸菸者依舊在吸菸。但研究人員表示，即便如此，他們的成功率仍遠遠超過了傳統療法，這表明提供經濟獎勵有可能帶來重大的公共衛生效益。

And even a small decline could have a big health effect. Smoking is the largest cause of preventable death in the United States. Diseases linked to it kill more than 480,000 Americans a year.

在美國，吸菸是可預防性死亡的首要原因。每年因吸菸相關疾病致死的美國人超過48萬人。因此，哪怕是吸菸率的小小降低也將帶來巨大的健康效應。