Savvy policymakers have long argued that working with people’s natural instincts always produces the best results. Incentivising citizens to act responsibly is an idea beloved of the centre-right, because when done correctly it can produce social benefits quicker than any penalty or tax, or so the argument goes. I suspect that if householders thought increased recycling would keep their council tax bills down, the amount of rubbish diligently sorted each week would go through the roof.
Where is the harm, therefore, in paying pregnant women £400 to stop smoking if it results in more of them staying off cigarettes, and reduces NHS spending by cutting the health problems associated with smoking mothers?
The idea was posited on Wednesday in the British Medical Journal by researchers who conducted a trial in Glasgow in which shopping vouchers were offered to a group of mothers in return for quitting smoking. After a year 15% of the group, who received £400 of vouchers for stores such as Iceland and Argos, had managed to stay off cigarettes compared with 4% in the control group, who received standard NHS smoking cessation support.
While many would argue 15% is by no means a convincing result, the researchers from Glasgow and Stirling universities claimed the vouchers were cost-effective. Smoking during pregnancy, they pointed out, results in the deaths of 5,000 foetuses and babies each year in the UK, and tens of millions of pounds of healthcare spending.
A depressing 11% of pregnant women in England are smokers at the time of delivery. So perhaps that small increase from 4% to 15% of those trying to kick the habit is worth it. But, we ought to ask, at what cost, financially and morally?
Behavioural theory has gone through various fads and fashions in government recently. Steve Hilton set up a so-called nudge unit in Downing Street in 2010 to encourage citizens to do the right thing. The previous year Gus O’Donnell, then head of the civil service, had commissioned the Institute of Government to review the issue. Its report, Mindspace: Influencing Behaviour Through Public Policy, makes fascinating reading. “If we provide the carrots and sticks,” it says, “people will weigh up the revised costs and benefits of their actions and respond accordingly … Unfortunately, evidence suggests that people do not always respond in this perfectly rational way.”
Providing incentives to promote good social behaviours can reduce people’s motivation to make the right decisions, it said. “Intrinsic motivations come from the reward from carrying out the task itself, the feeling of satisfaction or self-worth that comes from an act of altruism.” In other words, you had better be sure you understand how human beings, with all their complex psychological flaws, are going to respond to incentives before you get too carried away.
Sometimes, I fear, people respond to cash incentives by being downright grasping. Paying pregnant mothers to stop smoking could make it cost-effective for the more desperate to take up the habit just before pregnancy so they can then get paid for “giving up”. In a world where cash-strapped people stage road accidents, it won’t take long for the needy or the workshy to figure out there’s money to be made by stinking of fags at their first midwife appointment. And what’s to stop any woman giving up smoking for nine months and then starting again?
More importantly, what of the wider implications of sending out a message that the more you misbehave the more you are rewarded? If we are increasingly paid for behaviour that ought to be standard, then we risk losing that intrinsic sense of right for right’s sake that O’Donnell’s report outlined. We could eventually reach a situation where miscreants have to be paid not to break the law. Yobs with a good grasp of what’s on offer might have to be given vouchers not to burgle houses. Children will learn that the quickest route to profit is to do wrong until you are paid to do right.
So how do we incentivise ethically? Well, might I suggest that in this case we tell pregnant mothers that if they give up smoking they will be able to keep more of their own money? They will not face penalties and they will not lose any benefits they currently enjoy. Those who refuse to give up might be told they must smoke on their own financial steam: while they continue to abuse their unborn children, they will lose any housing or unemployment benefits, because the state does not want to sponsor the damage.
But ultimately there should also be positive incentives, which reward responsible citizens. Those with good habits – nonsmokers, nondrinkers, those who take regular exercise and have health checkups – should qualify for a small tax rebate. If this incentivises more people to follow better health practices, millions could be saved from the NHS bill. And, more important, it would be done without the flagrant bribery of the Glasgow research and the damaging moral message it sends out.
