How to prevent obesity? Look to anti-smoking efforts

May 25th, 2017

Almost half of deaths in the U.S. are caused by our decisions to engage in unhealthy behaviors like poor food choices and alcohol, tobacco, and illicit drug use. So it should be easy to improve health, right? Not really, as it turns out. People continue to make self-destructive choices, despite knowing that their behaviors will likely cause them problems in the long run. That means policymakers need to understand why people make those choices, and then give them good reasons to make different decisions, researchers say. That approach has led to successful efforts to change unhealthy behavior, according to a review of research by Warren Bickel and his colleagues in Policy Insights from the Behavioral and Brain Sciences.

Bickel and colleagues’ review finds that many common unhealthy choices share two features. The first is a tendency to over-value a reward or reinforcement; in other words, to think the payoff is so great it’s worth the accompanying problems. To change this equation, economists say we need to think about the concept of price, which is the ratio of reward to the amount of work required to get it. To reduce the likelihood of a behavior, we can raise its price, either by increasing the work required or decreasing the amount of the reinforcement. Research on drug use finds that such strategies can be effective; for example, substituting the “reward” of a drug high for an alternative reinforcement has sometimes been effective.

The second factor is something researchers call delay discounting – a tendency to place a much higher value on an immediate reinforcement than a longer-term one. Studies show that delay discounting is common among people addicted to drugs: they tend to pay more attention to the reward of a short-term high than the long-term one of a stable relationship or a long, healthy life. The greater their delay discounting tendency, the worse their addiction tends to be.

The rise in behavior-induced obesity appears to be related to both demand and delay discounting, according to Bickel his coauthors. Right around the same time, unhealthy foods became cheaper and more available (decreasing price and enhancing immediate rewards) and sedentary lifestyles became more alluring, thanks to personal computers and mobile technology (possibly contributing to delay discounting in decisions about physical activity). That means it may take multiple strategies to combat the obesity epidemic. Fortunately, previous research on other unhealthy behaviors can provide some clues of what to do – and what not to do.

Smoking rates have been significantly reduced due to strategies that target demand and delay discounting. Tobacco taxes have increased the financial price, and restrictions on smoking in public places have increased social costs. Nicotine patches and other substitutes have reduced demand, and behavioral programs that provide small daily rewards for abstaining have reduced delay discounting. On the other hand, for an example of what not to do, policymakers can look to drug policies, which the authors state have had “less remarkable effects.” A centerpiece of anti-drug policies is criminalization, which is supposed to increase cost and price, and create barriers to consumption. But it doesn’t work that way in practice, the authors say. Criminal punishment is “often a delayed and ambiguous consequence,” because most people don’t get caught or convicted, and even if they do, there is a long delay between use and consequence. Plus, the black market undercuts efforts to increase price, and criminalization alone doesn’t provide any viable substitute rewards.

Research suggests there is more for obesity prevention efforts to emulate in the anti-smoking movement than the anti-drug one. While some policymakers believe a tax on soda is one step in that direction, policymakers might be wise to add other strategies derived from behavioral economics, including improving the accessibility of healthy food substitutes, and offering immediate rewards or incentives for consuming them, Bickel and colleagues write. As the researchers point out, unhealthy behavior choices have multiple causes, so they will need multiple solutions.

Drawn from “Decision-Based Disorders: The Challenge of Dysfunctional Health Behavior and the Need for a Science of Behavior Change” by Warren K. Bickel, Derek A. Pope, Lara N. Moody, Sarah E. Snider, Liqa N. Athamneh, Jeffrey S. Stein, and Alexandra M. Mellis in Policy Insights from the Behavioral and Brain Sciences.