Encouraging Mammograms Using Behavioral Economics: A Randomized Controlled Trial in Chile.

OBJECTIVES: This article illustrates the effect of a direct mail campaign that used insights from behavioral economics and psychology to increase the number of free mammograms in Chilean women aged 50 years or older. METHODS: We hypothesized 4 barriers in obtaining a mammogram based on previous literature and focus group analysis. A behavioral economic approach providing incentives was used to help overcome these barriers. We accessed a unique data set, which comprised 12 000 women 50 years old or older, with private health insurance who have not had a mammogram for 24 or more months. We conducted a randomized controlled trial with 8 treatments, each involving a specific combination of messages. RESULTS: The intervention overall led to a 167% increase in the use of free mammograms, a 1.13% to 3.03% average increase from the control to treatment groups, respectively. Regarding barriers, we found that all messages were effective, with a slightly larger and persistent effect for the less complex ones in terms of information. This finding illustrates the benefits of keeping the message simple. CONCLUSIONS: Finally, these results suggest a successful public policy for increasing use of free mammography programs. Moreover, they are potentially transferable because the study considered decision-making heuristics that are not specific to one culture or social context.

Refining the marijuana purchase task: Using qualitative methods to inform measure development.

Behavioral economic demand for cannabis (i.e., relative reinforcing value) can be measured via marijuana purchase tasks (MPTs). However, commodity ambiguities pose challenges and design concerns exist regarding current MPTs. The aim of this 2-phase study was to modify and improve a MPT using qualitative methods. Phase I: Focus groups were conducted with regular (i.e., average use ≥ once/week) cannabis users (n = 31; 6-7 per group M[SD] age = 26 [7]; 28% female). Focus groups followed a semistructured agenda, and executive summaries were made concerning key MPT themes. Feedback was used to refine the MPT. Phase II: Cognitive interviews using the refined MPT were conducted with regular cannabis users (n = 20; M[SD] age = 28 [8]; 50% female). Phase I: Focus group analyses highlighted 4 critical areas for MPT improvement: (a) unit of purchase, (b) cannabis quality, (c) time duration specified for use episode, and (d) price. Participants suggested using grams as the unit of purchase, tailoring cannabis quality to the individual, and clarifying intended episode length. Phase II: Cognitive interviewing indicated additional areas for task refinement, resulting in a second iteration of the MPT based on the 2 phases. Qualitative research in both phases suggested a number of substantive modifications to the MPT format. MPT modifications are expected to improve comprehension, ecological validity, and general construct validity. Findings highlight the importance of careful instructional set development for drug purchase tasks for heterogeneous products that do not have standard units of consumption. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The behavioral economics of the bottomless cup: The effects of alcohol cup price on consumption in college students.

Heavy drinking among college students is a public health concern in part due to the accessibility of alcohol and promotions such as "happy hours," which discount the price of alcohol. In addition, consuming alcohol at unregulated off-campus parties may result in greater alcohol consumption, higher blood alcohol concentrations, and increased negative consequences. The purpose of the current study was to assess demand for a refillable red "Solo" cup using a new hypothetical purchase task, the Cup-Price Purchase Task (CPPT). The CPPT asked college student participants to read a description of an off-campus party drinking context and indicate the likelihood of purchasing a refillable cup at prices ranging from $0.00-$60.00. We found that at cup prices of $5.00 or below, the likelihood of purchase was 75% or higher; however, probability of purchase decreased to about 47% at a cup price of $10.00. In addition, several CPPT behavioral economic parameters were positively correlated with the Alcohol Purchase Task (APT) and other alcohol-related measures, providing support for the CPPT's construct validity. Finally, hierarchical regression analyses revealed that maximum expenditure on the CPPT was a unique predictor of both alcohol consumption and alcohol-related consequences, even after controlling for the APT metrics. These findings may inform future studies investigating the behavioral economics of high-risk drinking situations and potential strategies to reduce binge drinking. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Interactions between opioids and cannabinoids: Economic demand for opioid/cannabinoid mixtures.

BACKGROUND: Opioid abuse remains a significant public health challenge. With continuing emergence of novel psychoactive substances (e.g., synthetic cannabinoids found in "K2" or "spice" preparations), the co-administration of opioids and other novel drugs is likely to become more prevalent, which might increase the risk for abuse and other adverse effects. This study examined whether the synthetic cannabinoid receptor agonist JWH-018 alters the reinforcing effectiveness of the mu opioid receptor agonist remifentanil in rhesus monkeys (n = 4) using economic demand analyses. METHODS: Lever presses delivered intravenous infusions of a drug or drug mixture according to a fixed-ratio schedule. For each condition, the ratio progressively increased in quarter-log unit steps across sessions yielding a demand curve: consumption (infusions obtained) was plotted as a function of price (fixed-ratio value). RESULTS: When available alone, remifentanil (0.00032 mg/kg/infusion) occasioned the highest consumption at the lowest cost and highest essential value, while JWH-018 (0.0032 mg/kg/infusion) alone occasioned lower unconstrained demand and essential value. Unconstrained demand for a mixture of remifentanil and JWH-018 was lower than for remifentanil alone, but essential value of the mixture was not significantly different from that of remifentanil alone. CONCLUSION: These data indicate that synthetic cannabinoids such as JWH-018 might alter some aspects of opioid self-administration (i.e., decreased consumption at the lowest price) but do not enhance reinforcing effectiveness as measured by sensitivity of consumption to increasing costs. Opioid/cannabinoid mixtures do not appear to have greater or lesser abuse potential compared with opioids alone.

Economía del comportamiento para mejorar estilos de vida y reducir factores de riesgo / Behavioral economics to improve lifestyle choices and to reduce risk factors

Una parte importante de la morbimortalidad se debe a hábitos de vida y factores de riesgo modificables. Una estrategia prometedora para promover el cambio de tales factores pasa por la aplicación de intervenciones de salud pública basadas en la economía del comportamiento, rama del conocimiento que combina principios psicológicos y económicos. Este artículo se centra en un tipo de intervención conocida como nudge (traducida habitualmente como «empujón» o «acicate»), que modifica la conducta sin restringir la capacidad de elección de las personas. Se analizan las diferentes propiedades que caracterizan a los nudges y diversos ámbitos en los que se han aplicado con éxito: vacunación, alimentación, actividad física, cesación tabáquica y prescripción de medicamentos. En conclusión, la economía del comportamiento y los nudges tienen un gran potencial para su aplicación en la esfera de la salud pública en España

A large part of morbimortality is caused by lifestyle habits and modifiable risk factors. A promising strategy to promote the change of such factors is the implementation of public health interventions based on behavioral economics, a discipline that combines psychological and economic principles. In the present article, we focus on a type of intervention known as "nudge" (that has been translated into Spanish as empujón or acicate), that changes behaviour without limiting the individual's choice. We analyze the properties that characterize nudges, and several areas in which they have been successfully implemented: vaccination, nutrition, physical activity, smoking cessation and drug prescription. We conclude that behavioural economics and nudges have great potential for their implementation in the public health sphere in Spain

The drug purity discounting task: Ecstasy use likelihood is reduced by probabilistic impurity according to harmfulness of adulterants.

BACKGROUND: Ecstasy typically contains adulterants in addition to, or in lieu of, MDMA which may pose a greater risk to users than MDMA itself. The current study aimed to evaluate the effectiveness of adulterant-related informational prompts in reducing Ecstasy use using a novel probability discounting task. METHODS: An online sample of past-month Ecstasy users (N = 278) were randomized to one of four different framing prompt conditions: no prompt; a prompt describing MDMA's effects; a prompt describing adulterants as inert "filler"; or a prompt describing adulterants as pharmacologically-active, potentially-harmful compounds. Each prompt contained general, potential public-health information that was not specifically related to subsequent behavioral tasks. All participants then completed an identical Drug Purity Discounting Task, in which they indicated the likelihood of using a sample of Ecstasy across different probabilities of the sample being impure, and then completed a hypothetical Ecstasy purchasing task. RESULTS: Likelihood of Ecstasy use decreased as impurity probability increased across conditions. Ecstasy use likelihood was highest in the "inert" prompt condition, whereas pharmacologically-active adulterant or adulterant-nonspecific prompts resulted in comparably low likelihood of use. Ecstasy-use likelihood did not differ among conditions when the likelihood of sample impurity was 0. Ecstasy purchasing did not differ among groups. Inelastic purchasing was associated with greater likelihood of using potentially-impure Ecstasy. CONCLUSIONS: Altogether, these data highlight the necessity of education regarding pharmacologically-active, rather than inert, adulterants in Ecstasy, and suggest that increased access to drug checking kits and services may mitigate some of the harms associated with Ecstasy use.

Alcohol demand assessed daily: Validity, variability, and the influence of drinking-related consequences.

BACKGROUND: Alcohol demand, typically assessed at the trait-level, via single administration, reflects individualized alcohol value. We examined correspondence between baseline trait-level and daily brief measures of alcohol demand, and whether demand changes day-to-day in response to recent drinking-related consequences. Understanding whether consequences influence demand fluctuations may provide insight into when demand can be reduced in the context of intervention. METHODS: Heavy drinking college students (n = 95, age 18-20, 52% female) completed a baseline 14-item alcohol purchase task (APT). Observed demand indices were: intensity (consumption at zero cost), Omax (maximum expenditure), and breakpoint (cost whereby consumption is suppressed to zero). Participants subsequently completed 28 daily reports including a 3-item APT (one item corresponding to each baseline index) and prior day drinking and consequences. RESULTS: Intraclass correlations revealed within-person variability (i.e., day-to-day change) across daily demand indices. In hierarchical linear models (HLM), each daily demand index was significantly predicted by its corresponding baseline full APT index, when all three baseline indices were entered, suggesting convergent validity of the daily measure. Lower day-level intensity was predicted by more prior day negative consequences, controlling for several day- and person-level variables in HLM. Recent positive consequences did not impact intensity, and daily Omax and breakpoint were not predicted by any tested day- or person-level variables. CONCLUSIONS: APT indices collected daily map on well to traditional single-administration APT metrics and change in response to recent consequences. Intensity demonstrated the greatest within-person variability, the strongest association with its corresponding full APT index, and theoretically-consistent prediction by negative consequences of drinking.

The impact of vaping and regulatory environment on cigarette demand: behavioral economic perspective across four countries.

BACKGROUND AND AIMS: Government regulations of nicotine vaping products (NVP) have evolved rapidly during the past decade. The impact of NVP regulatory environment and vaping on cigarette demand is unknown. The current study aims to investigate whether or not respondents' reported cigarette demand, as measured by a hypothetical cigarette purchase task, varies with (1) smoking status, (2) vaping status or (3) NVP regulatory environment (country used as proxy). DESIGN: Cross-sectional survey data from wave 1 of the International Tobacco Control (ITC) Four Country Smoking and Vaping (4CV) Survey (2016). SETTING: Australia, Canada, England and the United States. PARTICIPANTS: A total of 10 316 adult smokers. MEASUREMENTS: A hypothetical purchase task asked smokers to estimate how many cigarettes they would purchase for consumption in a single day across multiple cigarette prices. Responses were used to derive measures of cigarette demand. Overall sensitivity of cigarette consumption to price increases was quantified to index cigarette demand elasticity, whereas estimated consumption when cigarettes are free was used to index cigarette demand intensity. FINDINGS: A majority of the non-daily smokers had previously smoked daily (72.3%); daily vapers were more likely to be former daily smokers (89.9%) compared to non-daily vapers (70.1%) and non-vapers (69.2%) (P < 0.001). The smoking status × vaping status interaction was significant for cigarette demand intensity (F = 4.93; P = 0.007) and elasticity (F = 7.30; P = 0.001): among non-daily smokers, vapers reported greater intensity but lower elasticity (i.e. greater demand) relative to non-vapers (Ps < 0.05). Among daily smokers, daily vapers reported greater intensity relative to non-vapers (P = 0.005), but vaping status did not impact elasticity (Ps > 0.38). Intensity was higher in Australia compared with all other countries (Ps < 0.001), but elasticity did not vary by country (F = 2.15; P = 0.09). CONCLUSIONS: In a hypothetical purchase task, non-daily smokers showed lower price elasticity if they used e-cigarettes than if they did not, while there was no clear difference in elasticity between e-cigarette users and non-users among daily smokers or according to regulatory environment of their country with regard to e-cigarettes.

Elevated Behavioral Economic Demand for Alcohol in Co-Users of Alcohol and Cannabis.

OBJECTIVE: Co-use of cannabis and alcohol is associated with increased drinking and other negative consequences relative to use of alcohol alone. One potential explanation for these differences is overvaluation of alcohol (e.g., alcohol demand) among co-users, similar to established overvaluation of alcohol among tobacco and alcohol co-users. This study examined differences in alcohol demand between an alcohol and cannabis co-user group and an alcohol-only group. METHOD: A large sample of adult drinkers (n = 1,643, 54% female) was recruited through an online crowdsourcing site (Amazon Mechanical Turk). Of the full sample, 476 participants reported weekly or greater cannabis use in the past 6 months (co-user group); 888 reported never using cannabis in the past 6 months (alcohol-only group). Assessments included a validated alcohol purchase task and self-report measures of alcohol and cannabis use. RESULTS: Co-users reported significantly higher alcohol consumption across the elastic portion of the alcohol demand curve (i.e., $1.50-$9.00/drink). Analyses of covariance controlling for alcohol use and demographics revealed significantly higher breakpoint (p = .025) and Omax (p = .002) and significantly lower elasticity (p < .003) in the co-user group. Intensity and Pmax did not significantly differ between groups. CONCLUSIONS: Co-users of cannabis and alcohol overvalue alcohol compared with individuals who drink alcohol but do not use cannabis. This study is generally consistent with prior studies on alcohol and tobacco co-users, providing converging evidence that polysubstance use is associated with overvaluation of alcohol. These findings have important implications for treatment and prevention, particularly in the context of changes in cannabis legalization.

Cigarette and e-liquid demand and substitution in e-cigarette-naïve smokers.

Behavioral economic methods allow experimental manipulation of price and examination of its effects on tobacco product purchasing. These methods may be used to examine tobacco product abuse liability and to prospectively model possible effects of price regulation. In the present study, we examined multiple measures of behavioral economic demand for cigarettes and e-liquid for use in a second-generation electronic cigarette (e-cigarette) in e-cigarette-naïve cigarette smokers. Twenty-five smokers received an e-cigarette (eGo ONE CT), sampled study e-liquid (24 mg/mL nicotine), and completed recurring sessions in which they used an experimental income to purchase real-world supplies of cigarettes and/or e-liquid. Participants also completed self-report measures of drug effects/liking. When products were available alone, we observed lower demand for e-liquid than for cigarettes. This effect was magnified when cigarettes and e-liquid were available concurrently. In additional assessments, e-liquid served as a partial substitute for cigarettes, but cigarettes did not serve as a substitute for e-liquid. Finally, participants rated e-liquid more poorly than cigarettes on several dimensions of drug effects/liking (any effects, liking, desire, and probability of continued use). We conclude that e-cigarette-naïve smokers value cigarettes more highly than e-liquid across multiple contexts and measurements. Nonetheless, participants still valued e-liquid positively and purchased it frequently, both as a substitute for cigarettes and independently of cigarettes. To understand the variables that influence transitions from exclusive smoking to either dual cigarette/e-cigarette use or exclusive e-cigarette use, future work should systematically examine the role of duration of e-liquid exposure. (PsycINFO Database Record

Developing a laboratory model of smoking lapse targeting stress and brief nicotine deprivation.

Stress plays a significant role in the maintenance of, and relapse to, smoking. The current study aims to develop a human laboratory model examining stress-precipitated tobacco lapse following brief nicotine deprivation. Daily smokers (N = 48; 50% female) who were nicotine deprived for 3 hr received a personalized imagery induction (stress or neutral, within-subject, counterbalanced) on 2 separate days. Following imagery induction, participants were instructed that they could smoke or receive monetary reinforcement ($0.25, $0.50, $1.00; between-subjects) for every 5 min they chose to delay tobacco self-administration during a 50-min delay period. After the delay period, participants engaged in a 1-hr ad libitum smoking period. Tobacco craving and mood were assessed throughout. The primary aim was to determine whether stress imagery would reduce the ability to resist following a brief nicotine deprivation in a laboratory setting. A secondary goal identified which level of monetary reinforcement highlighted the effect of stress on reduced ability to resist smoking (i.e., resisting ∼25 min of the 50-min window). Overall, stress versus neutral imagery decreased the ability to resist smoking, increased craving and negative mood states, decreased positive mood, but did not change ad libitum smoking. Increased monetary reinforcement increased the ability to resist smoking. Planned comparisons examining lapse behavior within each monetary condition demonstrated that $0.50 produced the only significant difference between stress and neutral imagery, demonstrating target model behavior. Findings highlight that stress negatively impacts smoking lapse behavior and can be effectively modeled in the human laboratory with a brief, 3-hr deprivation window. (PsycINFO Database Record

Evaluating Behavioral Economic Models of Heavy Drinking Among College Students.

BACKGROUND: Heavy drinking among college students is a significant public health concern that can lead to profound social and health consequences, including alcohol use disorder. Behavioral economics posits that low future orientation and high valuation of alcohol (alcohol demand) combined with deficits in alternative reinforcement increase the likelihood of alcohol misuse. Despite this, no study has examined the incremental utility of all 3 variables simultaneously in a comprehensive model. METHODS: This study uses structural equation modeling to test the associations between behavioral economic variables-alcohol demand (latent), future orientation (measured with a delay discounting task and the Consideration of Future Consequences [CFC] scale), and proportionate substance-related reinforcement-and alcohol consumption and problems among 393 heavy drinking college students. Two models are tested as follows: (i) an iteration of the reinforcer pathology model that includes an interaction between future orientation and alcohol demand; and (ii) an alternative model evaluating the interconnectedness of behavioral economic variables in predicting problematic alcohol use. RESULTS: The interaction effects in Model 1 were nonsignificant. Model 2 suggests that greater alcohol demand and proportionate substance-related reinforcement are associated with greater alcohol consumption and problems. Furthermore, CFC was associated with alcohol-related problems and lower proportionate substance-related reinforcement but was not significantly associated with alcohol consumption or alcohol demand. Finally, greater proportionate substance-related reinforcement was associated with greater alcohol demand. CONCLUSIONS: Our results support the validity of the behavioral economic reinforcer pathology model as applied to young adult heavy drinking.

Effects of Filter Ventilation on Behavioral Economic Demand for Cigarettes: A Preliminary Investigation.

Introduction: The majority of cigarettes sold in the United States and abroad feature filter ventilation holes designed to dilute mainstream smoke. Although initially intended to produce a safer cigarette, data instead suggest that filter ventilation increases total harm from smoking. In the present study, we examined the effects of blocking ventilation holes on behavioral economic demand for cigarettes (i.e., consumption as a function of price). Methods: In a within-subjects design, regular smokers (N = 15) of ventilated cigarettes sampled vent-blocked cigarettes for 3 days. Subsequently, they completed three sessions in which they used an experimental income to purchase vent-blocked and/or control cigarettes across a range of prices. Participants also completed the Drug Effects/Liking Scale. Results: In sessions in which only one cigarette type was available, demand measures were undifferentiated between cigarette types. However, in sessions in which both cigarettes were available at equivalent prices, significantly greater preference for ventilated control cigarettes emerged in demand measures. Regardless of session type, participants also rated vent-blocked cigarettes more poorly in the Drug Effects/Liking Scale (more bad effects, fewer good effects, and less liking, desire, and less likely to use again). Conclusions: Removing filter ventilation reduced cigarette abuse liability, as measured by behavioral economic demand and the Drug Effects/Liking Scale. However, reduced demand was only apparent when both cigarette types were concurrently available. This selective effect suggests that regulatory action banning filter ventilation would only reduce cigarette consumption when effective substitutes for vent-blocked cigarettes are available. Implications: This preliminary study indicates that regulatory action designed to ban or restrict cigarette filter ventilation may decrease cigarette abuse liability as measured by both behavioral economic demand and self-report measures. However, effects of removing filter ventilation on demand measures appear to depend on concurrent availability of alternative, preferred cigarette types.

Using institutional and behavioural economics to examine animal health systems.

Economics provides a framework for understanding management decisions and their policy implications for the animal health system. While the neoclassical economic model is useful for framing animal health decisions on the farm, some of its assumptions and prescriptive results may be unrealistic. Institutional and behavioural economics address some of these potential shortcomings by considering the role of information, psychology and social factors in decisions. Framing such decisions under contract theory allows us to consider asymmetric information between policy-makers and farmers. Perverse incentives may exist in the area of preventing and reporting disease. Behavioural economics examines the role of internal and external psychological and social factors. Biases, heuristics, habit, social norms and other such aspects can result in farm decision-makers arriving at what might be considered irrational or otherwise sub-optimal decisions. Framing choices and providing relevant information and examples can alleviate these behavioural issues. The implications of this approach for disease policy and an applied research and outreach programme to respond to animal diseases are discussed.

L'économie fournit un cadre permettant de comprendre les décisions managériales et leurs conséquences sur les politiques à mener en matière de santé animale. Le modèle économique néoclassique permet, certes, d'encadrer utilement les décisions de santé animale à l'échelle de l'exploitation, mais certaines de ses hypothèses et des préconisations qui en résultent paraissent irréalistes. Ces carences potentielles sont en partie traitées par l'économie institutionnelle et comportementale, qui prend en considération le rôle joué par l'information, par la psychologie et par les facteurs sociaux dans le processus de prise de décision. La formulation de ces décisions dans les termes de la théorie des contrats nous permet de prendre en compte l'asymétrie de l'information entre les décideurs politiques et les éleveurs. Des incitations à effets pervers peuvent exister dans le domaine de la prévention et de la notification des maladies. L'économie comportementale examine le rôle de facteurs internes et externes de nature psychologique et sociale. Les biais, les raisonnements heuristiques, le poids de l'habitude, les normes sociales et d'autres influences similaires peuvent donner lieu à des décisions que l'on peut considérer comme irrationnelles ou médiocres. La formulation des choix effectués et la diffusion d'informations pertinentes et d'exemples sont des moyens d'atténuer ces déterminations comportementales. Les auteurs examinent les conséquences de cette approche dans l'élaboration des politiques sanitaires et présentent un programme de recherche appliquée et d'information sur le terrain pour faire face aux maladies animales.

La economía ofrece un marco de referencia para entender las decisiones de gestión y sus consecuencias normativas para todo sistema zoosanitario. Mientras que el modelo económico neoclásico resulta útil para inscribir las decisiones de sanidad animal en el contexto de la explotación, a veces algunos de sus postulados y resultados prescriptivos no son realistas. La economía institucional y conductual da respuesta a varias de esas posibles insuficiencias porque tiene en cuenta el papel que cumplen la información, la psicología y los factores sociales a la hora de adoptar decisiones. El hecho de encuadrar tales decisiones en la teoría de los contratos nos permite tener en cuenta la asimetría de la información que manejan los planificadores de políticas y los productores agropecuarios. También puede haber incentivos perversos en cuanto a la prevención y notificación de enfermedades. La economía conductual examina la función de factores de orden social y psicológico, tanto internos como externos. Los prejuicios, la heurística, los hábitos, las normas sociales y otros aspectos de parecida índole pueden llevar a los responsables de una explotación a adoptar decisiones que cabría considerar irracionales, o en cualquier caso no idóneas. El hecho de inscribir en un marco de referencia las opciones existentes y de facilitar información y ejemplos pertinentes puede reducir el peso de estos problemas de conducta. El autor examina lo que estos métodos pueden aportar a las políticas sanitarias y los programas de divulgación e investigación aplicada para la lucha contra las enfermedades animales.

Leveraging Behavioral Economics to Improve Heart Failure Care and Outcomes.

Behavioral challenges are often present in human illness, so behavioral economics is increasingly being applied in healthcare settings to better understand why patients choose healthy or unhealthy behaviors. The application of behavioral economics to healthcare settings parallels recent shifts in policy and reimbursement structures that hold providers accountable for outcomes that are dependent on patient behaviors. Numerous studies have examined the application of behavioral economics principles to policy making and health behaviors, but there are limited data on applying these concepts to the management of chronic conditions, such as heart failure (HF). Given its increasing prevalence and high associated cost of care, HF is a paradigm case for studying novel approaches to improve health care; therefore, if we can better understand why patients with HF make the choices they do, then we may be more poised to help them manage their medications, influence daily behaviors, and encourage healthy decision making. In this article, we will give a brief explanation of the core behavioral economics concepts that apply to patients with HF. We will also examine how to craft these concepts into tools such as financial incentives and social networks that may improve the management of patients with HF. We believe that behavioral economics can help us understand barriers to change, encourage positive behaviors, and offer additional approaches to improving the outcomes of patients with HF.