Omar Metwally, MD
University of California, San Francisco

If I were a government or private health insurance company trying to improve public health and reduce costs associated with treating cancers, chronic obstructive pulmonary disease, cardiovascular diseases, and many other preventable tobacco-related illnesses, how would I take on this challenge? Would offering nicotine addicts cash or subsidizing their insurance premiums curtail these unhealthy behaviors? While there’s some evidence that paying smokers works in the short-term, the effect is modest and has not been shown to be a successful long-term strategy.  The 2017 recipient of the Nobel Prize in Economic Sciences, Professor Richard Thaler’s work demonstrates how humans’ bias toward short-term rewards contributes to poor long-term decision making. Especially in the case of chemical dependence, immediate positive reinforcement (e.g. a puff of a cigarette) trumps the relative abstractness of long-term planning. Who doesn’t want to live a long, healthy life free of suffering, expensive healthcare bills, and the loss of independence associated with frequent trips to the hospital? But to an addict, a drag from a cigarette is more attractive than the prospect of being rewarded with something like health, time, or disposable income in 10, 20, or 50 years time.

Breaking chemical dependence, and modifying behavior (such as a sedentary lifestyle, unhealthy eating habits, and compliance with preventive healthcare) in general, depends to a large extent on modifying one’s environment. This includes things like eliminating triggers (ashtrays, packs of cigarettes and lighters lying around), and enablers. More effective than paying someone to ditch unhealthy habits may be helping someone with an addiction change their social context. I’m skeptical about the efficacy of an incentive program that would, for example, pay smokers cash in exchange for urine tests that verify an individual’s nicotine-free status. The desire for long-term abstinence from substances, weight loss, or regular exercise must be intrinsic and reinforced by the company one keeps. A chronic smoker is more likely to smoke among a group of friends who also smoke than in an environment where they’re constantly subject to inconvenience, protest, or punishment whenever they reach for a cigarette. The corollary is the hypothesis that helping a smoker and their group of smoking friends quit together may be more effective than limiting an intervention to individuals.

Continuing the thought experiment, how does a health minister or surgeon general help people modify unhealthy behavior while changing one’s entire psychosocial situation? Instead of an intervention like a urine test, which people may find embarrassing or perhaps not worth the inconvenience of extra pocket money paid at the conclusion of a research study, what might a reward system look like which compensates individuals based on a convenient, dignified, and inexpensive  “proof-of-motivation”? If I’m a smoker interested in quitting  and make my intentions clear to my family, friends, and co-workers, could their vouching for me serve as such proof-of-motivation? If I truly muster the willpower to not smoke for a week, month, or year, could the people closest to me supplant something as sensitive/specific as a blood or urine test?

A hacker-mind will be quick to point out that a nicotine addict, if determined to do so, will find a way to game simple trust-based systems, whether it means stepping into -20C weather, walking for a mile to a secluded smoking spot, or sneaking cigarettes while driving to and from work. Moreover, a smoker could easily convince others to lie about their behavior in exchange for sharing the reward with colluders. What is necessary is a more perfect mechanism for allowing individuals to vouch for one another’s behavior. Earlier in my career, I had a tendency as a technologist in general and blockchain researcher in particular to reach for technology XYZ and ask, what can I do with this technology? I see this bias throughout Silicon Valley; we love to build things, and technology is an easy starting point for our desire to effect change.

The organizational and technological merits of my specialty’s distributed, peer-to-peer paradigms are rather clear. The other half of the blockchain equation, proof-of-work, makes sense in the context of value stores, a feature common to the two predominant cryptocurrencies (Ethereum and Bitcoin) — in addition to Ethereum’s Turing completeness and logic layer. In the excitement of embracing new technologies, one should be wary of shoehorning technologies into domains where a logical fit doesn’t exist. Bitcoin as a digital asset makes sense. Ethereum as a value store — and much of its organizational functionality  — makes sense.

But with the goals of promoting healthy behaviors, helping developing countries kick a terribly addictive habit, and improving air quality as our starting point, how does one begin to effect change without burning up the planet’s resources in the process (one Bitcoin transaction wastes enough energy to power a household in a developing country for weeks)?

I would love the feedback of people thinking about this problem from different points of view. More than a billion human lives, which will be claimed by the tobacco industry in the 21st century, depend on it.