We used outcome data from a randomized work site intervention trial to examine the cost-effectiveness of four cardiovascular disease (CVD) risk reduction programs: health risk assessment (HRA), risk factor education (RFE), behavioral counseling (BC), and behavioral counseling plus incentives (BCI). Composite CVD risk scores were derived from measures of serum total cholesterol, blood pressure, number of cigarettes smoked, body mass index, and aerobic capacity. The economic evaluation of the programs focused on the subset of costs most sensitive to the differences between the interventions, and a sensitivity analysis examined some of the relevant cost variations. At the 6-month follow-up (i.e., the "action" or initiation stage of lifestyle change), the RFE, BC, and BCI interventions produced a significant reduction in cardiovascular risk. Incremental analyses demonstrated RFE to be more cost-effective, but not as clinically effective as BC; BC was more cost-effective than RFE when assessment costs were included, and BCI was judged to be the least cost-effective. At the 12-month follow-up (i.e., the "maintenance" stage of lifestyle of change), BC was the only program found to produce a significant reduction in CVD risk. Individualized behavioral counseling was found to be a cost-effective strategy for the initiation and maintenance of CVD risk factor reduction.