A trial of 3,220 smokers puts cash rewards for quitting to the test

By Vijay Kumar MalesuReviewed by Susha Cheriyedath, M.Sc.Oct 11 2026

A large trial tests whether free medication, cash rewards, and texts about a smoke-free future can help patients quit, regardless of their initial motivation.

Study: Smoking Cessation Among Underserved Patients Referred for Lung Cancer Screening. Image Credit: New Africa  / Shutterstock

In a recent study published in The Journal of the American Medical Association (JAMA), researchers compared the effectiveness of usual care, free pharmacotherapy, financial incentives, and a mobile health tool to promote smoking cessation among medically underserved adults referred for lung cancer screening (LCS).

Background

Each year, cigarette smoking causes 7 million deaths worldwide, including approximately 450,000 in the United States (US). LCS with annual low-dose computed tomography can reduce mortality by nearly 25% among people with heavy tobacco smoking, yet about half of those screened continue to smoke.

Smoking cessation can further increase the benefits of screening. But people with lower socioeconomic status, living in rural areas, or belonging to racial or ethnic minority groups often have less access to cessation treatment.

Earlier trials generally enrolled people motivated to quit. Further research is needed to identify cessation strategies that can reach large populations regardless of readiness to quit.

About the study

The Healthy Lungs trial was a pragmatic, 4-group randomized clinical trial conducted at 5 US medical centers within 4 health systems. Adults aged 18 years or older with a clinician-ordered LCS scan who smoked at least 1 combustible cigarette daily and identified as Black, Hispanic or Latino/a, living in a rural area, or having low socioeconomic status were eligible.

Low socioeconomic status meant no formal education beyond high school or household income below 200% of the 2021 US federal poverty level. Participants needed a phone with text-messaging capability and intermittent internet access.

The trial used opt-out consent and enrolled participants regardless of their motivation to quit.

They were randomized to usual ask-advise-refer care; usual care plus free pharmacotherapy, including nicotine-replacement therapy (NRT) and reimbursement for varenicline or bupropion; the same treatment plus financial incentives up to $600; or all preceding interventions plus an episodic future-thinking mobile health tool that used text messages to prompt participants to imagine their future smoke-free lives.

Payments required verified abstinence: $100 at 2 weeks, $200 at 3 months, and $300 at 6 months. Kaiser Permanente participants entered only the three pharmacotherapy groups because free medication was already usual care.

The primary outcome was sustained smoking abstinence through 6 months, requiring self-reported cessation and biochemical confirmation at 2 weeks, 3 months, and 6 months after the target quit date.

Abstinence was assessed using urine cotinine, urine anabasine when NRT was used, or blood carboxyhemoglobin when electronic cigarettes were used. Participants with missing surveys or biochemical confirmation were classified as still smoking.

Study results

Of 9,963 patients assessed for eligibility, researchers randomized 3,259 and included 3,220 in the primary analysis. Participants had a median age of approximately 61 years and included Black and Hispanic adults, rural residents, and people with lower incomes or limited formal education. Most were women. More than half reported smoking more than 10 cigarettes per day.

Biochemically confirmed abstinence through 6 months occurred in 4.3% with ask-advise-refer alone, 5.1% with added pharmacotherapy, 8.8% with added financial incentives, and 7.2% with financial incentives plus the episodic future-thinking tool.

Financial incentives roughly doubled the proportion of participants achieving sustained abstinence compared with usual care. They also produced a significantly higher rate than usual care plus pharmacotherapy. Adding free pharmacotherapy to ask-advise-refer was not superior to ask-advise-refer alone.

Adding the future-thinking tool did not significantly improve abstinence compared with financial incentives without the tool. The authors also concluded that the mobile-tool combination was no better than free pharmacotherapy. Across tested subgroups, the researchers found no statistically detectable differences in intervention effects on sustained 6-month abstinence, including by readiness to quit.

Among participants offered incentives, about 1 in 8 received at least one payment. Around half of those offered the future-thinking tool created initial cues focused on their reasons for quitting, while fewer than one-quarter updated cues or requested them on demand.

Pharmacotherapy ordering rates were similar across the three groups offered medication. The authors did not analyze patient-reported outcomes because follow-up response rates were low, with only about one-third responding.

The paper also assessed 12-month abstinence and reported that it was largely sustained for six months after the interventions ended. Longer-term abstinence remains important because prior studies estimate around one in ten people relapse each year after achieving a year of abstinence.

Limitations included low uptake of varenicline and bupropion, absence of individualized counseling or tailored NRT support, and the need to establish longer-term durability. Limited engagement also qualifies the mobile tool’s results, and the adapted tool may not have fully reproduced the intended episodic future-thinking approach.

Conclusions

Among medically underserved adults who smoked cigarettes and were referred for LCS, adding financial incentives to ask-advise-refer care and free pharmacotherapy was associated with higher sustained tobacco abstinence through 6 months than ask-advise-refer alone or ask-advise-refer plus free pharmacotherapy.

Offering free pharmacotherapy alongside usual care did not significantly improve outcomes over usual care. Adding an episodic future-thinking mobile health tool did not significantly improve outcomes beyond financial incentives. 

These findings indicate that financial incentives improved cessation in this setting, but do not establish superiority over the mobile-tool combination or show that medications are ineffective when used appropriately.