Cash Rewards Nearly Double Smoking Quit Rates in Trial of Underserved Patients

A four-year clinical trial testing ways to help low-income, rural, Black and Hispanic smokers quit found that cash rewards tied to verified abstinence nearly doubled six-month quit rates compared with standard counseling and referral, according to findings published online Oct. 5 in JAMA. Free nicotine-replacement therapy and prescription quitting medication, offered without a financial incentive, produced no statistically significant improvement over counseling alone.

The trial enrolled 3,220 adults who were referred for low-dose CT lung cancer screening, a group researchers chose because screening visits create a recurring, teachable moment to raise smoking cessation with people who have often smoked for decades. Participants were recruited at Penn Medicine, Geisinger, Henry Ford Health and Kaiser Permanente Southern California as part of the Healthy Lungs trial, which was registered with the National Institutes of Health in 2021 and ran until last year.

What the trial found

Researchers randomly assigned participants to one of four approaches, each adding a layer onto the one before it. The base arm offered the usual advice-and-referral approach that most primary care clinics use. Later arms added free pharmacotherapy, then financial incentives of up to $600 for biochemically confirmed abstinence, and finally a mobile app built around prompting people to picture their future health.

• Advice and referral alone: 4.3% quit at six months
• Advice, referral and free medication: 5.1% quit
• Adding incentives of up to $600: 8.8% quit
• Incentives plus a future-focused mobile tool: 7.2% quit

The incentive arm's advantage over usual care was statistically significant and sizable: an absolute difference of 4.6 percentage points, meaning the intervention roughly doubled the share of people who successfully quit. Incentives also outperformed free medication alone by 4.1 percentage points. Free medication by itself, without a payment attached, produced only a 0.5-point improvement over counseling alone, a difference that did not reach statistical significance. Quitting was confirmed not by self-report but by laboratory tests for nicotine metabolites in blood or urine samples collected at two weeks, three months and six months, with payments released only when a sample came back clean: $100 at the first checkpoint, $200 at three months and $300 at six months for those who stayed smoke-free throughout.

The researchers screened nearly 10,000 patients to assemble the final study group of 3,220, drawing on records from five screening centers across four health systems. The typical participant was 61 years old, and more than half smoked more than 10 cigarettes a day at enrollment, a profile that put them well outside the age range and smoking history typically seen in workplace-based cessation trials. Enrollment began in the spring of 2021 and follow-up did not close until the spring of 2025, making this one of the longest-running tests of incentive-based cessation support conducted in a screening setting.

Why this population, and why now

Lung cancer screening programs have expanded steadily as Medicare and private insurers have broadened coverage for current and former heavy smokers, but the patients eligible for screening are often older, sicker and more likely to have tried and failed to quit multiple times than participants in typical smoking-cessation studies. The trial specifically targeted communities that have had limited access to cessation support: people with lower incomes, residents of rural areas, and Black and Hispanic patients who make up a disproportionate share of those referred for screening but an outsize share of smoking-related illness.

Researchers at Penn's behavioral economics and health policy programs have spent nearly two decades testing whether paying people to quit smoking works better than giving them tools for free. Much of that earlier work was done through employer wellness programs, where participants tended to be younger, more consistently employed and less likely to face the kind of financial strain that can make even a modest cash reward meaningful. The new trial was designed specifically to test whether the same approach would hold up in a population that employer-based studies rarely reach: people identified not through a workplace but through a medical referral for a cancer screening test, at an age when decades of smoking have already taken a toll.

"These participants had smoked for decades and likely made multiple unsuccessful quit attempts in the past," said Dr. Scott D. Halpern, the trial's senior investigator and a professor at the University of Pennsylvania.

Dr. Joanna L. Hart, the study's lead author, said the results matter because so few interventions have been tested specifically in this group. "Finding new approaches that help people successfully stop smoking can have an enormous impact," she said, according to coverage of the findings.

What happens next

The mobile app arm, which combined incentives with prompts encouraging participants to imagine their future selves, did not outperform incentives alone, suggesting the payment itself was doing most of the work rather than the behavioral add-on. That finding could simplify how health systems design future programs, since it points toward incentive payments as the more essential ingredient rather than a more elaborate app-based layer.

The study leaves open questions that matter for anyone trying to translate it into practice. Six months of confirmed abstinence is a meaningful milestone, but it does not establish how many participants stayed smoke-free once the payments stopped, and the researchers have not yet published longer-term follow-up. There is also the practical matter of who would pay for incentive programs at scale: a $600-per-patient reward is modest compared with the long-term costs of smoking-related disease, but it still requires a health system, insurer or employer willing to fund it upfront.

For now, the trial adds to a body of evidence on smoking-cessation strategies showing that free medication alone is rarely enough to move quit rates for people who have smoked the longest and tried the hardest to stop. Pairing a cessation visit with a direct financial reward, verified rather than taken on faith, produced the clearest signal in the trial. Screening appointments already bring smokers into contact with the health system on a recurring basis, and the trial suggests that attaching a modest, verified incentive to that contact point produces measurably better odds of quitting than advice alone.