Financial incentives improve smoking cessation in lung-screening trial

Financial incentives added to smoking-cessation support increased verified six-month abstinence among medically underserved adults referred for lung cancer screening, according to a randomized trial published October 5 in JAMA. The findings give screening programs evidence for improving prevention at an encounter with patients already at elevated risk of tobacco-related disease.

The strongest-performing group received usual cessation services, free medication access and rewards contingent on verified quitting. Its abstinence rate was 8.8%, compared with 4.3% under usual care. The improvement was meaningful, but most participants did not meet the sustained-abstinence endpoint.

What the trial tested

Researchers randomized 3,259 patients across five centers in four US health systems; 3,220 entered the primary analysis. Participants currently smoked and identified as Black, Hispanic, living in a rural area or having low socioeconomic status. Their median age was 61.1 years.

Enrollment began May 17, 2021, and the last follow-up occurred April 29, 2025. This week's development is publication of the findings, rather than the completion or launch of the trial.

The four groups received progressively expanded support. Usual care used an ask-advise-refer approach: identify smoking, advise cessation and direct patients to resources. A second group also received free nicotine replacement and reimbursement for prescription cessation medicines. A third added financial rewards of up to $600 for biochemically confirmed cessation. A fourth added a mobile tool encouraging participants to imagine their future health.

The study was funded by the Patient-Centered Outcomes Research Institute. Its project description frames lung-screening appointments as opportunities to connect underserved patients with cessation support, with patients, clinicians and community members involved in planning the research.

A measurable gain with important boundaries

The primary endpoint was sustained tobacco abstinence through six months, checked using biochemical testing rather than relying solely on participants' reports.

Abstinence reached 5.1% with free medication access and 7.2% with the full package including the mobile tool. For the incentive group without the mobile tool, the adjusted advantage over usual care was 4.6 percentage points, with a 95% confidence interval of 2.1 to 7.0 points. Its adjusted advantage over usual care plus free medication was 4.1 points.

Free medication access alone did not significantly outperform usual care. That finding concerns the effectiveness of offering access through this particular program; it does not establish that cessation medicines lack efficacy. Similarly, the numerical difference between the two incentive groups does not, by itself, establish that the mobile tool made outcomes worse.

For service planning, the absolute difference deserves as much attention as the relative improvement. Approximately doubling a low starting rate still leaves substantial unmet need. The results support considering incentives as one component of a cessation service, while leaving room to improve engagement and sustained success.

Why it matters for healthy aging

CDC guidance identifies quitting smoking as beneficial at any age, including after years of heavy smoking. Established benefits include lower risks of cardiovascular disease, chronic obstructive pulmonary disease, several cancers and premature death. Those benefits explain the healthspan relevance of helping adults stop smoking around the time of lung screening.

However, this trial's six-month cessation result does not quantify additional years of life, reductions in cancer incidence or improvements in physical function. Those outcomes cannot be inferred directly from the observed percentage-point gain.

Randomization and biochemical verification strengthen the evidence. Its practical limits include the specific screening population, delivery through participating health systems and the duration of the reported endpoint. Whether the benefit persists over longer periods, transfers to other settings and justifies implementation costs remains important for decisions about broader adoption.