TOPLINE

Financial incentives contingent on biochemically confirmed smoking cessation more than doubled sustained tobacco abstinence rates through 6 months among medically underserved adults referred for lung cancer screening (LCS), compared with ask-advise-refer alone or with the addition of free pharmacotherapy. Sustained abstinence rates were 4.3% with ask-advise-refer, 5.1% with added pharmacotherapy, 8.8% with added financial incentives (up to $600), and 7.2% with added incentives plus a mobile health tool.

METHODOLOGY

• Researchers conducted a pragmatic, 4-group randomized clinical trial at 5 US health systems (Geisinger Health System, Henry Ford Health, Kaiser Permanente Southern California, University of Pennsylvania Health System, and Lancaster General Health) from May 2021 to April 2025.
• A total of 3220 medically underserved adults (median age 61.1 years, 60.3% female, 25.5% Black, 8.9% Hispanic, 38.8% rural, 47.1% with household income ≤ 200% of federal poverty level) who currently smoked and were referred for LCS were included in the analysis.
• Participants were randomly assigned to 1 of 4 additive intervention groups: (1) ask-advise-refer (usual care); (2) usual care plus free nicotine replacement therapy (NRT) and reimbursement up to $300 for varenicline or bupropion; (3) usual care, free pharmacotherapy, and financial incentives up to $600 contingent on biochemically confirmed cessation; or (4) usual care, free pharmacotherapy, financial incentives, and an episodic future-thinking mobile health tool (FutureMe).
• The primary outcome was sustained, biochemically confirmed tobacco abstinence through 6 months, verified by urine cotinine (≤50 ng/mL), urine anabasine (<3 ng/mL if using NRT), or blood carboxyhemoglobin (≤4% if using electronic cigarettes) at 2 weeks, 3 months, and 6 months after the target quit date.
• Participants set their target quit date up to 60 days after enrollment and received a second chance to confirm abstinence 2 weeks later if initial biochemical tests indicated tobacco use.

TAKEAWAY

• Adding financial incentives (group 3) increased adjusted rates of sustained tobacco abstinence compared with usual care (difference, 4.6 [95% CI, 2.1-7.0] percentage points; P < .001) and compared with usual care plus free pharmacotherapy (difference, 4.1 [95% CI, 1.7-6.4] percentage points; P < .001).
• Adding free pharmacotherapy to ask-advise-refer was not superior to ask-advise-refer alone (difference, 0.5 [95% CI, −1.7 to 2.6] percentage points; P = .66).
• Group 4 (incentives plus episodic future-thinking tool) was not statistically different from group 3 (incentives alone) and was not superior to free pharmacotherapy (difference, 2.4 [95% CI, 0.1-4.6] percentage points; P = .04).
• No tested participant characteristics (including demographics, daily cigarette use, smartphone access, or LCS scan results) influenced intervention effects on sustained 6-month abstinence.

IN PRACTICE

"Smoking cessation enhances the lifesaving effects of LCS, further reducing mortality and morbidity, with estimates indicating that achieving abstinence in 10% to 15% of screened individuals prevents 70% to 80% more deaths," wrote the authors of the study.

SOURCE

The study was led by Joanna L. Hart, MD, University of Pennsylvania in Philadelphia. It was published online on October 5 in JAMA.

LIMITATIONS

Relatively low uptake of varenicline and bupropion (14.8%) may have occurred because clinicians outside the trial had to write prescriptions before patients could be reimbursed. The low response rate for patient-reported outcomes (34.3%-36.3%) limited the ability to ascertain intervention effects on outcomes such as perceived self-efficacy in quitting. The pragmatic interventions tested did not include individualized counseling or tailored support for use of NRT, which might have increased abstinence rates but substantially increased costs.

DISCLOSURES

The study was funded by the Patient-Centered Outcomes Research Institute. One author reported having stock in Pfizer, Gilead, and Viatris. One author reported receiving personal fees from UpToDate and the American Thoracic Society. One author reported serving as a part-time employee of the study. One author reported receiving grants from Independence Blue Cross and the American Heart Association, being part owner of VAL Health, having stock options in Thrive Global, and receiving personal fees from the American Heart Association. Additional author disclosures are reported in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.