Smoking Cessation for Lung Cancer Screening: Incentives Beat Free Pharmacotherapy

Adding financial incentives to an ask-advise-refer strategy and free pharmacotherapy increased the rate of sustained tobacco abstinence among medically underserved adults referred for lung cancer screening, according to a randomized clinical trial published in JAMA.

The Centers for Medicare & Medicaid Services requires health systems to offer smoking cessation services to patients undergoing lung cancer screening, but the most effective cessation methods for medically underserved patients are unknown, the investigators noted. The pragmatic trial enrolled currently smoking individuals referred for screening at 4 US health systems (5 centers) who identified as Black, Hispanic, living in a rural area, or being of low socioeconomic status.

Participants were randomized to ask-advise-refer to cessation services (usual care); usual care plus free pharmacotherapy (nicotine replacement and reimbursement for varenicline or bupropion); usual care, free pharmacotherapy, and financial incentives of up to $600 contingent on biochemically confirmed cessation; or all of these plus a mobile health tool motivating patients to think about their future health. The primary end point was biochemically confirmed, sustained tobacco abstinence through 6 months.

Of 3259 randomized patients, 3220 were included in the primary analysis (median age, 61.1 years; 60.3% female; 25.5% Black; 38.8% rural). Sustained abstinence rates were 4.3% with usual care, 5.1% with added pharmacotherapy, 8.8% with added financial incentives, and 7.2% with the added mobile health tool. Financial incentives increased the adjusted abstinence rate compared with usual care (difference, 4.6%; 95% CI, 2.1%-7.0%) and with usual care plus free pharmacotherapy (difference, 4.1%; 95% CI, 1.7%-6.4%). Free pharmacotherapy was not superior to ask-advise-refer alone (difference, 0.5%; 95% CI, −1.7% to 2.6%).

The investigators concluded that among medically underserved adults who smoked and were referred for lung cancer screening, sustained abstinence rates through 6 months were higher with financial incentives than with ask-advise-refer alone or with free pharmacotherapy added.

Source: Hart JL, Vachani A, Neslund-Dudas CM, et al. Smoking cessation among underserved patients referred for lung cancer screening: a randomized clinical trial. JAMA. Published online October 5, 2026. doi:10.1001/jama.2026.17192