Quit rates nearly doubled when medically underserved people who smoke were offered cash rewards for quitting, according to a large national trial published in JAMA. Participants who were offered up to $600 in payments tied to verified abstinence quit at almost twice the rate of those given standard care alone. The trial enrolled more than 3,200 adults who still smoked and had been referred for lung cancer screening, a group that traditional quit-smoking programmes often fail to reach.
The study, known as the Healthy Lungs trial, was led by researchers at the University of Pennsylvania’s Perelman School of Medicine and ran at five medical centres in four health systems: Penn Medicine, Geisinger, Henry Ford Health and Kaiser Permanente Southern California. The findings were published in JAMA on 5 October 2026. The researchers said it was believed to be the largest trial to test whether cash rewards could lift quit rates among patients referred for lung cancer screening, and one of the largest conducted among medically underserved groups.
The trial compared four approaches. One group received usual care, which meant being asked about smoking, advised to quit and referred to support services. A second group received usual care plus free cessation medication, including nicotine replacement therapy and reimbursement for varenicline or bupropion. A third group received the medication plus financial incentives of up to $600. A fourth group received all of that plus a text-based tool called FutureMe, which prompted participants to imagine their future smoke-free lives.
Quit rates across the four groups
After six months, the quit rates, confirmed by blood or urine tests, were 4.3 percent with usual care alone, 5.1 percent with free medication added, 8.8 percent with financial incentives added, and 7.2 percent with incentives plus the FutureMe tool. The incentive group quit at more than double the rate of the usual care group, and the gap was large enough that it could not be put down to chance. Free medication alone did not beat usual care by a clear margin.
The payments were tied to proof, not promises. Participants could earn $100 after two weeks smoke-free, $200 after three months and $300 after six months, with each payment depending on a blood or urine sample showing they were nicotine-free. The schedule was designed to reward early success and to lift quit rates through the six months when relapse is most common.
The people in the trial were the ones most often left behind by quit-smoking services. The median age was 61, six in ten participants were women, a quarter were Black, about 9 percent were Hispanic, and nearly four in ten lived in rural areas. Many came from lower-income backgrounds, and more than half smoked over 10 cigarettes a day. Screening for the trial began in May 2021, and the last follow-up was in April 2025.
Quit rates and the people the trial reached
Scott Halpern, director of the Palliative and Advanced Illness Research Center at Penn, said the team found that adding financial incentives increased quit rates in a population that can be especially difficult to reach with traditional smoking cessation approaches. The trial’s authors said the incentives worked better than usual care and better than usual care plus free medication, a result that held up after adjusting for other factors.
The FutureMe tool did not add to the effect of the incentives. The group that received incentives plus the text-message tool quit at 7.2 percent, below the 8.8 percent of the incentives-only group, and the trial did not show that the mobile tool was better than incentives alone. The authors said the finding does not show that medication is useless when used properly, only that free medication on its own did not lift quit rates in this group.
The trial was funded through a Patient-Centered Outcomes Research Institute award. Its authors said the results point to a practical option for health systems that serve people with fewer resources: paying people to quit, with proof required, can work where advice and free medication have not lifted quit rates. The payments are small next to the cost of treating smoking-related illness, and the trial’s design makes the approach easy to copy.
Questions remain. The trial followed people for six months, so it does not show how many stayed smoke-free for years, and it does not show whether the same approach would work for people who are not being screened for lung cancer. The researchers also note that the incentives were tested alongside free medication and standard care, not on their own. Even so, the quit rates in the incentive group were the highest in the trial, and the gap over usual care was clear.