Four ways to help underserved smokers quit were tested. Only cash moved the needle.

Lung cancer screening exists partly to catch cancer early and partly as a moment to help people stop smoking. In the United States, health systems that offer screening are required to offer cessation help alongside it. What is far less clear is which kind of help actually works — especially for the patients screening programmes most struggle to reach.

JAMA published on October 5 a randomised trial that tested four escalating strategies head to head, in a population deliberately chosen to be medically underserved [s1].

Who was studied

The trial enrolled people who currently smoked and had been referred for lung cancer screening at four US health systems, across five centres [s1]. Eligibility was restricted to patients who identified as Black or Hispanic, lived in a rural area, or were of low socioeconomic status — groups that quit-smoking research has historically underrepresented [s1].

Of 9,963 patients assessed for eligibility, 3,259 were randomised and 3,220 were included in the primary analysis [s1]. The median age was 61.1 years; 1,948 participants (60.3%) were female, 823 (25.5%) were Black, 287 (8.9%) were Hispanic, 1,251 (38.8%) lived in rural areas, and 1,519 (74.9%) had low socioeconomic status [s1]. More than half — 1,792 (55.5%) — reported smoking more than 10 cigarettes a day at enrolment [s1].

The first participant was enrolled on May 17, 2021, and the last follow-up was on April 29, 2025 [s1].

The four strategies

Everyone started from the same base: the ask-advise-refer approach, in which a clinician asks about smoking, advises quitting, and refers the patient to cessation services. That was usual care [s1].

The other three arms added to it, cumulatively:

• Free pharmacotherapy — nicotine replacement plus reimbursement for varenicline or bupropion [s1].
• Financial incentives — the same free medication, plus up to $600 paid out contingent on biochemically confirmed quitting [s1].
• A mobile health tool — the medication and incentives, plus a digital prompt encouraging patients to think about their future health [s1].

The primary endpoint was biochemically confirmed, sustained tobacco abstinence through six months, verified with laboratory markers — cotinine, anabasine, or carboxyhaemoglobin — rather than self-report [s1]. That biochemical confirmation matters: it removes the wishful reporting that inflates quit rates in weaker studies.

The result

Sustained abstinence through six months was low across the board, which is itself part of the finding. The rates were 4.3% with usual care, 5.1% with the addition of free pharmacotherapy, 8.8% with the addition of financial incentives, and 7.2% with the addition of the mobile health tool [s1].

Two comparisons carry the message.

Adding financial incentives raised the adjusted abstinence rate compared with usual care — a difference of 4.6 percentage points (95% CI, 2.1 to 7.0; P<.001) — and also beat usual care plus free pharmacotherapy, a difference of 4.1 points (95% CI, 1.7 to 6.4; P<.001) [s1].

Adding free pharmacotherapy to ask-advise-refer, by contrast, was not superior to ask-advise-refer alone: a difference of 0.5 points (95% CI, −1.7 to 2.6; P=.66) [s1]. In other words, simply removing the cost of quit-smoking medication, without more, did not move the needle in this population.

What it does and does not establish

The ceiling is low. Even the best-performing strategy left roughly nine in ten participants still smoking at six months. The trial identifies what helps relative to usual care; it does not describe a solution.

Pharmacotherapy "not superior" is not "doesn't work." The comparison here is about adding free medication to a referral, in a group facing many barriers beyond cost. The result argues that access to medication alone is not the binding constraint — not that the medicines are ineffective.

Incentives were conditional and verified. The $600 was paid only on biochemically confirmed abstinence, which is both why the signal is credible and why real-world programmes would have to replicate that verification to expect the same effect.

It was confined to underserved groups by design. That is the trial's strength — these patients are usually understudied — but it also means the rates should not be read as representative of all screened smokers.

What to watch

The practical question the trial raises is whether screening programmes, and the insurers behind them, will pay modest conditional incentives when free medication alone does not deliver. The finding is specific: in this underserved population, money contingent on quitting outperformed free drugs. The trial is registered on ClinicalTrials.gov as NCT04798664 [s2].

If you are trying to stop smoking, free confidential help is available in the US at 1-800-QUIT-NOW. This article describes trial results for informational purposes only and is not medical advice.

Sources

• [s1] Smoking Cessation Among Underserved Patients Referred for Lung Cancer Screening. JAMA, published online 2026-10-05.
• [s2] Comparing Smoking Cessation Interventions Among Underserved Patients Referred for Lung Cancer Screening. ClinicalTrials.gov identifier NCT04798664.