Among medically underserved adults who smoked and were referred for lung cancer screening, the addition of financial incentives to usual care and free pharmacotherapy significantly increased rates of sustained tobacco abstinence compared with usual care alone or usual care plus free pharmacotherapy, according to findings from a pragmatic trial published by Hart et al in JAMA.
“These findings could be rapidly scaled into practice,” the investigators wrote, as the interventions “avoided individualized, labor-intensive outreach and counseling that would be challenging for [lung cancer screening] programs to scale.”
Study Details
The analysis included a total of 3,259 patients who currently smoked, were referred for lung cancer screening at five centers across four U.S. health systems, and identified as Black or Hispanic, lived in rural areas, or had low socioeconomic status. They were randomly assigned to one of four groups:
- Usual care consisting of an ask-advise-refer approach to smoking cessation services
- Usual care plus free pharmacotherapy (ie, nicotine replacement therapy and reimbursement for varenicline or bupropion)
- Usual care plus free pharmacotherapy and financial incentives of up to $600 contingent on biochemically confirmed smoking cessation
- Usual care plus free pharmacotherapy, financial incentives, and a mobile health tool encouraging patients to consider their future health.
A total of 3,220 patients were included in the primary analysis. The investigators documented a median age of approximately 61 years, with 60.3% of patients being female and 55.5% reporting smoking more than 10 cigarettes per day at enrollment. Additionally, 25.5% were Black, 8.9% were Hispanic, 38.8% lived in rural areas, 47.1% reported a household income at or below 200% of the U.S. federal poverty level, and 52.5% reported receipt of no more than a high school education.
The primary endpoint was sustained tobacco abstinence through 6 months, biochemically confirmed using cotinine, anabasine, or carboxyhemoglobin.
Key Findings
At 6 months, sustained tobacco abstinence rates were 4.3% with usual care alone, 5.1% with added pharmacotherapy, 8.8% with added financial incentives, and 7.2% with the further addition of a mobile health tool.
The addition of financial incentives to usual care plus free pharmacotherapy was found to be associated with significantly higher adjusted rates of sustained tobacco abstinence compared with usual care alone and usual care plus free pharmacotherapy (both P < .001). Sustained tobacco abstinence rates did not appear to significantly differ between patients receiving usual care alone and those receiving additional free pharmacotherapy (P = .66).
Of note, the further addition of the mobile health tool was not found to significantly improve sustained tobacco abstinence compared with financial incentives without the tool (P = .19).
“This pragmatic trial demonstrated that among four additive interventions to promote smoking cessation among medically underserved patients undergoing [lung cancer screening], addition of financial incentives was the most effective intervention,” the investigators concluded. “Importantly, in this nonselected population, the common practice of offering free pharmacotherapy did not promote smoking cessation.”
Joanna L. Hart, MD, of the University of Pennsylvania, Philadelphia, is the corresponding author of the article in JAMA.
Disclosure: The study was funded by the Patient-Centered Outcomes Research Institute. For full disclosures of the study authors, visit jamanetwork.com.
