Lung cancer screening creates a uniquely important opportunity to address two major determinants of lung cancer mortality at the same time: detecting cancer earlier and helping people stop smoking. Yet smoking cessation remains difficult to achieve, particularly among populations affected by socioeconomic, geographic, and racial disparities in access to preventive care.
A large randomized clinical trial published online in JAMA on October 5, 2026, suggests that simply offering pharmacotherapy may not be enough. Among medically underserved adults referred for CT lung cancer screening, adding financial incentives contingent on biochemically verified smoking abstinence produced substantially higher sustained quit rates than the usual ask-advise-refer strategy or the addition of free pharmacotherapy alone (Hart et al., 2026).
The findings raise an important implementation question for lung cancer screening programs: if screening identifies people at high risk of lung cancer, should cessation programs also incorporate stronger behavioral incentives rather than relying mainly on referral and medication access?
A Pragmatic Trial in More Than 3,000 Patients
The randomized trial enrolled current smokers referred for lung cancer screening across four US health systems and five clinical centers. Participants were medically underserved and identified as at least one of the following: Black, Hispanic, living in a rural area, or having low socioeconomic status.
Between May 2021 and April 2025, 3,259 participants were randomized, with 3,220 included in the primary analysis. Median age was 61.1 years, 60.3% were women, 25.5% were Black, 8.9% were Hispanic, 38.8% lived in rural communities, and nearly three-quarters were classified as having low socioeconomic status. More than half reported smoking more than 10 cigarettes per day at enrollment (Hart et al., 2026).
Four Different Smoking-Cessation Strategies
Participants were randomized to one of four approaches. The first received the standard ask-advise-refer strategy, which served as usual care. The second received usual care plus free smoking-cessation pharmacotherapy, including nicotine replacement therapy and reimbursement for varenicline or bupropion.
The third received usual care, free pharmacotherapy, and financial incentives of up to $600, contingent on biochemical confirmation of smoking cessation. The fourth received all of those components plus a mobile health intervention designed to encourage participants to think about their future health. The primary endpoint was rigorous: sustained tobacco abstinence through six months had to be biochemically confirmed using cotinine, anabasine, or carboxyhemoglobin.
That makes the trial more informative than studies relying exclusively on self-reported cessation.
Financial Incentives Produced the Highest Quit Rate
Sustained tobacco abstinence through six months was:
- 4.3% with ask-advise-refer alone
- 5.1% with free pharmacotherapy added
- 8.8% with pharmacotherapy + financial incentives
- 7.2% with pharmacotherapy + financial incentives + the mobile health tool.
The financial-incentive strategy significantly increased smoking cessation compared with usual care.
The adjusted absolute difference was:
- +4.6 percentage points
- with a 95% CI of 2.1%–7.0% and P < .001.
Financial incentives also significantly outperformed free pharmacotherapy without incentives:
- +4.1 percentage points
- 95% CI 1.7%–6.4%, P < .001
The magnitude may look modest in absolute terms, but the quit rate was more than twice that seen with the basic ask-advise-refer approach. For a behavior as difficult to change as established cigarette smoking, particularly in populations facing structural barriers to cessation, that difference is clinically meaningful.
Free Pharmacotherapy Alone Was Not Enough
One of the most striking findings was what did not work. Adding free pharmacotherapy to ask-advise-refer produced a sustained abstinence rate of 5.1% compared with 4.3% with usual care.
The adjusted difference was only:
- 0.5 percentage points
- 95% CI −1.7% to 2.6%
- with P = .66.
In other words, simply making cessation medication available without additional behavioral reinforcement did not significantly improve sustained abstinence in this trial. This should not be interpreted as evidence that nicotine replacement, varenicline, or bupropion are ineffective smoking-cessation therapies.
Rather, it suggests that access to medication alone may not overcome all of the behavioral, socioeconomic, motivational, and structural barriers faced by medically underserved populations.
The Mobile Health Tool Did Not Improve on Financial Incentives
Adding the mobile health intervention to pharmacotherapy and financial incentives produced a quit rate of 7.2%, numerically lower than the 8.8% achieved with financial incentives without the mobile tool. The trial therefore provides no evidence from the reported primary results that the additional digital component improved cessation beyond the incentive-based strategy.
That finding is also informative. Digital interventions are attractive because they are scalable and relatively inexpensive, but adding more components does not automatically improve outcomes. The effectiveness of smoking-cessation programs may depend less on technological complexity and more on whether the intervention meaningfully changes behavior.
Lung Cancer Screening Is a Critical Opportunity for Smoking Cessation
The setting of this study matters. Patients presenting for LDCT screening are already confronting their personal risk of developing lung cancer. This creates what is often described as a teachable moment, a period in which motivation to stop smoking may be particularly high.
Screening programs therefore have an opportunity to do more than detect early-stage cancer. They can potentially become integrated prevention programs combining:
- LDCT screening
with
- evidence-based smoking cessation
For patients who stop smoking, the potential health gains extend well beyond lung cancer. Smoking cessation also reduces cardiovascular, respiratory, and other cancer-related morbidity and mortality. The screening encounter is therefore one of the most strategically important places to offer structured cessation treatment.
Why Underserved Populations Matter
The trial deliberately focused on populations that are frequently underrepresented in clinical research and that often face greater barriers to cessation care. Financial cost is one obvious barrier. But transportation, unstable employment, competing health priorities, medication access, digital access, stress, and limited continuity of medical care may all make sustained smoking cessation more difficult.
Financial incentives may work partly because they provide an immediate and tangible reward for a health behavior whose major benefits, reduced cancer, cardiovascular disease, and mortality, may otherwise feel distant. The trial was not designed to establish the psychological mechanism responsible for the effect. But from an implementation standpoint, the result suggests that behavioral economics may have a practical role within lung cancer prevention programs.
A Doubling of Quit Rates Does Not Mean the Problem Is Solved
The results are encouraging, but they also reveal how difficult sustained cessation remains. Even with the most successful intervention, only 8.8% of participants achieved sustained biochemically verified abstinence through six months. More than 90% did not meet the primary cessation endpoint. That means financial incentives should not be viewed as a complete solution.
Instead, the study identifies a strategy that improves outcomes while highlighting the need for better and more individualized approaches. Future programs may need to combine behavioral incentives with pharmacotherapy, counseling intensity, repeated quit attempts, treatment of nicotine dependence, mental health support, and longer-term follow-up.
The Main Clinical Message
The trial challenges the assumption that improving access to cessation medications alone will necessarily translate into meaningful population-level quit rates. For medically underserved patients referred for lung cancer screening:
- usual care: 4.3% quit rate
- usual care + free pharmacotherapy: 5.1%
- usual care + pharmacotherapy + financial incentives: 8.8%
- same strategy + mobile health tool: 7.2%.
Financial incentives were the component associated with the clearest improvement in sustained abstinence (Hart et al., 2026). The finding is particularly relevant as lung cancer screening programs expand. If health systems invest in detecting lung cancer earlier but fail to optimize smoking cessation at the same encounter, an important prevention opportunity may be lost.
The Bottom Line
The randomized JAMA trial by Hart and colleagues demonstrates that among medically underserved adults referred for lung cancer screening, financial incentives significantly improved biochemically verified sustained smoking cessation through six months. The most effective strategy achieved an abstinence rate of:
- 8.8%
compared with:
- 4.3% with ask-advise-refer alone.
Free pharmacotherapy alone did not significantly improve cessation compared with usual care, while adding a mobile health intervention did not further improve the incentive-based strategy. The implications extend beyond smoking cessation itself. Lung cancer screening should increasingly be viewed not simply as an imaging program, but as a broader lung cancer prevention platform.
LDCT can detect disease earlier. But helping patients stop smoking remains one of the most powerful interventions available to reduce future lung cancer risk. The new trial suggests that, particularly for underserved populations, how cessation support is structured may matter as much as whether it is offered.
Reference
- Hart, J. L., Vachani, A., Neslund-Dudas, C. M., et al. (2026). Smoking cessation among underserved patients referred for lung cancer screening: A randomized clinical trial. JAMA. https://doi.org/10.1001/jama.2026.17192
