Background: Smoking is the leading preventable cause of death and disability in the United States, posing an enormous economic burden. While smoking rates in the United States are at an 80-year low, there remains a need for alternative approaches to further decrease smoking rates and prevent smoking associated morbidity and mortality. Financial incentives grounded in behavioral economic theory have emerged as an innovative approach for smoking cessation. 

Objective: To evaluate the efficacy of goal-directed financial incentives compared to outcome-based financial incentives strategies on rates of smoking cessation.

Methods: Smokers >18 years of age (n = 1,030) contemplating smoking cessation were recruited from Bellevue Hospital and Olive View-UCLA Medical Center from February 2019 to December 2023. Participants were randomized in a 2:2:1 ratio into one of 3 groups: (1) Goal-Directed, which linked financial incentives to utilization of evidence-based smoking cessation therapies; (2) Outcome-Based, which linked financial incentives to biochemically confirmed smoking cessation; or (3) Enhanced Usual Care, which included hospital-directed smoking cessation information, nicotine replacement therapy, and Quitline referral. All participants received enhanced usual care and earned $20 for each completed follow-up interview and $30 for each completed smoking cessation test. Participants in the incentive groups could earn up to $700.

Results: The 6-month rate of biochemically confirmed smoking cessation was 14.9% in the goal-directed group, compared to 23.8% in the outcome-based group (OR of 1.79; 95% CI, 1.26 - 2.55; p < 0.001). However, participants in the goal-directed financial incentive group were significantly more likely to utilize evidence-based therapies compared to outcome-based (p < 0.05) and enhanced usual care (p < 0.05) groups.  

Conclusion: Goal-directed financial incentives increased participation in evidence-based smoking cessation therapies, but outcome-based incentives increased abstinence rates compared to goal-directed incentives by the 6-month endpoint.