Money Helps: Financial Incentives for Smoking Cessation Among People Experiencing Homelessness

Abstract

Introduction: Over 70% of people experiencing homelessness report current cigarette smoking. We conducted a randomized controlled trial of an extended (6-month) contingency management (CM) intervention for smoking cessation among adults experiencing homelessness and who were engaged in primary care. We examined experiences and perspectives on cessation among a subset of participants in the trial. Methods: The CM group received escalating incentives in the form of gift cards contingent on carbon monoxide-verified abstinence; the control group received fixed incentives for attending visits, not contingent on abstinence. All participants received cessation care through their primary care clinics. At one‑year follow‑up, we invited a convenience sample (N = 31) from both study arms to complete in‑depth interviews. We conducted thematic analysis and mapped themes to Social Cognitive Theory constructs of reciprocal determinism, reinforcements, behavioral capability, self-efficacy, observational learning, and outcome expectancies. Results: Smoking was a reciprocal interaction among personal, environmental, and behavioral factors, with many participants ascribing their use to ongoing mental health and substance use. Participants in the CM and control groups reported that financial incentives reinforced smoking cessation and supported daily expenses. Incentives increased behavioral capability for cessation by increasing motivation and self-efficacy to quit. Participants reported that friends and family modeled smoking cessation, promoting observational learning. Outcome expectancies for smoking cessation included improvements in one’s own, friends’, and family’s health and improved quality of life. Conclusion: Participants experiencing homelessness viewed financial incentives as reinforcing smoking cessation and contributing to improved quality of life.