The U.S. is grappling with two leading and interwoven crises of addiction that result in far too many preventable deaths each year. While one is a problem that the country has been battling for decades, the other is relatively new. By now, you may have guessed the crises at hand: tobacco use and opioid and stimulant-related overdoses.
Policymakers, health researchers, and clinicians alike have advocated for and instituted countless measures to try to quell the high levels of tobacco and substance use and resulting morbidity and mortality — to no avail. Yet, one approach has not received nearly enough attention: contingency management, or paying cash incentives to reduce tobacco and substance use.
Before I get into the nuts and bolts of this approach, let’s take a closer look at the toll of tobacco and substance use, and the populations most impacted.
The Impact
In the U.S., smoking is the leading preventable cause of disease and death, with 480,000 people dying annually from tobacco-related illness. Meanwhile, nearly 108,000 individuals died in 2022 from drug-involved overdoses, including illicit drugs and prescription opioids. According to a 2022 report, more than 168 million individuals in the U.S. had used tobacco products, vaped nicotine, or used alcohol or an illicit drug in the past month.
A significant number of those who use tobacco or illicit drugs — and therefore endure the health consequences — face extreme poverty. Of the approximately 40 million people who live below the federal poverty line, 24% report current tobacco use. Data from a nationally representative sample showed that those living in the lowest income bracket were 34% more likely to use drugs in the past year. Among those living in extreme poverty — many of whom are experiencing homelessness — approximately 70% report current smoking, and of those, 30% to 50% report concurrent substance use.
In the context of the high proportion of tobacco and drug users who are extremely poor or experiencing homelessness, we should be considering the role that money and support play in reducing harmful tobacco or substance use.
The Case for Contingency Management
Three decades of research show that paying cash incentives, otherwise known as contingency management, can reduce tobacco and substance use among people who use these substances, including those who are poor. Especially when accompanied by medication-assisted treatment to prevent cravings and withdrawal, this combination is one of the most effective treatments for tobacco and substance use.
Research has also shown that treating tobacco and substance use together increases chances of quitting and lowers risk of relapse.
Over the past 2 years, I have been leading a research study on an integrated contingency management treatment protocol for tobacco cessation among people experiencing homelessness who had co-occurring substance use disorders and engaged in primary care in a safety net health system.
One group received escalating financial incentives, starting at $13 with an incremental increase of $0.50 each time they demonstrated quitting, up to $475 over 6 months. The other group received a fixed $5 incentive for attending each assessment visit. Both groups received evidence-based tobacco treatment that included medications and counseling through their primary care providers.
Our preliminary results showed that the group that received escalating financial incentives for quitting tobacco were, on average, quitting more than the group that received nominal incentives for engagement. The group that received the fixed incentives for engagement was also quitting more than expected. (Specific numbers will be published once the trial concludes.) When asked how groups used their gift cards, the most common answers were pet supplies, toiletries, laundry detergent, or food — items that supported daily life.
More importantly, participants reported that receiving incentives consistently improved their sense of well-being while also motivating tobacco cessation.
An Underutilized Approach
Despite the evidence, contingency management is the least utilized addiction treatment in community settings.
There are few integrated tobacco and substance use treatment protocols, and very few that use evidence-based cash incentives as an adjunct to medication assisted treatment. For stimulant use disorder, where there is no FDA-approved pharmacotherapy, contingency management is the only effective treatment.
So, why is it underutilized? Because of legal, logistical, philosophical, and ethical considerations that get in the way of access.
Legally, cash incentives conflict with federal and state anti-kickback laws. Community-based substance use treatment programs face criminal penalties for providing rewards for any services that are reimbursable by federal healthcare programs like Medicare and Medicaid. While small incentives may be no more than $75 per year, large incentives of $400-$600 (which are needed for effective contingency management) are not permissible under federal anti-kickback statues.
Furthermore, treatment protocols that incorporate contingency management can be logistically challenging and require intensive human resources. Providers need training on how to implement escalating incentive protocols that offer increasing reward amounts with longer periods of abstinence. Fidelity to treatment protocols is essential to treatment efficacy.
Lastly, opponents of this treatment plan take issue with providing monetary rewards to people who use tobacco or drugs because of the concern that people may use their rewards to purchase tobacco or drugs. Others express that people might “game the system” by demonstrating abstinence to receive cash but not exhibit real motivation to quit.
These barriers are real, but not insurmountable.
Overcoming Barriers to Implementation
Several professional organizations and advocacy groups like the American Society of Addiction Medicine and American Psychiatric Association have advocated for safe harbor protections to use contingency management through federally funded health plans. And in 2022, the HHS Office of Inspector General issued an advisory opinion saying that it would not impose sanctions upon a particular program involving a cash reward — issued through a debit card — for cessation of substance use.
These efforts have led to successes. The Veterans Health Administration has a successful national program supporting this treatment approach for addictions. A recent evaluation of its program showed improved substance use treatment outcomes in over 3,000 enrolled patients.
Several states have applied for a Section 1115 demonstration waiver that allows states to use Medicaid funds to support pilot or demonstration projects that improve delivery of services aligned with the Medicaid program.
In 2023, California was one of the first states to receive a Section 1115 waiver to use contingency management for stimulant use disorder. An independent evaluation of California’s Recovery Incentives program showed that the state’s outpatient program increased access to treatment, connected people to services, and was linked with high patient satisfaction. Other states, including New York and Washington, have similar programs.
Technical assistance centers like the Addiction Technology Transfer Centers offer training, assistance, and resources to outpatient treatment programs to integrate these treatment protocols for opioid and stimulant use. While these programs target substance use in general, there is an opportunity to better integrate tobacco cessation management into substance use treatment protocols. Through integration, these technical assistance centers could increase opportunities to utilize such effective treatment in community settings.
As healthcare providers caring for people who use tobacco or other substances, the collective call to action for policymakers, community leaders, advocates, and citizens must be to encourage states to use their Section 1115 demonstration waivers to integrate contingency management treatment protocols into community-based addiction treatment. It is also urgent to increase training of providers to offer this treatment.
Why? Quite simply, it saves lives.
Maya Vijayaraghavan, MD, MAS, is an associate professor of medicine and director of the Smoking Cessation Leadership Center at the University of California, San Francisco. She is a public voices fellow on homelessness with the OpEd Project in partnership with the UCSF Benioff Homelessness and Housing Initiative.
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