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Contingency Management Smoking Cessation in Appalachia

  • Need: To reduce smoking rates of pregnant women and adolescents in Appalachian regions of eastern Kentucky and Ohio.
  • Intervention: A web-based smoking cessation program that offered monetary incentives to reducing smoking.
  • Results: Participants significantly reduced smoking rates or quit altogether.


Promising (About evidence-level criteria)


According to the University of Kentucky, research results continue to find that the Appalachian population has the highest rates of smoking and smoking-related diseases in the nation. In addition, Appalachian women who are pregnant are more likely to smoke, with as many as one in four smoking while pregnant.

In 2009, University of Kentucky Associate Professor of Behavioral Sciences Brady Reynolds started working with a web-based contingency management (CM) smoking cessation program. This web-based model has the potential to solve the isolation or travel issues that come with living in rural areas. The program focused on pregnant women and adolescents in Appalachian regions of Kentucky and Ohio. Reynolds used the web-based program Motiv8 as a server for the project. Like other CM curriculums, the smoking cessation program offers rewards to achieve results. Participants are given monetary incentives in the form of vouchers to reduce their smoking. These vouchers are then used for online purchases. Program directors buy the items for participants in order to make sure purchases are appropriate.

Two to three times a day during each phase, participants would submit video recordings of themselves giving breath samples using a handheld breath carbon monoxide (CO) reader known as a Smokerlyzer. Similar to a breathalyzer for alcohol, the Smokerlyzer requires a person to breathe into the device which produces results within seconds. The readings show participants how much CO is in the person's lungs and bloodstream. A higher CO level indicates recent smoking from the participant. While abstinence was the goal for every participant, goals for reducing smoking were individualized based on the participant's initial smoking rate. Goals and CO levels were mapped so participants could track their improvements in real time.

The web-based CM smoking cessation program was funded by a grant from the National Cancer Institute.

Services offered

The CM program lasted 6 weeks and consisted of five phases. Each phase had monetary incentives that increased with each accomplished goal. Total potential earnings from all phases combined could total approximately $830.

  • Baseline (7 days) – Participants become accustomed to submitting CO breath samples and determine their baseline average CO level
  • Shaping (4 days) – Participants receive reinforcements for gradual decreases in CO level
  • Abstinence (21 days) – The goal of this phase was to promote continued abstinence. Abstinence from smoking was defined as 4 part per million (ppm) carbon CO or less.
  • Thinning (5 days) – The purpose of the thinning phase was for participants to gradually transition from the high incentives for abstinence. In this phase, participants were still required to submit the same amount of breath samples at the same ppm.
  • Return to Baseline (5 days) – Incentives were removed and participants were evaluated to see if they would return to smoking


In a pilot study of 7 pregnant women:

  • Participants provided an average of 68% of their required, twice daily breath samples
  • Participants who quit or reduced smoking in this program provided 71.4% of their required breath samples
  • At peak abstinence, 30% (2 of 7) of participants were able to quit smoking
  • Continuing smokers reduced smoking by 50% on average

In a study of 62 adolescent smokers, teens were split between an active group that required breath CO reduction, and a control group where no requirements were implemented. However, both had access to the same potential monetary incentives.

  • Both groups significantly reduced their breath CO
  • Active group participants reduced their average CO from baseline to return-to-baseline phase by 4.4 ppm compared to 1.7 ppm reduction by the control group
  • Only participants from the active group maintained all reductions until 6-week post treatment
  • On average, active group participants earned $147.90 compared to $345.26 earned on average from members of the control group

Research and publications relating to smoking cessation program:

Harris, M., Reynolds, B. (2015). A pilot study of home-based smoking cessation programs for rural, Appalachian, pregnant smokers. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 44(2), 236-245. Article abstract.

Reynolds, B., Harris, M., Slone, S.A., Shelton, B.J., Dallery, J., Stoops, W. and Lewis, R. (2015). A feasibility study of home-based contingency management with adolescent smokers of rural Appalachia. Experimental and Clinical Psychopharmacology, 23(6), 486-493. Free full-text.


A lack of Internet service and computer equipment were the principal barriers of this program since many living in Appalachia have limited or no broadband access. Used loaner equipment was a necessity and was reused as much as possible. Roughly 95% of smoking cessation participants required loaner equipment.

CM cost approximately $296 per participant for program financial incentives. Additionally, there were ongoing costs for loaner equipment (e.g., laptop, web camera, CO monitor) and Internet access that would further increase the expense of implementing CM. These costs could make this program difficult to use widely without grant funding.


Providing smoking cessation treatment to rural smokers is often difficult due to travel, economic, and cultural barriers. This makes web-based programs attractive to project creators. However, determining equipment and broadband service needs should be a main priority when constructing a rural, web-based, cessation program.

Dr. Reynolds and collaborators found that a similar phone-based model used for pregnant smokers also showed success. While tracking CO levels of participants would require creative thinking, a phone-based program could be a replication alternative to deal with broadband and equipment barriers.

Children and youth
Maternal health and prenatal care
Technology for health and human services
Tobacco use
Wellness, health promotion, and disease prevention

States served
Kentucky, Ohio

Date added
February 24, 2016

Date updated or reviewed
June 3, 2022

Suggested citation: Rural Health Information Hub, 2022. Contingency Management Smoking Cessation in Appalachia [online]. Rural Health Information Hub. Available at: [Accessed 29 May 2024]

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.