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.
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
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
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.
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
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.
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
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
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
Children and youth
Maternal health and prenatal care
Technology for health and human services
Wellness, health promotion, and disease prevention
February 24, 2016
Date updated or reviewed
June 3, 2022
Suggested citation: Rural Health Information Hub,
Contingency Management Smoking Cessation in Appalachia [online]. Rural Health Information Hub. Available at:
[Accessed 2 October 2023]
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