Internet-based contingency management to promote smoking cessation: a randomized controlled study

Using behavioral economics to optimize safer undergraduate late-night transportation

Many universities sponsor student-oriented transit services that could reduce alcohol-induced risks but only if services adequately anticipate and adapt to student needs. Human choice data offer an optimal foundation for planning and executing late-night transit services. In this simulated choice experiment, respondents opted to either (a) wait an escalating delay for a free university-sponsored "safe" option, (b) pay an escalating fee for an on-demand rideshare service, or (c) pick a free, immediately available "unsafe" option (e.g., ride with an alcohol-impaired driver). Behavioral-economic nonlinear models of averaged-choice data describe preference across arrangements. Best-fit metrics indicate adequate sensitivity to contextual factors (i.e., wait time, preceding late-night activity). At short delays, students preferred the free transit option. As delays extend beyond 30 min, most students preferred competing alternatives. These data depict a policy-relevant delay threshold to better safeguard undergraduate student safety.

Cocaine abstinence during the "critical period" of a contingency management trial predicts future abstinence in people with cocaine use disorder

BACKGROUND

Contingency Management (CM) is being piloted as a treatment for stimulant use disorder in several US states, highlighting the need for treatment optimization. One important goal of optimization is decreasing drug use during the early stages of treatment, which has predicted success in other interventions. However, this "critical period" has not been reported in CM trials. The purpose of this analysis was to determine if, after accounting for baseline abstinence and incentive condition, abstinence in a CM trial for people with Cocaine Use Disorder (CUD) could be predicted by cocaine use during a first-week critical period.

METHODS

Eighty-seven participants with CUD were randomized to receive contingent high or low value incentives for cocaine abstinence or were in a non-contingent control group. Generalized estimating equations (GEE) were used to analyze urine test results over 36 timepoints during the 12-week intervention. To assess for a critical period, the first three visits were included in the GEE as a covariate for remaining urine test results.

RESULTS

Participants who provided more negative samples during the critical period were significantly more likely to produce a negative urine sample during the remainder of the trial, though some effects of group remained after controlling for the critical period.

CONCLUSIONS

These results indicate that a critical period exists for CM trials, and it can explain a substantial amount of future performance. Early contact with an abstinence-contingent high magnitude alternative reinforcer may explain additional performance beyond the critical period, further justifying the use of high magnitude alternative reinforcers.

A Secondary Analysis of a Preliminary Contingency Management Intervention for Presurgical Cancer Patients: Evaluating Individual Participant Data

INTRODUCTION

Contingency management (CM) interventions deliver monetary reinforcers contingent upon biochemically verified abstinence from smoking. CM has been found to be effective, however, individual participant, analyses are warranted to further elucidate how individual-level behavior patterns vary during the intervention period, both within and across treatment groups.

AIMS AND METHODS

This is a secondary analysis of a randomized controlled pilot trial of presurgical cancer patients who smoke (RCT N = 40). All participants were current everyday smokers and were enrolled in cessation counseling, offered nicotine replacement therapy, and submitted breath CO testing 3 times per week for 2-5 weeks. Participants randomized to CM received monetary reinforcers for breath CO ≤6 ppm on an escalating schedule of reinforcement with a reset for positive samples. Sufficient breath CO data exist for 28 participants (CM = 14; monitoring only [MO] = 14). Effect size was calculated for differences in negative CO tests. Time to first negative test was tested using survival analysis. Fisher's exact test was used to assess relapse.

RESULTS

The CM group achieved abstinence more quickly (p < .05), had a lower percentage of positive tests (h = 0.80), and experienced fewer lapses following abstinence (p = .00). While 11 of 14 participants in the CM group achieved and sustained abstinence by their third breath test, this was only true for 2 of the 14 MO participants.

CONCLUSIONS

Those in CM achieved abstinence quicker and with fewer lapses than those engaged in MO speaking to the efficacy of the schedule of financial reinforcement. This is particularly important within presurgical populations given the potential benefits to postoperative cardiovascular and wound infection risk.

IMPLICATIONS

While the efficacy of CM as an intervention is well established, this secondary analysis provides insight into the individual behavior patterns underlying successful abstinence. Those assigned to CM were not only more likely to achieve abstinence, but did so more quickly and with fewer instances of relapse. This is of particular importance to those scheduled for surgery where achieving abstinence as early as possible impacts on the risk of postoperative complications. CM interventions may be particularly well suited for critical windows in which timely and sustained abstinence is advantageous.

A Scoping Review and Meta-analysis of the Use of Remote Biochemical Verification Methods of Smoking Status in Tobacco Research

INTRODUCTION

Increasing digital delivery of smoking cessation interventions has resulted in the need to employ novel strategies for remote biochemical verification.

AIMS AND METHODS

This scoping review and meta-analysis aimed to investigate best practices for remote biochemical verification of smoking status. The scientific literature was searched for studies that reported remotely obtained (not in-person) biochemical confirmation of smoking status (ie, combustible tobacco). A meta-analysis of proportions was conducted to investigate key outcomes, which included rates of returned biological samples and the ratio of biochemically verified to self-reported abstinence rates.

RESULTS

A total of 82 studies were included. The most common samples were expired air (46%) and saliva (40% of studies), the most common biomarkers were carbon monoxide (48%) and cotinine (44%), and the most common verification methods were video confirmation (37%) and mail-in samples for lab analysis (26%). Mean sample return rates determined by random-effects meta-analysis were 70% for smoking cessation intervention studies without contingency management (CM), 77% for CM studies, and 65% for other studies (eg, feasibility and secondary analyses). Among smoking cessation intervention studies without CM, self-reported abstinence rates were 21%, biochemically verified abstinence rates were 10%, and 47% of individuals who self-reported abstinence were also biochemically confirmed as abstinent.

CONCLUSIONS

This scoping review suggests that improvements in sample return rates in remote biochemical verification studies of smoking status are needed. Recommendations for reporting standards are provided that may enhance confidence in the validity of reported abstinence rates in remote studies.

IMPLICATIONS

This scoping review and meta-analysis included studies using remote biochemical verification to determine smoking status. Challenges exist regarding implementation and ensuring high sample return rates. Higher self-reported compared to biochemically verified abstinence rates suggest the possibility that participants in remote studies may be misreporting abstinence or not returning samples for other reasons (eg, participant burden, inconvenience). Remote biochemical confirmation of self-reported smoking abstinence should be included in smoking cessation studies whenever feasible. However, findings should be considered in the context of challenges to sample return rates. Better reporting guidelines for future studies in this area are needed.

Delay discounting and substance use treatment outcomes: A systematic review focused on treatment outcomes and discounting methodology

INTRODUCTION

Delay discounting-the tendency to choose small, immediate rewards over larger, delayed rewards-is robustly associated with substance use. Delay discounting may present challenges in treatment for substance use disorders, as individuals with elevated discounting may struggle to wait for the long-term rewards that come from abstinence, which may yield poorer treatment outcomes. However, evidence on the role of discounting in treatment outcomes has been inconsistent. The study conducted a systematic review of the literature to characterize the prospective effects of delay discounting measured pre-treatment on substance use treatment outcomes, with a focus on characterizing findings across: 1) type of treatment outcome and 2) methodology used to assess and characterize discounting.

METHOD

A systematic literature search identified N = 17 studies that examined the association between delay discounting at treatment entry (pre-treatment) and substance use treatment outcomes. Findings were reported across the following substance use treatment outcomes: abstinence, relapse, use frequency and related problems, and treatment adherence. Findings regarding discounting methodology were reported by type of discounting measure (adjusting choice task, fixed choice task, or experiential task) and parameter used to characterize discounting (k, log transformed k (lnk), and area under the curve).

RESULTS

Delay discounting at treatment entry was not consistently associated with substance use treatment outcomes when examined across all studies overall (47 %) or by treatment outcome (0-40 % for most outcomes). The majority of studies (64 %) that used an adjusting choice, computer-based task reported a significant association between discounting and treatment outcomes, whereas few studies that used a fixed choice or experiential task reported significant associations with treatment outcomes (0-25 %). Most studies (71 %) that used the lnk parameter to characterize discounting reported significant associations between discounting and a range of treatment outcomes. In contrast, few studies that used k or AUC (25-33 %) reported significant associations between discounting and treatment outcomes.

CONCLUSION

When examined overall and by treatment outcome, evidence did not consistently indicate that delay discounting was prospectively associated with substance use treatment outcomes. However, delay discounting at treatment entry was more commonly associated with a variety of poorer treatment outcomes when researchers used more fine-grained methods to characterize discounting.

A delayed intervention start randomized controlled trial of high- and low-tech communication training approaches for school-age autistic children with co-occurring intellectual disability

The researchers designed a delayed intervention start randomized controlled trial to compare improvements in functional communication following augmentative and alternative communication (AAC) interventions. The study compared outcomes from function-based applied behavior analytic (ABA) and eclectic non-ABA forms of classroom-based communication strategies (waitlist control) as well as from high- and low-tech forms of AAC. High-tech AAC consisted of tablet-based communication, and low-tech AAC used an exchange of picture cards. The community-based sample consisted of 29 autistic children with a co-occurring intellectual disability. Participants were randomized to groups (AAC, waitlist control), and each group received approximately 3 months of communication intervention. Multilevel modeling of learner outcomes indicated that the function-based approach produced greater improvements than the eclectic alternative, but significant differences were not observed between outcomes of high- and low-tech forms of function-based AAC. These results are consistent with earlier investigations and provide supporting evidence that both high- and low-tech forms of function-based intervention are effective for use with autistic children with accompanying intellectual disability. Additional discussion is provided regarding further research into how technology is applied and incorporated into behavior analytic programming.

A systematic review of remotely delivered contingency management treatment for substance use

BACKGROUND

Substance use and related consequences (e.g., impaired driving, injuries, disease transmission) continue to be major public health concerns. Contingency management (CM) is a highly effective treatment for substance use disorders. Yet CM remains vastly underutilized, in large part due to implementation barriers to in-person delivery. If feasible and effective, remote delivery of CM may reduce barriers at both the clinic- and patient-level, thus increasing reach and access to effective care. Here, we summarize data from a systematic review of studies reporting remote delivery of CM for substance use treatment.

METHODS

We conducted a systematic review, reported according to PRISMA guidelines. The study team identified a total of 4358 articles after deduplication. Following title and abstract screening, full-text screening, and reference tracking, 39 studies met the eligibility criteria. We evaluated the methodological quality of the included studies using the Effective Public Health Practice Project Quality tool.

RESULTS

Of 39 articles included in the review, most (n = 26) targeted cigarette smoking, with others focusing on alcohol (n = 9) or other substance use or targeting multiple substances (n = 4). Most remotely delivered CM studies focused on abstinence (n = 29), with others targeting substance use reduction (n = 2), intervention engagement (n = 5), and both abstinence and intervention engagement (n = 3). CM was associated with better outcomes (either abstinence, use reduction, or engagement), with increasingly more remotely delivered CM studies published in more recent years. Studies ranged from moderate to strong quality, with the majority (57.5 %) of studies being strong quality.

CONCLUSIONS

Consistent with in-person CM, remotely delivered CM focusing on abstinence or use reduction from substances or engagement in substance use treatment services improves outcomes at the end of treatment compared to control conditions. Moreover, remotely delivered CM is feasible across a variety of digital delivery platforms (e.g., web, mobile, and wearable), with acceptability and reduced clinic and patient burden as technological advancements streamline monitoring and reinforcer delivery.

Comparative effectiveness of mobile health smoking cessation approaches among underserved patients in primary care: Study protocol for the PROMOTE-UP trial

INTRODUCTION

Tobacco smoking is the leading cause of preventable disease, disability, and premature death in the United States. Recent advances have led to two efficacious mobile health (mHealth) treatments for smoking cessation: iCanQuit, an Acceptance and Commitment Therapy-based behavioral treatment promoting cessation through accepting triggers and committing to values; and Motiv8, a contingency management intervention promoting smoking cessation with financial incentives via biochemically verified abstinence. This study will evaluate the comparative effectiveness of the Florida Quitline, iCanQuit alone, and iCanQuit+Motiv8 in a pragmatic trial among patients who smoke in underserved primary care settings.

METHODS

The study will be an individually-randomized controlled trial with three arms (Florida Quitline, iCanQuit alone, iCanQuit+Motiv8 combined) conducted in multiple primary care practices affiliated with the OneFlorida+ Clinical Research Consortium. Adult patients who smoke will be randomized to one of the 3 study arms (n = 444/arm), stratified by healthcare setting (academic vs. community). The primary outcome will be 7-day point prevalence smoking abstinence at 6 months post-randomization. Secondary outcomes will be 12-month smoking abstinence, patient satisfaction with the interventions, and changes in patient quality of life and self-efficacy. The study will also assess how and for whom the interventions help sub-group patients in achieving smoking abstinence by measuring theory-derived factors that mediate smoking outcome-specific baseline moderators.

CONCLUSIONS

Results from this study will provide evidence for the comparative effectiveness of mHealth smoking cessation interventions in healthcare settings. Use of mHealth interventions can make smoking cessation resources more equitably accessible and have far-reaching impact on community and population health.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05415761, Registered 13 June 2022.

The 2022 Ferno Award Address: CrEATE, an Efficient Crossover Evaluation of Addiction Treatment Efficacy

Dozens of drugs have been evaluated in recent decades for initial evidence of efficacy to aid smoking cessation (i.e. "early Phase 2" testing, according to U.S. FDA terminology), with the vast majority failing to show efficacy. Even small randomized clinical trials (RCTs), the most common early Phase 2 tests, are costly undertakings, made more unappealing by their high likelihood of failure. At the same time, another early Phase 2 approach, acute tests of drug effects on surrogate endpoints such as withdrawal or craving severity, are more practical but have little predictive clinical validity. Described here is an innovative procedure that optimally combines the validity of clinical trials with the practical advantages of surrogate endpoint studies to more efficiently determine whether or not a novel drug warrants continued clinical development. This CrEATE procedure, or Crossover Evaluation of Addiction Treatment Efficacy, does so by assessing short-term quit success in smokers highly motivated to quit when briefly treated with active drug versus placebo in a crossover design, so that quit efficacy from both conditions is compared within participants. The program to develop and evaluate CrEATE demonstrates its sensitivity to efficacy from all three FDA-approved first-line cessation medications (NRT, varenicline, bupropion), tested here as model drugs, as well as specificity in identifying lack of efficacy with a drug known to be ineffective for cessation (modafinil). CrEATE has subsequently been used to evaluate a few novel interventions, concluding they lack efficacy in increasing quit success. Future directions for the potential utility of CrEATE are provided. Implications: The ability of CrEATE to reach a Go/No Go decision more quickly and with far less cost lowers the risk of failure, meaning widespread use of the procedure should encourage the evaluation of more novel candidate drugs. With its greater efficiency, failed tests, unfortunately the most likely outcome in early Phase 2 studies, will cause less waste of resources. At the same time, CrEATE tests that indicate a novel treatment has efficacy will justify the substantial time and expense of moving forward to evaluate the drug in late Phase 2 RCTs.

Pilot trial of QuitBet: A digital social game that pays you to stop smoking

Contingency management is an effective treatment for cigarette smoking cessation but feasibility and acceptability concerns have been barriers to implementation. We conducted a pilot test of QuitBet, a commercial, digital (smartphone) social game for smoking cessation during which participants earned financial incentives for abstinence. QuitBet included a social feed for posting messages and entirely participant-funded incentives in the form of a deposit contract (the "bet"). QuitBet had a bet of $30 and lasted for 28 days. After a week to prepare for quitting, the quit day was Day 8. Between Day 9-28 (a 20-day period), participants earned back $1 of their $30 bet for each day of carbon monoxide (CO)-verified abstinence (≤ 6 ppm). Remaining bet money was pooled into a "grand prize" pot. Participants who were abstinent on at least 19 of the 20 days (1 "lapse" day allowed) were declared "winners" and split the grand prize pot equally. A game host posted a daily message containing evidence-based education about smoking cessation or a discussion topic. Recruitment goals were met. Among the players (N = 50 U.S. adults, 78% female), 17 (34%) were winners. Thirty-seven participants (74%) responded to a post-QuitBet survey, of whom 95% said they would be interested in playing another QuitBet and would recommend QuitBet to others. Overall, feedback was positive with some suggestions for improvement. In conclusion, a digital social game for smoking cessation with a deposit contract was feasible and acceptable. Next steps include conducting a randomized trial to establish efficacy and a sustainable business model. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A preliminary investigation of schedule parameters on cocaine abstinence in contingency management

Contingency management (CM) interventions are the most effective psychosocial interventions for substance use disorders. However, further investigation is needed to create the most robust intervention possible. This study investigated the effects of 1) reinforcer magnitude; and 2) fixed and escalating and resetting incentives on cocaine abstinence in an outpatient trial. In this analysis, 34 treatment-seeking individuals with Cocaine Use Disorder received either high or low value incentives for providing a benzoylecgonine-negative urine sample or were in a control condition and received incentives for providing a urine sample regardless of the results. Participants received either escalating and resetting incentives, wherein the value of each incentive increased with consecutive negative samples and reset to the initial level upon a positive sample (Experiment 1), or fixed incentives, wherein they received the same value incentive for each negative urine sample they provided (Experiment 2). Large incentives produced more abstinence, although escalating and resetting reinforcer values did not have a differential effect. Large, fixed incentives promoted abstinence faster than other reinforcers, whereas smaller incentives resulted in poor abstinence and took many visits to achieve initial abstinence. Future research comparing different schedules on cocaine abstinence in a randomized control trial with a larger sample size is required.

Mobile contingency management for smoking cessation among socioeconomically disadvantaged adults: Protocol for a randomized trial

BACKGROUND

Smoking rates remain high among socioeconomically disadvantaged adults. Offering small escalating financial incentives for abstinence (i.e., contingency management [CM]), alongside clinic-based treatment dramatically increases cessation rates in this vulnerable population. However, innovative approaches are needed for those who are less able to attend office visits. The current study will evaluate an automated mobile phone-based CM approach that will allow socioeconomically disadvantaged individuals to remotely earn financial incentives for smoking cessation.

METHODS

The investigators have previously combined technologies, including 1) carbon monoxide monitors that connect with mobile phones to remotely verify abstinence, 2) facial recognition software to confirm identity during breath sample submissions, and 3) automated delivery of incentives triggered by biochemical abstinence confirmation. This automated CM approach will be evaluated in a randomized controlled trial of 532 low-income adults seeking cessation treatment. Participants will be randomly assigned to telephone counseling and nicotine replacement therapy (standard care [SC]) or SC plus mobile financial incentives (CM) for abstinence.

RESULTS

Biochemically-verified 7-day point prevalence abstinence at 26 weeks post-quit is the primary outcome. The cost-effectiveness of the interventions will be evaluated. Potential treatment mechanisms, including self-efficacy, motivation, and treatment engagement, will be explored to optimize future interventions.

DISCUSSION

Automated mobile CM may offer a low-cost approach to smoking cessation that can be combined with telephone counseling and pharmacological interventions. This approach represents a critical step toward the widespread dissemination of CM treatment to real-world settings, to reduce tobacco-related disease and disparities.

New Directions for Motivational Incentive Interventions for Smoking Cessation

Background

Motivational incentive interventions are highly effective for smoking cessation. Yet, these interventions are not widely available to people who want to quit smoking, in part, due to barriers such as administrative burden, concern about the use of extrinsic reinforcement (i.e., incentives) to improve cessation outcomes, suboptimal intervention engagement, individual burden, and up-front costs.

Purpose

Technological advancements can mitigate some of these barriers. For example, mobile abstinence monitoring and digital, automated incentive delivery have the potential to lower the clinic burden associated with monitoring abstinence and administering incentives while also reducing the frequency of clinic visits. However, to fully realize the potential of digital technologies to deliver motivational incentives it is critical to develop strategies to mitigate longstanding concerns that reliance on extrinsic monetary reinforcement may hamper internal motivation for cessation, improve individual engagement with the intervention, and address scalability limitations due to the up-front cost of monetary incentives. Herein, we describe the state of digitally-delivered motivational incentives. We then build on existing principles for creating just-in-time adaptive interventions to highlight new directions in leveraging digital technology to improve the effectiveness and scalability of motivational incentive interventions.

Conclusions

Technological advancement in abstinence monitoring coupled with digital delivery of reinforcers has made the use of motivational incentives for smoking cessation increasingly feasible. We propose future directions for a new era of motivational incentive interventions that leverage technology to integrate monetary and non-monetary incentives in a way that addresses the changing needs of individuals as they unfold in real-time.

Smartband-Based Automatic Smoking Detection and Real-time Mindfulness Intervention: Protocol for a Feasibility Trial

Background

Smoking is the leading cause of preventable death in the United States. Smoking cessation interventions delivered by smartphone apps are a promising tool for helping smokers quit. However, currently available smartphone apps for smoking cessation have not exploited their unique potential advantages to aid quitting. Notably, few to no available apps use wearable technologies, most apps require users to self-report their smoking, and few to no apps deliver treatment automatically contingent upon smoking.

Objective

This pilot trial tests the feasibility of using a smartband and smartphone to monitor and detect smoking and deliver brief mindfulness interventions in real time to reduce smoking.

Methods

Daily smokers (N=100, ≥5 cigarettes per day) wear a smartband for 60 days to monitor and detect smoking, notify them about their smoking events in real time, and deliver real-time brief mindfulness exercises triggered by detected smoking events or targeted at predicted smoking events. Smokers set a quit date at 30 days. A three-step intervention to reduce smoking is tested. First, participants wear a smartband to monitor and detect smoking, and notify them of smoking events in real time to bring awareness to smoking and triggers for 21 days. Next, a “mindful smoking” exercise is triggered by detected smoking events to bring a clear recognition of the actual effects of smoking for 7 days. Finally, after their quit date, a “RAIN” (recognize, allow, investigate, nonidentification) exercise is delivered to predicted smoking events (based on the initial 3 weeks of tracking smoking data) to help smokers learn to work mindfully with cravings rather than smoke for 30 days. The primary outcomes are feasibility measures of treatment fidelity, adherence, and acceptability. The secondary outcomes are smoking rates at end of treatment.

Results

Recruitment for this trial started in May 2021 and will continue until November 2021 or until enrollment is completed. Data monitoring and management are ongoing for enrolled participants. The final 60-day end of treatment data is anticipated in January 2022. We expect that all trial results will be available in April 2022.

Conclusions

Findings will provide data and information on the feasibility of using a smartband and smartphone to monitor and detect smoking and deliver real-time brief mindfulness interventions, and whether the intervention warrants additional testing for smoking cessation.

Trial Registration

ClinicalTrials.gov NCT03995225; https://clinicaltrials.gov/ct2/show/NCT03995225

International Registered Report Identifier (IRRID)

DERR1-10.2196/32521

Behavior analytic contributions to public health and telehealth

The Journal of Applied Behavior Analysis is launching a special series on the topics of public health and telehealth. The special series begins with the articles in this issue and will continue for the next 2 to 3 issues with an open submission window until September 1, 2020. Behavior analysis has much to offer with respect to public health and much to gain from continued and expanded use of telehealth. This paper outlines the importance of these topics in the current crisis and in our ongoing evolution as a field. The historical literature in behavior analysis is reviewed for each topic along with suggestions for future research. The articles from the special series will be combined with historical contributions from JABA into a virtual issue. We encourage continued submissions on these topics even after the special series is completed as future papers will also be incorporated into the special issue.

Delayed Reward Discounting as a Prognostic Factor for Smoking Cessation Treatment Outcome: A Systematic Review

INTRODUCTION

While large proportions of smokers attempt to quit, rates of relapse remain high and identification of valid prognostic markers is of high priority. Delayed reward discounting (DRD) is a behavioral economic index of impulsivity that has been associated with smoking cessation, albeit inconsistently. This systematic review sought to synthesize the empirical findings on DRD as a predictor of smoking cessation treatment outcome, to critically appraise the quality of the literature, and to propose directions for future research.

AIMS AND METHODS

A total of 734 articles were identified, yielding k = 14 studies that met the eligibility criteria. The Quality in Prognosis Studies (QUIPS) tool was used to assess methodological quality of the included studies.

RESULTS

Individual study methods were highly heterogeneous, including substantial variation in research design, DRD task, clinical subpopulation, and treatment format. The predominant finding was that steeper DRD (higher impulsivity) was associated with significantly worse smoking cessation outcomes (10/14 studies). Negative results tended to be in pregnant and adolescent subpopulations. The QUIPS results suggested low risk of bias across studies; 11/14 studies were rated as low risk of bias for 5/6 QUIPS domains.

CONCLUSIONS

This review revealed consistent low-bias evidence for impulsive DRD as a negative prognostic predictor of smoking cessation treatment outcome in adults. However, methodological heterogeneity was high, precluding meta-analysis and formal tests of small study bias. The prospects of targeting impulsive DRD as a potentially modifiable risk factor or providing targeted treatment for smokers exhibiting high levels of discounting are discussed.

IMPLICATIONS

These findings indicate consistent evidence for DRD as a negative prognostic factor for smoking cessation outcome in adults. As such, DRD may be a useful as a novel treatment target or for identifying high-risk populations requiring more intensive treatment.

Remotely delivered incentives to promote buprenorphine treatment engagement in out-of-treatment adults with opioid use disorder

BACKGROUND

Opioid overdose remains a leading cause of death. Office-based buprenorphine could expand access to treatment to the many opioid users who are not in treatment and who are at risk for opioid overdose. However, many people in need of buprenorphine treatment do not enroll in treatment. This randomized pilot trial evaluated efficacy of a remotely delivered incentive intervention in promoting engagement in buprenorphine treatment in out-of-treatment adults with opioid use disorder.

METHODS

Participants (N = 41) were offered referrals to buprenorphine treatment and randomly assigned to Control or Incentive groups for 6 months. Incentive participants were offered incentives for enrolling in buprenorphine treatment, verified by providing documentation showing that they received a buprenorphine prescription, and providing videos taking daily buprenorphine doses. Participants used a smartphone application to record and submit a video of their buprenorphine prescription and daily buprenorphine administration. Incentive earnings were added remotely to reloadable credit cards.

RESULTS

Incentive participants were significantly more likely to enroll in treatment compared to control participants (71.4 % versus 30.0 % of participants; OR [95 % CI]: 6.24 [1.46-26.72], p = .014). Few participants in either group adhered to buprenorphine treatment, and the two groups continued to use opioids, including fentanyl at high and comparable rates. The two groups did not differ in the percentage of urine samples that were positive for buprenorphine, opiates, fentanyl, or methadone at monthly assessments conducted during the 6-month intervention.

CONCLUSIONS

Remotely delivered incentives can connect out-of-treatment adults with opioid use disorder to treatment, but additional supports are needed to promote buprenorphine adherence.

Pilot Study of an Integrated Smartphone and Breathalyzer Contingency Management Intervention for Alcohol Use

INTRODUCTION

Monitoring devices provide a platform for assessing alcohol use and implementing alcohol interventions. This pilot study focused on assessing the early-stage feasibility and usability of a smartphone-based application and breathalyzer used in a contingency management intervention for alcohol use.

METHODS

Six nontreatment-seeking participants completed a 9-week ABA within-subjects designed intervention targeting alcohol use. Participants submitted 2 to 8 alcohol breathalyzer samples per day and completed self-report drinking measures and usability assessments. During the A phases (weeks 1-3 and 8-9), participants received reinforces for submitting breathalyzer samples, regardless of their results. During the contingency management, B phase (weeks 4-7), and received reinforcers only when negative breathalyzer samples were submitted. Usability assessment of the application was also conducted during weeks 2 and 9.

RESULTS

Participants in the contingent B phase (49%) were more likely to submit alcohol-negative breathalyzer samples compared with the noncontingent A phases (27%; P < 0.001). Usability assessment of the application varied, and participants noted several technical concerns.

CONCLUSION

The use of smartphones and breathalyzers may be a practical solution to extend the reach of contingency management during and after treatment.

Cessation classification likelihood increases with higher expired-air carbon monoxide cutoffs: a meta-analysis

BACKGROUND

Expired-air carbon monoxide (CO) is commonly used to biochemically verify smoking status. The CO cutoff and CO monitor brand may affect the probability of classifying smokers as abstinent, thus influencing conclusions about the efficacy of cessation trials. No systematic reviews have tested this hypothesis. Therefore, we performed a meta-analysis examining whether the likelihood of smoking cessation classification varied due to CO cutoff and monitor brand.

METHODS

Eligible studies (k = 122) longitudinally assessed CO-verified cessation in adult smokers in randomized trials. Primary meta-regressions separately assessed differences in quit classification likelihood due to continuous and categorical CO cutoffs (Low, 3-4 parts per million [ppm]; [SRNT] Recommended, 5-6 ppm; Moderate, 7-8 ppm; and High, 9-10 ppm); exploratory analyses compared likelihood outcomes between monitor brands: Bedfont and Vitalograph.

RESULTS

The likelihood of quit classification increased 18% with each 1 ppm increase above the lowest cutoff (3 ppm). Odds of classification as quit significantly increased between each cutoff category and High: 261% increase from Low; 162% increase from Recommended; and 150% increase from Moderate. There were no differences in cessation classification between monitor brands.

CONCLUSIONS

As expected, higher CO cutoffs were associated with greater likelihood of cessation classification. The lack of CO monitor brand differences may have been due to model-level variance not able to be followed up in the present dataset. Researchers are advised to report outcomes using a range of cutoffs-including the recommended range (5-6 ppm)-and the CO monitor brand/model used. Using higher CO cutoffs significantly increases likelihood of quit classification, possibly artificially elevating treatment strategies.

Systematic review on use of health incentives in U.S. to change maternal health behavior

Use of financial incentives contingent on health outcomes has shown effective in health behavior change. Evidence-based information on the effect of incentive use for maternal health behavior change can inform whether and how to proceed with future research as well as incorporate incentive-based interventions in the existing healthcare system. This systematic literature review was conducted among prospective studies on incentive use for maternal health behavior change in a U.S. cohort according to the PRISMA methodology. Databases subject to the search included PubMed, Web of Science, PsycINFO, and EBSCOhost. Studies published in peer-reviewed journals on or before January 7, 2019, written in English, conducted in U.S., using incentives contingent on maternal health behavior change, and prospectively designed were included. Two authors independently searched titles and abstracts. An abstraction table was constructed, and the risk of bias was assessed using the GRADE approach. The review showed that incentives such as vouchers and other financial incentives were effective in improving outcomes especially related to substance use, tobacco use, and breastfeeding. Mixed evidence was found in improving treatment adherence outcomes; however the studies with randomized trials on the outcome of treatment adherence also showed low certainty. Continued improvements need to be made in implementing an incentive-based approach in the context of comprehensive treatment and routine healthcare, exploring electronic- or mobile-based implementation of the approach, and implementing the approach for a wider variety of outcomes during both prenatal and postpartum periods.

Web-Based Contingency Management for Adolescent Tobacco Smokers: A Clinical Trial

INTRODUCTION

Adolescence is a critical time when the majority of tobacco users initiate smoking. Contingency management for adolescent smoking cessation has shown promise in previous studies, but efficacy following removal of contingencies is not well understood. This study examined a remote form of contingency management among non-treatment-seeking adolescent smokers.

METHODS

Participants (N = 127) submitted breath carbon monoxide (CO) three times daily throughout a 42-day program. For this randomized trial, participants in the active condition (n = 63) were reinforced for providing CO measurements on schedule and below a set criterion, whereas those in the control condition (n = 64) were reinforced for providing CO measurements on schedule. Self-reported smoking and urinary cotinine levels were collected at several timepoints.

RESULTS

Active condition showed greater within-group reductions in CO levels relative to control condition, but not at 3- or 6-month follow-up. Active condition reported significantly less smoking during treatment compared to control condition, but not at follow-up. There were no significant differences for urinary cotinine. Overall treatment adherence was low, with only 37% and 51% of possible CO samples being submitted among active and control, respectively. Poor treatment adherence may explain the disparity between CO and cotinine results, and poor follow-up treatment efficacy.

CONCLUSIONS

This study replicates feasibility of a remote form of contingency management for adolescent smoking. CO results suggest active condition reduced smoking within group, but treatment adherence and posttreatment efficacy was poor. Future research should focus on increasing adherence for this type of program among adolescent smokers.

IMPLICATIONS

This study demonstrates feasibility of a remote form of contingency management therapy for smoking cessation among adolescents, while providing posttreatment efficacy data. Within-group efficacy of this form of treatment is suggested, but treatment adherence and follow-up efficacy were poor. This study underscores the need for further development of contingency management therapy for adolescent smoking cessation, which emphasizes better treatment adherence and posttreatment efficacy.

Craving to Quit: A Randomized Controlled Trial of Smartphone App-Based Mindfulness Training for Smoking Cessation

INTRODUCTION

Mindfulness training may reduce smoking rates and lessen the association between craving and smoking. This trial tested the efficacy of mindfulness training via smartphone app to reduce smoking. Experience sampling (ES) was used to measure real-time craving, smoking, and mindfulness.

METHODS

A researcher-blind, parallel randomized controlled trial compared the efficacy of mobile mindfulness training with experience sampling (MMT-ES; Craving to Quit) versus experience sampling only (ES) to (1) increase 1-week point-prevalence abstinence rates at 6 months, and (2) lessen the association between craving and smoking. A modified intent-to-treat approach was used for treatment starters (MMT-ES n = 143; ES n = 182; 72% female, 81% white, age 41 ± 12 year).

RESULTS

No group difference was found in smoking abstinence at 6 months (overall, 11.1%; MMT-ES, 9.8%; ES, 12.1%; χ2(1) = 0.43, p = .51). From baseline to 6 months, both groups showed a reduction in cigarettes per day (p < .0001), craving strength (p < .0001) and frequency (p < .0001), and an increase in mindfulness (p < .05). Using ES data, a craving by group interaction was observed (F(1,3785) = 3.71, p = .05) driven by a stronger positive association between craving and cigarettes per day for ES (t = 4.96, p < .0001) versus MMT-ES (t = 2.03, p = .04). Within MMT-ES, the relationship between craving and cigarettes per day decreased as treatment completion increased (F(1,104) = 4.44, p = .04).

CONCLUSIONS

Although mindfulness training via smartphone app did not lead to reduced smoking rates compared with control, our findings provide preliminary evidence that mindfulness training via smartphone app may help lessen the association between craving and smoking, an effect that may be meaningful to support quitting in the longer term.

IMPLICATIONS

This is the first reported full-scale randomized controlled trial of any smartphone app for smoking cessation. Findings provide preliminary evidence that smartphone app-based MMT-ES may lessen the association between craving and smoking.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02134509.

Adaptation of contingency management for stimulant use disorder during the COVID-19 pandemic

The current coronavirus disease (COVID-19) pandemic has rapidly spread across the world. Individuals with stimulant use disorder are a vulnerable population, who are particularly at risk of negative outcomes during this pandemic due to several risk factors, including mental and physical comorbidities, weakened immune responses, high-risk behaviors, and barriers to healthcare access. Engaging patients with stimulant use disorder in regular treatment has become even more difficult during this pandemic, which has resulted in many cuts to addiction treatment programs. The most effective treatment options for stimulant use disorder are psychosocial interventions, which rely heavily on in-person interactions, posing an added challenge during physical distancing. In particular, contingency management (CM) is a behavioral therapy that utilizes tangible reinforcements to incentivize targeted behavior changes, and is an effective treatment intervention used for stimulant use disorder. This paper highlights the treatment challenges for individuals with stimulant use disorder and the importance of adapting CM programs during COVID-19. We present strategies for how CM can be adapted and its role expanded in a safe way during the COVID-19 pandemic to help prevent infection spread, stimulant use relapse, and worsened psychosocial consequences.

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Stimulant users face increased risk of relapse and infection during a pandemic.

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Contingency management is an effective treatment for stimulant use disorder.

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Contingency management can be adapted to mitigate negative outcomes of COVID-19.

Contingency management for smoking cessation among individuals with type 2 diabetes: protocol for a multi-center randomized controlled feasibility trial

BACKGROUND

Individuals with type 2 diabetes (T2D) who smoke are at increased risk for many types of cancers as well as an accelerated progression of microvascular and macrovascular complications. Smoking cessation is recommended as a standard treatment for T2D; however, individuals with T2D are faced with competing lifestyle changes. Glycemic and blood pressure control often take precedence over smoking cessation, and patients are often unmotivated to quit. Contingency management in combination with standard smoking cessation treatment has been demonstrated to improve cessation outcomes in various populations. The purpose of this randomized controlled feasibility trial is to explore the feasibility of contingency management and biochemical verification using a remote smartphone-based carbon monoxide monitor for smoking cessation among individuals with T2D.

METHODS

A three-arm, randomized controlled feasibility trial will be conducted in two study sites that include the USA and UK. We will recruit 60 participants who will each receive usual care smoking cessation treatment (counseling and nicotine replacement therapy) and be randomized to a short term incentives (6 weeks), long term incentives (12 weeks), or no incentives (control) group. Participants will receive a smartphone and carbon monoxide monitor to complete daily remote assessments throughout the 12 weeks and will complete an exit interview at the end of the study. The primary outcomes for this feasibility study include completion of the protocol and proportion of daily assessments completed. Secondary outcomes include recruitment measures, acceptability, and smoking abstinence.

DISCUSSION

We will explore the feasibility of recruiting smokers with T2D and their engagement in the program, particularly related to the use of the remote biochemical verification and smartphone application. In addition, we will evaluate the intervention content, study procedures, data collection methods, and follow-up and will qualitatively assess the participants' acceptability of the program. The results of this study will inform the design of a larger trial to test the efficacy of the contingency management program for improving smoking cessation outcomes among individuals with T2D.

TRIAL REGISTRATION

This randomized controlled feasibility trial has been registered at ClinicalTrials.gov with an ID NCT03527667 on May 4, 2018.

Automated Mobile Delivery of Financial Incentives for Smoking Cessation Among Socioeconomically Disadvantaged Adults: Feasibility Study

BACKGROUND

Socioeconomic disadvantage is associated with a reduced likelihood of smoking cessation. Smartphone ownership is increasing rapidly, including among low-income adults, and smartphone interventions for smoking cessation may increase access to smoking cessation treatment among socioeconomically disadvantaged adults.

OBJECTIVE

This study aimed to evaluate the feasibility of an automated smartphone-based approach to delivering financial incentives for smoking cessation.

METHODS

Socioeconomically disadvantaged adults initiating tobacco cessation treatment were followed from 1 week before a scheduled quit attempt through 26 weeks after the quit date. Participants received telephone counseling and nicotine replacement therapy. Smoking cessation was verified 5 times per week via smartphone prompts to self-report smoking status and submit a breath sample via a portable carbon monoxide (CO) monitor that was connected with participants' smartphones. Identity was verified during smoking status assessments using smartphone-based facial recognition software. When smoking abstinence and identity were verified, an automated credit card payment was triggered. Participants were incentivized for abstinence on the quit date and up to five days per week during the first 4 weeks after the scheduled quit date, with additional incentives offered during postquit weeks 8 and 12. In total, participants had the opportunity to earn up to US $250 in abstinence-contingent incentives over the first 12 weeks of the quit attempt.

RESULTS

Participants (N=16) were predominantly female (12/16, 75%) and non-Hispanic white (11/16, 69%), black (4/16, 25%), or Hispanic of any race (1/16, 6%). Most participants (9/16, 56%) reported an annual household income of <US $11,000. During the first 4 weeks after the scheduled quit date, participants completed a median of 16 (out of 21; range 1-21) mobile smoking status assessments, and they earned a median of US $28 in abstinence-contingent incentives (out of a possible US $150; range US $0-US $135). Median earnings did not change during the 8- and 12-week incentivized follow-up periods (total median earnings over 12 weeks=US $28; range US $0-US $167). During the first 4 weeks after the scheduled quit date, participants abstained from smoking on a median of 5 (out of 21) assessment days (range 0-20). At the in-person follow-up visits, the expired CO-confirmed 7-day point prevalence abstinence rates were 19% (3/16) and 13% (2/16) at 12 and 26 weeks postquit, respectively. Overall, most participants reported that the system was easy to use and that they would recommend this treatment to their friends and family.

CONCLUSIONS

Preliminary data suggest that this smartphone-based approach to verifying identity and smoking status and automating the delivery of abstinence-contingent incentives to a credit card is feasible for use among socioeconomically disadvantaged adults. However, continued refinement is warranted.

An Implementation Trial to Improve Tobacco Treatment for Cancer Patients: Patient Preferences, Treatment Acceptability and Effectiveness

Continued smoking after a cancer diagnosis increases mortality, risk of recurrence, and negatively impacts treatment effectiveness. However, utilization of tobacco use cessation treatment among cancer patients remains low. We conducted a clinical trial assessing patient preferences, treatment acceptability, and preliminary effectiveness (7-day point prevalence at 12 weeks) of three tobacco treatment options among cancer patients at an academic health center. Implementation strategies included electronic referral and offering the choice of three treatment options: referral to external services, including the quitline (PhoneQuit) and in-person group counseling (GroupQuit), or an internal service consisting of 6-week cognitive behavioral therapy delivered via smartphone video conferencing by a tobacco treatment specialist (SmartQuit). Of 545 eligible patients, 90 (16.5%) agreed to enroll. Of the enrolled patients, 39 (43.3%) chose PhoneQuit, 37 (41.1%) SmartQuit, and 14 (15.6%) GroupQuit. Of patients reached for 12-week follow-up (n = 35), 19 (54.3%) reported receiving tobacco treatment. Of all patients referred, 3 (7.7%) PhoneQuit, 2 (5.4%) SmartQuit, and 2 (14.3%) GroupQuit patients reported 7-day point prevalence abstinence from smoking at 12 weeks. Participants rated the SmartQuit intervention highly in terms of treatment acceptability. Results indicate that more intensive interventions may be needed for this population, and opportunities remain for improving reach and utilization.

Como a Análise do Comportamento tem Contribuído para Área da Saúde?

Resumo A Psicologia da Saúde tem investigado variáveis e proposto estratégias de prevenção e promoção de problemas de saúde. Especificamente na Análise do Comportamento Aplicada o foco tem sido a alteração e manutenção de comportamentos relacionados à saúde. Por meio de uma revisão de literatura, o objetivo deste trabalho foi identificar estudos, pautados na Análise do Comportamento Aplicada, que apresentassem contribuições à área de Saúde. Para tanto, foram revisadas todas as edições do Journal of Applied Behavior Analysis, publicadas entre 2000 e 2015. Os artigos que continham em seus títulos ou resumos, termos relacionados à saúde foram selecionados. Ao todo 160 artigos foram encontrados e após análise dos mesmos, considerando, o objetivo, métodos e os resultados, 11 temas relacionados à saúde foram definidos (adesão, diabetes, problemas alimentares, uso de drogas, procedimentos hospitalares, saúde ocupacional, saúde bucal, atividade física, comportamento autolesivo, problemas de sono e segurança no trânsito). Os estudos baseados nos pressupostos analíticos comportamentais demonstram a aplicabilidade dos conceitos na área de saúde. Além disto, foi também possível identificar e analisar as principais características metodológicas utilizadas e sua eficácia para a alteração de padrões de comportamentos de saúde.

Technology-based contingency management and e-cigarettes during the initial weeks of a smoking quit attempt

Contingency management (CM) interventions are among the most effective behavioral interventions for smoking. This study assessed the effects of CM and electronic cigarettes (ECs) on smoking reductions and abstinence for durations of 30-36 days. Twelve participants were exposed to Baseline, EC alone, and EC + CM conditions. An internet-based platform was used to monitor smoking via breath carbon monoxide (CO) and deliver CM for smoking abstinence (CO ≤4 ppm). A Bluetooth-enabled EC monitored daily EC puffs. Abstinence rates were equivalent between EC (34.4%) and EC + CM (30.4%) conditions. Both conditions promoted smoking reductions. We observed an inverse correlation between smoking and EC puffs (r = -.62, p < .05). Results suggest the use of electronic cigarettes can promote smoking reductions and abstinence, and CM did not improve these outcomes. Larger magnitude consequences or tailoring EC characteristics (e.g., flavor) may have improved outcomes. Technology-based methods to collect intensive, longitudinal measures of smoking and electronic cigarette use may be useful to characterize their environmental determinants.

Technology-Based Contingency Management in the Treatment of Substance-Use Disorders

Contingency management is one of the most efficacious interventions to promote drug abstinence. Contingency management has traditionally been delivered in person so that clinicians could confirm drug abstinence and provide access to additional therapeutic services. Now, new technologies not only permit remote confirmation of abstinence, but also remote delivery of incentives. We discuss several technology-based tools to assess substance use, and new ways to deliver contingency management to promote tobacco, alcohol, and cannabis abstinence. These new tools have the potential to dramatically increase access while maintaining high levels of treatment fidelity. Technology-based methods also allow arranging group contingencies that harness online communities, and they permit targeting multiple health-risk behaviors with a combination of sensor-based technologies. Overall, there are unprecedented opportunities to link technology with contingency management to promote drug abstinence.

Considerations for Implementing Contingency Management in Substance Abuse Treatment Clinics: The Veterans Affairs Initiative as a Model

Contingency management (CM) is an efficacious intervention for the treatment of substance use disorders that is widely applicable across a range of client populations and characteristics. Despite its strong evidence base, CM remains underutilized in real world practice. This article introduces CM for clinicians interested in adopting CM and briefly reviews this research evidence. In addition, CM protocols are described, with emphasis on the specific design considerations important to CM's efficacy. The recent Department of Veterans Affairs (VA) initiative, which represents the first successful large-scale implementation effort, is presented. It provides a model for the training and supervision components that may be critical to implementation with fidelity. Continued research in this area, as well as further demonstrations of successful dissemination and implementation, will be critical for improving the adoption of this intervention in clinical, nonresearch settings.

Contingency management and cognitive behavioral therapy for trauma-exposed smokers with and without posttraumatic stress disorder

INTRODUCTION

Trauma-exposed individuals with and without posttraumatic stress disorder (PTSD) are more likely to smoke and less successful in quit attempts than individuals without psychopathology. Contingency management (CM) techniques (i.e., incentives for abstinence) have demonstrable efficacy for smoking cessation in some populations with psychopathology, but have not been well tested in PTSD. This pilot study examined the feasibility of CM plus brief cognitive behavioral therapy (CBT) in promoting smoking cessation among trauma-exposed individuals with and without PTSD.

METHODS

Fifty trauma-exposed smokers (18 with PTSD) were asked to abstain from tobacco and nicotine replacement therapy for one month. During week one of cessation, CBT was provided daily and increasing CM stipends were paid for each continuous day of biochemically-verified abstinence; CM stipends were withheld in response to smoking lapses and reset to the initial payment level upon abstinence resumption. CBT and fixed payments for study visits were provided during the subsequent three weeks.

RESULTS

Of the 50 eligible participants who attended at least one pre-quit visit (49% female, 35% current PTSD), 43 (86%) attended the first post-quit study visit, 32 (64%) completed the first week of CM/CBT treatment, and 26 (52%) completed the study. Post-quit seven-day point prevalence abstinence rates for participants with and without PTSD, respectively, were similar: 39% vs. 38% (1 week), 33% vs. 28% (2 weeks), 22% vs. 19% (3 weeks), and 22% vs. 13% (4 weeks).

CONCLUSIONS

Use of CM + CBT to support tobacco abstinence is a promising intervention for trauma-exposed smokers with and without PTSD.

Remote Alcohol Monitoring to Facilitate Incentive-Based Treatment for Alcohol Use Disorder: A Randomized Trial

Background

The delivery of monetary incentives contingent on verified abstinence is an effective treatment for alcohol use disorder. However, technological barriers to accurate, frequent biochemical verification of alcohol abstinence have limited the dissemination of this technique.

Methods

In the present randomized parallel trial, we employed a breathalyzer that allows remote, user‐verified collection of a breath alcohol sample, text messaging, and reloadable debit cards for remote delivery of incentives to evaluate a contingency management treatment for alcohol use disorder that can be delivered with no in‐person contact. Treatment‐seeking participants with alcohol use disorder (n = 40) were recruited from the community and randomized to either a contingent or a noncontingent group (n = 20 each). The contingent group received nearly immediate monetary incentives each day they remotely provided negative breathalyzer samples. The noncontingent group received matched monetary payments each day they successfully provided samples independent of alcohol content. Groups were not masked as awareness of group contingencies was an essential intervention component.

Results

The primary outcome of the intent‐to‐treat analyses (analyzed n = 40) was percent days abstinent as measured by the remote breathalyzer samples. Abstinence rates in the contingent group were 85%, which was significantly higher than the 38% recorded in the noncontingent group, corresponding to an odds ratio of 9.4 (95% CI = 4.0 to 22.2). Breathalyzer collection adherence rates were over 95%, and participant ratings of acceptability were also high.

Conclusions

These results support the efficacy, acceptability, and feasibility of this remotely deliverable abstinence reinforcement incentive intervention for the initiation and near‐term maintenance of abstinence from alcohol in adults with alcohol use disorder. Due to low provider and participant burden, this procedure has the potential for broad dissemination.

Combining ecological momentary assessment with objective, ambulatory measures of behavior and physiology in substance-use research

Whereas substance-use researchers have long combined self-report with objective measures of behavior and physiology inside the laboratory, developments in mobile/wearable electronic technology are increasingly allowing for the collection of both subjective and objective information in participants' daily lives. For self-report, ecological momentary assessment (EMA), as implemented on contemporary smartphones or personal digital assistants, can provide researchers with near-real-time information on participants' behavior and mood in their natural environments. Data from portable/wearable electronic sensors measuring participants' internal and external environments can be combined with EMA (e.g., by timestamps recorded on questionnaires) to provide objective information useful in determining the momentary context of behavior and mood and/or validating participants' self-reports. Here, we review three objective ambulatory monitoring techniques that have been combined with EMA, with a focus on detecting drug use and/or measuring the behavioral or physiological correlates of mental events (i.e., emotions, cognitions): (1) collection and processing of biological samples in the field to measure drug use or participants' physiological activity (e.g., hypothalamic-pituitary-adrenal axis activity); (2) global positioning system (GPS) location information to link environmental characteristics (disorder/disadvantage, retail drug outlets) to drug use and affect; (3) ambulatory electronic physiological monitoring (e.g., electrocardiography) to detect drug use and mental events, as advances in machine learning algorithms make it possible to distinguish target changes from confounds (e.g., physical activity). Finally, we consider several other mobile/wearable technologies that hold promise to be combined with EMA, as well as potential challenges faced by researchers working with multiple mobile/wearable technologies simultaneously in the field.

The use of ambulatory assessment in smoking cessation

Ambulatory assessment of smoking behavior has greatly advanced our knowledge of the smoking cessation process. The current article first provides a brief overview of ecological momentary assessment for smoking cessation and highlights some of the primary advantages and scientific advancements made from this data collection method. Next, a discussion of how certain data collection tools (i.e., smoking topography and carbon monoxide detection) that have been traditionally used in lab-based settings are now being used to collect data in the real world. The second half of the paper focuses on the use of wearable wireless sensors to collect data during the smoking cessation process. Details regarding how these sensor-based technologies work, their application to newer tobacco products, and their potential to be used as intervention tools are discussed. Specific focus is placed on the opportunity to utilize novel intervention approaches, such as Just-In-Time Adaptive Interventions, to intervene upon smoking behavior. Finally, a discussion of some of the current challenges and limitations related to using sensor-based tools for smoking cessation are presented, along with suggestions for future research in this area.

A novel and remote biochemical verification method of smoking abstinence: Predictors of participant compliance

INTRODUCTION

Biochemical verification of smoking abstinence remains an important validity check of cessation trial outcomes. Digital health trials rarely establish in-person contacts between participants and intervention providers, requiring novel strategies to biochemically verify outcomes. We describe remote verification of smoking abstinence via saliva cotinine and individual predictors of compliance in a digital intervention.

METHODS

Data came from a feasibility trial and randomized controlled trial of a Facebook smoking cessation intervention for young adults. In both trials, participants completed baseline and follow-up surveys at 3, 6 and 12 months. Participants indicating past 7-day point prevalence smoking abstinence were mailed a saliva cotinine kit. Participants were instructed to electronically send two photos - one of them giving a saliva sample and the other with the test results. We investigated predictors of compliance with these procedures, independent of verification results, among participants that were mailed a kit at any follow-up point (N=130; mean age = 21.3; 59.2% female) using logistic and multinomial regression.

RESULTS

A total of 189 kits were sent out, of which 97 were completed (51.3% compliance). We did not identify significant predictors of completing any vs no kits using logistic regression. We also found no significant predictors of extent of kit completion (none vs some; none vs all) using multinomial regression and controlling for number of kits sent.

CONCLUSIONS

Findings demonstrate the feasibility of this biochemical verification method and suggest low risk for bias of results. Future studies should replicate findings in larger samples and improve compliance with verification procedures.

Validating Use of Internet-Submitted Carbon Monoxide Values by Video to Determine Quit Status

Introduction

Daily visits to biochemically verify continuous smoking abstinence via expired-air carbon monoxide (CO) may deter participation in cessation trials. One way to reduce need for daily visits while continuing to monitor abstinence success may be use of a recent procedure to verify abstinence from daily CO values via the Internet. This method requires participants submit to study staff video recordings of themselves correctly using a CO monitor. However, it has not been clearly demonstrated that those classified quit via Internet-submitted videos of CO would be reliably classified quit when assessed in lab.

Methods

Our study examined agreement in quit status from Internet-submitted CO values with quit status via CO collected in later same-day lab visits. Participants (n = 23) were from a short-term cessation study who agreed to record and submit videos of offsite CO testing, in addition to attending daily lab visits. All CO values were obtained via Bedfont pico+ Smokerlyzer monitors, with CO < 8 ppm indicating quit. During two 4-day practice quit attempts, a video was submitted before daily lab visits, up to eight videos each.

Results

Of the total of 150 videos submitted, 97 videos indicated "not quit" and 53 "quit." Cohen's Kappa indicated substantial agreement in quit status between assessments, 0.70, p < .001, as 85% of the videos indicating "quit" CO were also "quit" CO in lab.

Conclusions

To our knowledge, these results are the first validation of daily Internet-submitted CO values to confirm daily quit status, supporting the utility of this approach for close monitoring of continuous abstinence.

Implications

This study compared consistency between quit status from CO values submitted over the Internet and quit status via CO collected in later same-day lab visits. Findings indicate substantial agreement in quit status between these two methods of CO assessment. Our results validate the use of Internet-submitted CO values to verify daily quit status. This method can be used in future cessation trials as a means to biochemically validate continuous abstinence without the burden of daily lab visits or relying on self-report of recent smoking lapses.

Rationale, design and pilot feasibility results of a smartphone-assisted, mindfulness-based intervention for smokers with mood disorders: Project mSMART MIND

BACKGROUND

Although individuals with psychiatric disorders are disproportionately affected by cigarette smoking, few outpatient mental health treatment facilities offer smoking cessation services. In this paper, we describe the development of a smartphone-assisted mindfulness smoking cessation intervention with contingency management (SMI-CM), as well as the design and methods of an ongoing pilot randomized controlled trial (RCT) targeting smokers receiving outpatient psychiatric treatment. We also report the results of an open-label pilot feasibility study.

METHODS

In phase 1, we developed and pilot-tested SMI-CM, which includes a smartphone intervention app that prompts participants to practice mindfulness, complete ecological momentary assessment (EMA) reports 5 times per day, and submit carbon monoxide (CO) videos twice per day. Participants earned incentives if submitted videos showed CO≤6ppm. In phase 2, smokers receiving outpatient treatment for mood disorders are randomized to receive SMI-CM or enhanced standard treatment plus non-contingent CM (EST).

RESULTS

The results from the pilot feasibility study (N=8) showed that participants practiced mindfulness an average of 3.4times/day (≥3min), completed 72.3% of prompted EMA reports, and submitted 68.0% of requested CO videos. Participants reported that the program was helpful overall (M=4.85/5) and that daily mindfulness practice was helpful for both managing mood and quitting smoking (Ms=4.50/5).

CONCLUSIONS

The results from the feasibility study indicated high levels of acceptability and satisfaction with SMI-CM. The ongoing RCT will allow evaluation of the efficacy and mechanisms of action underlying SMI-CM for improving cessation rates among smokers with mood disorders.

Contingency management treatment for substance use disorders: How far has it come, and where does it need to go?

Contingency management (CM) interventions consistently improve substance abuse treatment outcomes, yet CM remains a highly controversial intervention and is rarely implemented in practice settings. This article briefly outlines the evidence base of CM and then describes 4 of the most often-cited concerns about it: philosophical, motivational, durability, and economic. Data supporting and refuting each of these issues are reviewed. The article concludes with suggestions to address these matters and other important areas for CM research and implementation, with the aims of improving uptake of this efficacious intervention in practice settings and outcomes of patients with substance use disorders. (PsycINFO Database Record

Use of Expired Air Carbon Monoxide Testing in Clinical Tobacco Treatment Settings

Carbon monoxide (CO) testing is considered an easy, noninvasive, and objective contribution to the assessment of smoking behavior, as CO is rapidly absorbed into the bloodstream when lit cigarettes or cigars are inhaled. CO testing is a medically important billable outpatient service that can contribute to sustainability of face to face tobacco use treatment services by clinicians. This article reviews research on the clinical use of CO testing to provide biomedical feedback in assessing smoking behavior, educating smokers on tobacco health effects, assisting with treatment planning, and as a motivational tool to encourage people to become tobacco free. Further research can focus on how to best incorporate CO testing into clinical practice, including more research on outcomes and methods to ensure that insurers reimburse for testing and improved ways to use CO testing to initiate attempts to quit tobacco use, to maintain cessation, and to prevent relapse.

The Use of Observational Technology to Study In-Store Behavior: Consumer Choice, Video Surveillance, and Retail Analytics

The store is the main laboratory for in-store experimental analysis. This article provides an introduction to a research program aimed at improving research practices in this laboratory, particularly emphasizing the importance of behavioral data and the new opportunities that technology offers. This complex modern-day Skinner box has sets of well-studied stimuli-behavior interactions that constantly adapt to the latest economic environment and as such constantly stretch the boundaries of behavioral analytic theory. However, the retail setting is highly important to applied behavior analysis for such issues as health, debt, environmental conservation, animal welfare, self-control, and consumer protection in general. This article presents a research strategy that emphasizes key environmental touch points throughout the customer journey in grocery retailing. We highlight the latest development by examining a particular research case and discussing the need for behavioral economic understanding of the start of the grocery journey, that is, the consumer choice of in-store product carrying equipment (e.g., cart, basket, or nothing). The conceptual system consists of a molecular four-term contingency framework as well as a more molar approach with conversion-rate modeling, where actual choice behavior is detected through video surveillance. The data are analyzed using a Shopper Flow© Tracking System in which software is designed to provide automatic data on shopper behavior and to assist human observers in tracking individual shopping trips. We discuss behavioral classifications, methodology, and implications related to the data from consumer tracking efforts.

Online Healthy Food Experiments: Capturing Complexity by Using Choice-Based Conjoint Analysis

The impact of complex environmental factors on consumer choices and preferences can be analyzed through the prism of consumer behavior analysis, whereas variations of marketing attributes and their impact on choice can be measured using conjoint analysis. Considering the case of the constantly growing online food selections, we discuss choice-based conjoint analysis and explore the opportunities for behavior analysts to examine the interrelationships of multiple variables and socially important choice settings, and to promote desired behaviors. We show a few examples of using trade-off analyses in online food retail to understand consumer behavior with respect to healthy food items. As demonstrated in these examples based on our own pilot research, conjoint analysis can be used for complex behavior-that which is not amenable directly to an experimental analysis-or as an efficient initial step before moving into further experiments or analyses using biometrics (e.g., eye-tracking) or web analytics conducted in different settings such as e-commerce, e-mail, social media, or on mobile platforms. This paper summarizes the personalized, data driven economic analysis that is possible with a choice-based conjoint analysis.

An open-label pilot study of an intervention using mobile phones to deliver contingency management of tobacco abstinence to high school students

This pilot study assessed the feasibility, acceptability, and preliminary efficacy of a smoking cessation intervention that used mobile phones to remotely deliver reinforcements contingent on tobacco abstinence (contingency management [CM]) and weekly in-person cognitive-behavioral therapy to adolescent smokers. Daily adolescent smokers (N = 15; 12 completed study procedures, 3 dropped out) were recruited to participate in a 4-week study. During the first 2 weeks, daily text messages sent at random times prompted participants to transmit a video of themselves providing a carbon monoxide (CO) sample. During the last 2 weeks, text messages sent on 3 randomly chosen days each week prompted participants to transmit a video of themselves providing a saliva sample. Negative samples (CO ≤8 ppm; cotinine ≤100 ng/ml) were reinforced with monetary incentives. Feasibility was assessed using the number of on-time, valid videos, and acceptability was determined using participant perceptions of the intervention. Seven-day point-prevalence (PP) abstinence (self-reported abstinence, cotinine <100 ng/ml) was assessed at end of treatment (EOT) and at a 1-month follow-up. The study findings indicate that remote delivery of CM using mobile phones was feasible (85.8% of the CO videos and 67% of the saliva cotinine videos were on time) and acceptable (positive perceptions of the CM procedures). Seven-day PP was 60% at EOT and 46.7% at the follow-up. Although larger randomized controlled trials are needed to evaluate efficacy, this pilot study suggests that the use of mobile phones to deliver CM for smoking cessation among adolescent smokers was acceptable and feasible. (PsycINFO Database Record

Internet-based interventions for smoking cessation

BACKGROUND

Tobacco use is estimated to kill 7 million people a year. Nicotine is highly addictive, but surveys indicate that almost 70% of US and UK smokers would like to stop smoking. Although many smokers attempt to give up on their own, advice from a health professional increases the chances of quitting. As of 2016 there were 3.5 billion Internet users worldwide, making the Internet a potential platform to help people quit smoking.

OBJECTIVES

To determine the effectiveness of Internet-based interventions for smoking cessation, whether intervention effectiveness is altered by tailoring or interactive features, and if there is a difference in effectiveness between adolescents, young adults, and adults.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, which included searches of MEDLINE, Embase and PsycINFO (through OVID). There were no restrictions placed on language, publication status or publication date. The most recent search was conducted in August 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs). Participants were people who smoked, with no exclusions based on age, gender, ethnicity, language or health status. Any type of Internet intervention was eligible. The comparison condition could be a no-intervention control, a different Internet intervention, or a non-Internet intervention. To be included, studies must have measured smoking cessation at four weeks or longer.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed and extracted data. We extracted and, where appropriate, pooled smoking cessation outcomes of six-month follow-up or more, reporting short-term outcomes narratively where longer-term outcomes were not available. We reported study effects as a risk ratio (RR) with a 95% confidence interval (CI).We grouped studies according to whether they (1) compared an Internet intervention with a non-active control arm (e.g. printed self-help guides), (2) compared an Internet intervention with an active control arm (e.g. face-to-face counselling), (3) evaluated the addition of behavioural support to an Internet programme, or (4) compared one Internet intervention with another. Where appropriate we grouped studies by age.

MAIN RESULTS

We identified 67 RCTs, including data from over 110,000 participants. We pooled data from 35,969 participants.There were only four RCTs conducted in adolescence or young adults that were eligible for meta-analysis.Results for trials in adults: Eight trials compared a tailored and interactive Internet intervention to a non-active control. Pooled results demonstrated an effect in favour of the intervention (RR 1.15, 95% CI 1.01 to 1.30, n = 6786). However, statistical heterogeneity was high (I2 = 58%) and was unexplained, and the overall quality of evidence was low according to GRADE. Five trials compared an Internet intervention to an active control. The pooled effect estimate favoured the control group, but crossed the null (RR 0.92, 95% CI 0.78 to 1.09, n = 3806, I2 = 0%); GRADE quality rating was moderate. Five studies evaluated an Internet programme plus behavioural support compared to a non-active control (n = 2334). Pooled, these studies indicated a positive effect of the intervention (RR 1.69, 95% CI 1.30 to 2.18). Although statistical heterogeneity was substantial (I2 = 60%) and was unexplained, the GRADE rating was moderate. Four studies evaluated the Internet plus behavioural support compared to active control. None of the studies detected a difference between trial arms (RR 1.00, 95% CI 0.84 to 1.18, n = 2769, I2 = 0%); GRADE rating was moderate. Seven studies compared an interactive or tailored Internet intervention, or both, to an Internet intervention that was not tailored/interactive. Pooled results favoured the interactive or tailored programme, but the estimate crossed the null (RR 1.10, 95% CI 0.99 to 1.22, n = 14,623, I2 = 0%); GRADE rating was moderate. Three studies compared tailored with non-tailored Internet-based messages, compared to non-tailored messages. The tailored messages produced higher cessation rates compared to control, but the estimate was not precise (RR 1.17, 95% CI 0.97 to 1.41, n = 4040), and there was evidence of unexplained substantial statistical heterogeneity (I2 = 57%); GRADE rating was low.Results should be interpreted with caution as we judged some of the included studies to be at high risk of bias.

AUTHORS' CONCLUSIONS

The evidence from trials in adults suggests that interactive and tailored Internet-based interventions with or without additional behavioural support are moderately more effective than non-active controls at six months or longer, but there was no evidence that these interventions were better than other active smoking treatments. However some of the studies were at high risk of bias, and there was evidence of substantial statistical heterogeneity. Treatment effectiveness in younger people is unknown.

Attitudes and interest in technology-based treatment and the remote monitoring of smoking among adolescents and emerging adults

INTRODUCTION

Despite the public health relevance of smoking in adolescents and emerging adults, this group remains understudied and underserved. High technology utilization among this group may be harnessed as a tool for better understanding of smoking, yet little is known regarding the acceptability of mobile health (mHealth) integration.

METHODS

Participants (ages 14-21) enrolled in a smoking cessation clinical trial provided feedback on their technology utilization, perceptions, and attitudes; and interest in remote monitoring for smoking. Characteristics that predicted greater technology acceptability for smoking treatment were also explored.

RESULTS

Participants (N=87) averaged 19 years old and were mostly male (67%). Technology utilization was high for smart phone ownership (93%), Internet use (98%), and social media use (94%). Despite this, only one-third of participants had ever searched the Internet for cessation tips or counseling (33%). Participants showed interest in mHealth-enabled treatment (48%) and felt that it could be somewhat helpful (83%). Heavier smokers had more favorable attitudes toward technology-based treatment, as did those with smartphones and unlimited data.

CONCLUSIONS

Our results demonstrate high technology utilization, favorable attitudes towards technology, and minimal concerns. Technology integration among this population should be pursued, though in a tailored fashion, to accomplish the goal of providing maximally effective, just-in-time interventions.

Nationwide access to an internet-based contingency management intervention to promote smoking cessation: a randomized controlled trial

BACKGROUND AND AIMS

Contingency management (CM) is one of the most effective behavioral interventions to promote drug abstinence, but availability of this treatment is limited. We evaluated the efficacy and acceptability of internet-based CM relative to an internet-based monitoring and goal-setting control group in a nationwide sample of cigarette smokers.

DESIGN

Randomized controlled trial with 3- and 6-month follow-ups.

SETTING

United States.

PARTICIPANTS

Smokers (n = 94) from 26 states were enrolled (mean age 36, 56% female).

INTERVENTION AND COMPARATOR

Participants were randomized to earn financial incentives (up to $480 over 7 weeks) based on video-verified abstinence using breath carbon monoxide (CO) output (n = 48; abstinent contingent group, AC), or based on submitting CO samples (n = 46, submission contingent, SC). Both groups also received the same CO-based goals. A $50 deposit was required in both groups that could be recouped from initial earnings.

MEASURES

The primary outcome was point prevalence at week 4. Secondary outcomes were point prevalence at the 3- and 6-month follow-ups, percentages of negative CO samples, adherence to the CO sampling protocol, and treatment acceptability ratings on a 0-100-mm visual analog scale.

FINDINGS

Abstinence rates differed at 4 weeks between the AC (39.6%) and SC (13.0%) groups [odds ratio (OR) = 4.4, 95% confidence interval (CI) = 1.6-12.3], but not at the 3- (29.2% AC and 19.6% SC, OR = 1.7, 95% CI = 0.6-4.4) or 6- (22.9% AC and 13.0% SC, OR = 2.0, 95% CI = 0.7-5.9) month follow-ups. During the two main treatment phases, there were significant differences in negative COs (53.9% AC and 24.8% SC, OR = 3.5, 95% CI = 3.1-4.0; 43.4% AC and 24.6% SC, OR = 2.3, 95% CI = 1.6-3.4). Adherence to the CO submission protocol was equivalent (78% AC and 85% SC, difference = 7.0%, 95% CI = -10.3 to 23.8 %, F < 1, P = 0.39). The lowest acceptability ratings were for the items assessing the deposit, whereas the highest ratings concerned the ease of the intervention, the graph of CO results, and earning money.

CONCLUSIONS

A contingency management/financial incentive program delivered via the internet improved short-term abstinence rates compared with an internet program without the incentives.

A Randomized Trial of Adjunct mHealth Abstinence Reinforcement With Transdermal Nicotine and Counseling for Smoking Cessation

INTRODUCTION

Abstinence reinforcement is efficacious for improving smoking treatment outcomes, but practical constraints related to the need for multiple in-person carbon monoxide (CO) breath tests daily to verify smoking abstinence have limited its use. This study tested an mHealth procedure to remotely monitor and reinforce smoking abstinence in individuals' natural environment.

METHODS

Eligible treatment-seeking smokers (N = 90) were randomized to (1) usual care and ecological monitoring with abstinence reinforcement (mHealth reinforcement) or (2) without reinforcement (mHealth monitoring). Usual care was 8 weeks of transdermal nicotine and twice-weekly telephone counseling. Following training, an interactive voice response system prompted participants to conduct CO tests 1-3 daily at pseudorandom times (7 am to 10 pm) for 4 weeks. When prompted, participants used a study cell phone and CO monitor to complete a CO self-test, video record the process, and submit videos using multimedia messaging. mHealth reinforcement participants could earn prizes for smoking-negative on-time CO tests. The interactive voice response generated preliminary earnings immediately. Earnings were finalized by comparing video records against participants' self-reports.

RESULTS

mHealth reinforcement was associated with a greater proportion of smoking-negative CO tests, longest duration of prolonged abstinence, and point-prevalence abstinence during the monitoring/reinforcement phase compared to mHealth monitoring (p < .01, d = 0.8-1.3). Follow-up (weeks 4-24) analyses indicated main effects of reinforcement on point-prevalence abstinence and proportion of days smoked (p ≤ .05); values were comparable by week 24.

CONCLUSIONS

mHealth reinforcement has short-term efficacy. Research on methods to enhance and sustain benefits is needed.

IMPLICATIONS

This study suggests that mHealth abstinence reinforcement is efficacious and may present temporal and spatial opportunities to research, engage, and support smokers trying to quit that do not exist with conventional (not technology-based) reinforcement interventions.