New methods for tobacco dependence treatment research

Project phoenix: Pilot randomized controlled trial of a smartphone-delivered intervention for people who are not ready to quit smoking

BACKGROUND

Most people who smoke cigarettes report they want to quit in the future, but only 20 % are ready to quit within the next 30 days. This 3-arm pilot randomized controlled trial examined the feasibility and initial efficacy of a novel smartphone-based intervention that aimed to induce smoking cessation attempts among adults not initially ready to quit.

METHODS

Participants randomized into the two intervention groups (Group 1: Phoenix App Only; Group 2: Phoenix App + Nicotine Replacement Therapy) received daily smoking cessation messages via smartphone application that were tailored to their current readiness to quit, while the attention control group (i.e., Factoid) received messages not related to smoking cessation. All participants completed a weekly survey for 26 weeks and used the app to set quit dates when/if desired.

RESULTS

Participants (N=152) were female (67.8 %), White (75.7 %), 50.0 years old (SD=12.5), and smoked 20.4 cigarettes per day (SD=10.5). Results indicated that the Phoenix interventions were feasible (e.g., participants viewed ~185 messages over 26 weeks; 74.8 % of weekly surveys were completed; 85.5 % completed the 26-week follow-up assessment). Phoenix participants set more quit dates, set quit dates sooner, were abstinent for more days, and used smoking cessation medications on more days than those assigned to the Factoid group.

CONCLUSIONS

This low-burden, smartphone-based smoking cessation induction intervention may increase smoking cessation attempts, and may reduce barriers that are encountered with traditional in-person or call-based interventions.

TRIAL REGISTRATION

Clinicaltrials.gov number: NCT03405129; https://clinicaltrials.gov/ct2/show/NCT03405129.

Smartphone-Based Survey and Message Compliance in Adults Initially Unready to Quit Smoking: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Efficacy of smartphone-based interventions depends on intervention content quality and level of exposure to that content. Smartphone-based survey completion rates tend to decline over time; however, few studies have identified variables that predict this decline over longer-term interventions (eg, 26 weeks).

OBJECTIVE

This study aims to identify predictors of survey completion and message viewing over time within a 26-week smoking cessation trial.

METHODS

This study examined data from a 3-group pilot randomized controlled trial of adults who smoke (N=152) and were not ready to quit smoking within the next 30 days. For 182 days, two intervention groups received smartphone-based morning and evening messages based on current readiness to quit smoking. The control group received 2 daily messages unrelated to smoking. All participants were prompted to complete 26 weekly smartphone-based surveys that assessed smoking behavior, quit attempts, and readiness to quit. Compliance was operationalized as percentages of weekly surveys completed and daily messages viewed. Linear regression and mixed-effects models were used to identify predictors (eg, intervention group, age, and sex) of weekly survey completion and daily message viewing and decline in compliance over time.

RESULTS

The sample (mean age 50, SD 12.5, range 19-75 years; mean years of education 13.3, SD 1.6, range 10-20 years) was 67.8% (n=103) female, 74.3% (n=113) White, 77% (n=117) urban, and 52.6% (n=80) unemployed, and 61.2% (n=93) had mental health diagnoses. On average, participants completed 18.3 (71.8%) out of 25.5 prompted weekly surveys and viewed 207.3 (60.6%) out of 345.1 presented messages (31,503/52,460 total). Age was positively associated with overall weekly survey completion (P=.003) and daily message viewing (P=.02). Mixed-effects models indicated a decline in survey completion from 77% (114/148) in the first week of the intervention to 56% (84/150) in the last week of the intervention (P<.001), which was significantly moderated by age, sex, ethnicity, municipality (ie, rural/urban), and employment status. Similarly, message viewing declined from 72.3% (1533/2120) in the first week of the intervention to 44.6% (868/1946) in the last week of the intervention (P<.001). This decline in message viewing was significantly moderated by age, sex, municipality, employment status, and education.

CONCLUSIONS

This study demonstrated the feasibility of a 26-week smartphone-based smoking cessation intervention. Study results identified subgroups that displayed accelerated rates in the decline of survey completion and message viewing. Future research should identify ways to maintain high levels of interaction with mobile health interventions that span long intervention periods, especially among subgroups that have demonstrated declining rates of intervention engagement over time.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03405129; https://clinicaltrials.gov/ct2/show/NCT03405129.

What to do after smoking relapse? A sequential multiple assignment randomized trial of chronic care smoking treatments

AIM

To compare effects of three post-relapse interventions on smoking abstinence.

DESIGN

Sequential three-phase multiple assignment randomized trial (SMART).

SETTING

Eighteen Wisconsin, USA, primary care clinics.

PARTICIPANTS

A total of 1154 primary care patients (53.6% women, 81.2% White) interested in quitting smoking enrolled from 2015 to 2019; 582 relapsed and were randomized to relapse recovery treatment.

INTERVENTIONS

In phase 1, patients received cessation counseling and 8 weeks nicotine patch. Those who relapsed and agreed were randomized to a phase 2 relapse recovery group: (1) reduction counseling + nicotine mini-lozenges + encouragement to quit starting 1 month post-randomization (preparation); (2) repeated encouragement to quit starting immediately post-randomization (recycling); or (3) advice to call the tobacco quitline (control). The first two groups could opt into phase 3 new quit treatment [8 weeks nicotine patch + mini-lozenges plus randomization to two treatment factors (skill training and supportive counseling) in a 2 × 2 design]. Phase 2 and 3 interventions lasted ≤ 15 months.

MEASUREMENTS

The study was powered to compare each active phase 2 treatment with the control on the primary outcome: biochemically confirmed 7-day point-prevalence abstinence 14 months post initiating phase 2 relapse recovery treatment. Exploratory analyses tested for phase 3 counseling factor effects.

FINDINGS

Neither skill training nor supportive counseling (each on versus off) increased 14-month abstinence rates; skills on versus off 9.3% (14/151) versus 5.2% (8/153), P = 0.19; support on versus off 6.6% (10/152) versus 7.9% (12/152), P = 0.73. Phase 2 preparation did not produce higher 14-month abstinence rates than quitline referral; 3.6% (8/220) versus 2.1% [3/145; risk difference = 1.5%, 95% confidence interval (CI) = -1.8-5.0%, odds ratio (OR) = 1.8, 95% CI = 0.5-6.9]. Recycling, however, produced higher abstinence rates than quitline referral; 6.9% (15/217) versus 2.1% (three of 145; risk difference, 4.8%, 95% CI = 0.7-8.9%, OR = 3.5, 95% CI = 1.0-12.4). Recycling produced greater entry into new quit treatment than preparation: 83.4% (181/217) versus 55.9% (123/220), P < 0.0001.

CONCLUSIONS

Among people interested in quitting smoking, immediate encouragement post-relapse to enter a new round of smoking cessation treatment ('recycling') produced higher probability of abstinence than tobacco quitline referral. Recycling produced higher rates of cessation treatment re-engagement than did preparation/cutting down using more intensive counseling and pharmacotherapy.

Personalized feedback intervention for individuals with low distress tolerance who smoke cigarettes: A randomized controlled trial of a digital intervention

INTRODUCTION

Cigarette smoking remains the leading preventable cause of death and disability in the United States and frequently co-occurs with anxiety and depressive symptoms. A novel and integrative, theory-driven approach to address the heterogeneity of mood-related symptoms associated with cigarette use is to focus on transdiagnostic processes, such as distress tolerance, that underpin both mood-related symptoms and smoking behavior. The current study sought to develop and examine the feasibility, acceptability, and initial efficacy of a digitally delivered integrated personalized feedback intervention (PFI) that addresses smoking-distress tolerance relations.

METHODS

Participants included 121 adults (71.1 % male; Mage = 29.33 years, SD = 7.52) who smoked cigarettes daily and reported low distress tolerance. The study randomized participants to the Active PFI (feedback on distress tolerance and smoking) or the Control PFI (feedback on smoking only).

RESULTS

Results indicated feasibility and acceptability demonstrated by the ability to retain participants through the 1-month follow-up (98.2 % retention rate) and positive feedback from participants, including satisfaction regarding the Active PFI. The Active PFI (vs. Control PFI) was also a statistically significant predictor of change in motivation and intention to quit smoking and willingness to use adaptive coping strategies from baseline to 1-month follow-up.

CONCLUSIONS

For individuals with low distress tolerance who smoke cigarettes, this study's findings suggest that the current intervention may be a first-step to aid in increasing motivation/intention to quit smoking and willingness to use adaptive coping strategies.

Development of a targeted behavioral treatment for smoking cessation among individuals with Chronic Obstructive Pulmonary Disease

OBJECTIVE

Smoking cessation for individuals with Chronic Obstructive Pulmonary Disease (COPD) is medically critical, but smoking for coping motives is a common barrier.

METHOD

In this evaluation of three treatment components (Mindfulness, Practice Quitting, and Countering Emotional Behaviors), we conducted two studies guided by the ORBIT model. Study 1 was a single-case design experiment (N = 18); Study 2 was a pilot feasibility study (N = 30). In both studies, participants were randomized to receive one of the three treatment modules. Study 1 examined implementation targets, changes in smoking for coping motives, and changes in smoking rate. Study 2 examined overall feasibility and participant-rated acceptability, and changes in smoking rate.

RESULTS

Study 1: Treatment implementation targets were met by 3/5 Mindfulness participants, 2/4 Practice Quitting participants, and 0/6 Countering Emotional Behaviors participants. The Practice Quitting condition led to 100% of participants meeting the clinically significant threshold in smoking for coping motives. Incidence of quit attempts ranged from 0-50%, and smoking rate was reduced by 50% overall. Study 2: Recruitment and retention met feasibility targets, with 97% of participants completing all four treatment sessions. Participants reported high treatment satisfaction by qualitative responses and rating scales (M = 4.8/ 5.0). Incidence of quit attempts ranged from 25-58%, and smoking rate was reduced by 56% overall.

CONCLUSIONS

These two small-N studies provide complementary findings on internal validity and implementation of the novel intervention. While Study 1 provided initial support for plausibility of clinically significant change, Study 2 provided data on key feasibility parameters.

IMPLICATIONS

Smoking cessation for individuals with COPD is medically critical. We conducted an early-phase evaluation of a novel behavioral treatment focused on reducing smoking for coping motives. Results provided initial support for plausibility of clinically significant change and feasibility of the intervention.

Feasibility, Acceptability, and Preliminary Effects of a Video-Based Intervention for Smoking Cessation Among People with HIV in Kathmandu, Nepal: A Single-Armed Pilot Study

Despite the evidence of the disproportionate burden of tobacco use among people with HIV (PWH), little effort has been made to design and test smoking cessation interventions for PWH in resource-limited countries. We assessed the feasibility, acceptability, and preliminary effects of a video-based smoking cessation intervention consisting of eleven 3-8-minute sessions among PWH in Nepal, a lower-middle-income country. Guided by the phased-based model, our 3-month intervention focused on setting the quit date, smoking cessation, and abstinence maintenance. We screened 103 PWH over three weeks for our single-arm trial, with 53 considered eligible and 48 recruited (91%). Forty-six participants watched all video clips, while two watched 7-9. All participants were retained at a 3-month follow-up. The 1-week point prevalence abstinence (self-report supported with expired carbon monoxide levels < 5ppm) at 3-month follow-up was 39.6%. Most (90%) participants reported "very much" or "much" comfort with watching the videos on their smartphones, and all would recommend the intervention to other PWH who smoke. Overall, our pilot trial demonstrated the feasibility, acceptability, and high-level efficacy of the video-based smoking cessation intervention highlighting its potential for scaling up in Nepal and other resource-limited countries.

Virtual reality cue exposure therapy for tobacco relapse prevention: a comparative study with standard intervention

BACKGROUND

Successful interventions have been developed for smoking cessation although the success of smoking relapse prevention protocols has been limited. Cognitive behavioural therapy (CBT) in particular has been hampered by a high relapse rate. Because relapse can be due to conditions associated with tobacco consumption (such as drinking in bars with friends), virtual reality cue exposure therapy (VRCE) can be a potential tool to generate 3D interactive environments that simulate risk situations for relapse prevention procedures.

METHODS

To assess the effectiveness of VRCE with CBT, a comparative trial involving 100 smoking abstinent participants was designed with all required virtual environments (VE) created with an inexpensive graphic engine/game level editor.

RESULTS

Outcome measures confirmed the immersive and craving eliciting effect of these VEs. Results demonstrated that more participants in the VRCE group did not experience smoking relapse and that VRCE is at least as efficacious as traditional CBT in terms of craving reduction and decrease in nicotine dependence. Dropout and relapse rate in the VRCE group was noticeably lower than the CBT group. Aside from mood scores, no significant differences were found regarding the other scales.

CONCLUSION

The present clinical trial provides evidence that VRCE was effective in preventing smoking relapse. Improvement in technology and methodology for future research and applications is delineated.

Ending Tobacco Use Through Interactive Tailored Messaging for Cambodian People With HIV (Project EndIT): Protocol for a Randomized Controlled Trial

BACKGROUND

The prevalence of smoking remains high in many low- and middle-income countries (LMICs), including the Southeast Asian nation of Cambodia. Smoking is especially hazardous for people with HIV. In Cambodia, approximately 43%-65% of men with HIV and 3%-5% of women with HIV smoke cigarettes. Thus, there is a critical need for cost-effective smoking cessation interventions for Cambodian people with HIV. This paper describes the design, methods, and data analysis plans for a randomized controlled trial assessing the efficacy of a theory-based mobile health smoking cessation intervention in Cambodian people with HIV.

OBJECTIVE

This 2-group randomized controlled trial compares the efficacy of a mobile health-based automated messaging (AM) intervention versus standard care (SC) in facilitating smoking cessation among Cambodian people with HIV.

METHODS

Cambodian people with HIV who currently smoke and are receiving antiretroviral treatment (target, N=800) will be randomized to (1) SC or (2) the AM intervention. SC participants will receive brief advice to quit smoking, written self-help materials, nicotine patches, and will complete weekly app-delivered dietary assessments for 26 weeks. AM participants will receive all SC components (but will complete smoking-related weekly assessments instead of dietary assessments), in addition to a fully automated tailored messaging program driven by the weekly assessments to facilitate smoking cessation. In the Phase-Based Model of smoking cessation, the cessation process is partitioned into 4 phases: motivation, preparation (precessation), cessation (quit date to 2 weeks post quit), and maintenance (up to 6 months post quit). Our AM program targets processes within these phases, including increasing motivation to quit, enhancing self-efficacy, obtaining social support, skills to cope with nicotine withdrawal symptoms and stress, and skills to maintain abstinence. All participants will complete baseline and 3-, 6-, and 12-month in-person follow-up assessments. The primary outcome is biochemically confirmed abstinence at 12 months, with 3- and 6-month abstinence as secondary outcomes. Potential mediators and moderators underlying treatment effects will be explored, and cost-effectiveness will be assessed.

RESULTS

This study was approved by all relevant domestic and international institutional and ethical review boards. Participant recruitment commenced in January 2023. Data collection is expected to conclude by the end of 2025.

CONCLUSIONS

By demonstrating the greater efficacy and cost-effectiveness of AM relative to SC, this study has the potential to transform HIV care in Cambodia and prevent tobacco-related diseases. Furthermore, it may be adapted for use in other Cambodian populations and in other low- and middle-income countries. Ultimately, the AM approach to smoking cessation could greatly improve public health in the developing world and beyond.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05746442; https://clinicaltrials.gov/ct2/show/NCT05746442.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/48923.

Tips to Quit Smoking: Perspectives from Vietnamese Healthcare Providers, Community Leaders, and Past Tobacco Users in the United States

This study focuses on smoking-cessation strategies for United States (US) Vietnamese individuals, a group with high smoking rates, particularly those with limited English proficiency (LEP). The researchers conducted 16 in-depth interviews with a diverse group of participants, including healthcare professionals, community leaders, and former tobacco users. Data were analyzed using the Phase-Based Model of smoking cessation, resulting in several helpful strategies across the four phases: Motivation, Preparation, Cessation, and Maintenance. Prominent advice for the Motivation Phase included having a strong determination to quit and a reason why, such as protecting loved ones. For the Preparation and Cessation Phases, participants recommended healthy coping mechanisms, avoiding triggers, changing habits, and gradually reducing the number of cigarettes smoked. In the Maintenance Phase, strategies included regular exercise and setting boundaries with other people who smoke. Participants also stressed the importance of social support throughout all four phases. These findings have implications for healthcare providers working with US Vietnamese who smoke, especially those with LEP. By understanding the unique challenges this group faces in accessing smoking-cessation resources, providers can offer tailored support and guidance. Ultimately, this study provides useful strategies for helping US Vietnamese quit smoking, improving their health outcomes and quality of life.

A systematic review and meta-analysis of interventions to induce attempts to quit tobacco among adults not ready to quit

The prevalence of past-year smoking cessation remains below 10% in the U.S. Most who smoke are not ready to quit in the near future. Cessation requires both (a) initiating a quit attempt (QA) and (b) maintaining abstinence. Most research has focused on abstinence among people already motivated to quit. We systematically reviewed interventions to promote QAs among people not motivated to quit tobacco. We searched PubMed, CENTRAL, PsycINFO, Embase, and our personal libraries for randomized trials of tobacco interventions that reported QAs as an outcome among adults not ready to quit. We screened studies and extracted data in duplicate. We pooled findings of the 25 included studies using Mantel-Haenszel random effects meta-analyses when ≥ 2 studies tested the same intervention. Most (24) trials addressed cigarettes and one addressed smokeless tobacco. Substantial heterogeneity among trials resulted in a series of small meta-analyses. Findings indicate varenicline may increase QAs more than no varenicline, n = 320; RR = 1.4, 95% CI [1.1, 1.7]; I² = 0%, and nicotine replacement therapy (NRT) may increase QAs more than no NRT, n = 2,568; RR = 1.1, 95% CI [1.02, 1.3]; I² = 0%. Pooled effects for motivational counseling, reduction counseling, and very low nicotine content cigarettes showed no clear evidence of benefit or harm. The evidence was judged to be of medium to very low certainty due to imprecision, inconsistency, and risk of bias, suggesting that further research is likely to change interpretation of our results. Findings demonstrate the need for more high-quality research on interventions to induce QAs among adults not ready to quit tobacco. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Successful Optimization of Tobacco Dependence Treatment in the Emergency Department: A Randomized Controlled Trial Using the Multiphase Optimization Strategy

STUDY OBJECTIVE

Tobacco dependence treatment initiated in the hospital emergency department (ED) is effective. However, trials typically use multicomponent interventions, making it difficult to distinguish specific components that are effective. In addition, interactions between components cannot be assessed. The Multiphase Optimization Strategy allows investigators to identify these effects.

METHODS

We conducted a full-factorial, 24 or 16-condition optimization trial in a busy hospital ED to examine the performance of 4 tobacco dependence interventions: a brief negotiation interview; 6 weeks of nicotine replacement therapy with the first dose delivered in the ED; active referral to a telephone quitline; and enrollment in SmokefreeTXT, a free short-messaging service program. Study data were analyzed with a novel mixed methods approach to assess clinical efficacy, cost-effectiveness, and qualitative participant feedback. The primary endpoint was tobacco abstinence at 3 months, verified by exhaled carbon monoxide using a Bedfont Micro+ Smokerlyzer.

RESULTS

Between February 2017 and May 2019, we enrolled 1,056 adult smokers visiting the ED. Odd ratios (95% confidence intervals) from the primary analysis of biochemically confirmed abstinence rates at 3 months for each intervention, versus control, were: brief negotiation interview, 1.8 (1.1, 2.8); nicotine replacement therapy, 2.1 (1.3, 3.2); quitline, 1.4 (0.9, 2.2); SmokefreeTXT, 1.1 (0.7, 1.7). There were no statistically significant interactions among components. Economic and qualitative analyses are in progress.

CONCLUSION

The brief negotiation interview and nicotine replacement therapy were efficacious. This study is the first to identify components of ED-initiated tobacco dependence treatment that are individually effective. Future work will address the scalability of the brief negotiation interview and nicotine replacement therapy by offering provider-delivered brief negotiation interviews and nicotine replacement therapy prescriptions.

Feasibility and utility of a structured guide for cannabis tolerance breaks in young adults

Objective: To explore the feasibility and utility of a tolerance break (T-Break) guide on young adults' cannabis use. Participants: Young adults aged 18-29 (n = 125) who were current cannabis users. Methods: Participants recruited through posters and listservs at various universities were offered the T-Break Guide-daily activities, advice, and encouragement-to help complete a 21-day cannabis break. Bivariate analyses examined associations between Guide use and follow-up measures. Results: Compared to non-Guide users, participants who used the Guide "a lot" were more likely to complete the 21-day abstinence break (84% vs. 57%), revise their personal definition of balance to mean less cannabis (84% vs. 62%), and plan a future break (32% vs. 11%). Conclusion: Use of this self-directed T-Break Guide may help young adults take a break from cannabis use and reduce future use. Further research using more rigorous designs to test the Guide's efficacy and assess longer-term maintenance of effects is needed.

Strengthening the evidence base for mHealth in clinical practice: Conducting research with standalone or interoperable systems - a viewpoint

Objective

The aim of this viewpoint is to inform mobile health (mHealth) evidence development in using standalone or interoperable systems in hospital practice.

Methods

There is a gap between mHealth research and its widespread uptake in clinical practice. Evidence generation is not keeping up with the introduction and implementation of technologies. This is partly a consequence of the technology characteristics and the way research is conducted in a clinical setting. Research and development of mHealth technology can be conducted standalone in a laboratory like setting, standalone in a clinical setting or interoperable with already existing technology in hospital practice.

Results

Standalone systems operate relatively independent from an organizations' existing infrastructure. Using laboratory settings does not reflect the complexity of real-life, but in clinical practice this may be suitable for research assessing usability, feasibility or even clinical and process outcomes at a small scale. Realizing research and development on interoperable mHealth technology solutions, especially with operational EMR systems, is a challenging, time- and resource intensive process and requires large(r) investments, as it is often complicated by a myriad of interfering factors. Interoperable systems are however a more sustainable option in the long run, and generated evidence reflects the real hospital care setting and this option may therefore facilitate dissemination. Choosing either a standalone or interoperable setting affects the research design, the implementation pace and ultimately widespread adoption of the mHealth technology.

Conclusion

We recommend to include these technology characteristics in implementation frameworks and think of evaluation research designs in an early phase.

Smoking reduction among homeless smokers in a randomized controlled trial targeting cessation

INTRODUCTION

Homeless populations have high rates of smoking and unique barriers to quitting. General cessation strategies have been unsuccessful in this population. Smoking reduction may be a good intermediate goal. We conducted a secondary analysis to identify predictors of smoking reduction in a cohort of homeless smokers enrolled in a 26-week randomized clinical trial (RCT) targeting smoking cessation.

METHODS

Data are from an RCT comparing motivational interviewing counseling plus nicotine replacement therapy (NRT) to brief advice to quit (standard care) plus NRT among homeless smokers. Using bivariate analyses and multinomial logistic regression, we compared demographics, health and psychosocial variables, tobacco use, substance use, and NRT adherence among those who reported: quitting; reducing smoking by 50-99%; and not reducing smoking by 50%.

RESULTS

Of 324 participants who completed 26-week follow-up, 18.8% and 63.9% self-reported quitting and reducing, respectively. Compared to those who did not reduce smoking, participants reporting reducing indicated higher baseline cigarette use (OR=1.08; CI:1.04-1.12) and menthol use (OR=2.24; CI:1.05-4.77). Compared to participants who reduced, participants reporting quitting were more likely to be male (OR=1.998; CI:1.00-3.98), experience more housing instability (OR=1.97; CI:1.08-3.59), indicate higher importance of quitting (OR=1.27; CI:1.041.55), have higher NRT adherence (OR=1.75; CI:1.00-3.06), and lower odds of reported illicit drug use (OR=0.48; CI:0.24-0.95).

CONCLUSIONS

Over half of participants reduced smoking by at least 50%, indicating reduction is feasible among homeless smokers. Further research is required to understand the impact of reduction on future cessation attempts in homeless smokers. This study shows that reduction is achievable and may be a valid intermediate goal.

Proposing a Model of Proactive Outreach to Advance Clinical Research and Care Delivery for Patients Who Use Tobacco

There are evidence-based treatments for tobacco dependence, but inequities exist in the access to and reach of these treatments. Traditional models of tobacco treatment delivery are "reactive" and typically provide treatment only to patients who are highly motivated to quit and seek out tobacco treatment. Newer models involve "proactive" outreach, with benefits that include increasing access to tobacco treatment, prompting quit attempts among patients with low motivation, addressing health disparities, and improving population-level quit rates. However, the definition of "proactive" is not clear, and adoption has been slow. This commentary introduces a comprehensive yet flexible model of proactive outreach and describes how proactive outreach can optimize clinical research and care delivery in these domains: (1) identifying the population, (2) offering treatment, and (3) delivering treatment. Dimensions relevant to each domain are the intensity of proactive outreach (low to high) and the extent to which proactive outreach activities rely on human interaction or are facilitated by information technology (IT). Adoption of the proposed proactive outreach model could improve the precision and rigor with which tobacco cessation research and tobacco treatment programs report data, which could have a positive effect on care delivery and patient outcomes.

Characterizing tobacco and marijuana use among youth combustible tobacco users experiencing homelessness - considering product type, brand, flavor, frequency, and higher-risk use patterns and predictors

BACKGROUND

Cigarette smoking is three times more prevalent among youth experiencing homelessness compared with the general population. Co-use of tobacco and marijuana is also common. The aim of this study is to characterize tobacco and marijuana use among youth experiencing homelessness who use combustible tobacco in a Midwestern city to inform smoking cessation intervention.

METHODS

This study included 96 youth (ages 14-24 years; 52% male, 39% female, 5% transgender/non-binary) attending a homeless drop-in center who had used at least one combustible tobacco product in the past week. We assessed past-month use of tobacco products and marijuana, other product use characteristics (e.g., frequency, brand and flavor), and psychosocial predictors of more frequent (i.e., daily) use of combustible tobacco and marijuana.

RESULTS

Most youth experiencing homelessness with past-week combustible tobacco use had used cigarettes (n = 85, 88.5%), cigars (n = 89, 92.7%), and marijuana (n = 82, 85.4%) in the past month. One-third (n = 34) used electronic vapor products (EVPs), 19.8% (n = 19) smoked hookah, and 11.5% (n = 11) used smokeless tobacco (ST). Most marijuana users co-administered with tobacco (n = 67, 69.8%). Daily combustible tobacco smoking was associated with having a child and smoking out of boredom/habit. Daily marijuana use was associated with using substances to cope with one's housing situation. Newport (n = 66, 72.5%) and Black & Mild (n = 48, 51.1%) were the most popular brands of cigarettes and cigars among ever users. Most non-combustible tobacco ever users reported not having a usual brand (EVPs: n = 51, 73.9%; ST: n = 16, 57.1%). Cigar smokers reported the most varied selection of flavors.

CONCLUSIONS

Young combustible tobacco users experiencing homelessness engage in high-risk use patterns, including poly-tobacco use, co-use of tobacco with marijuana, and frequent combustible product use. Interventions that consider the full context of tobacco and marijuana use are needed to support smoking cessation in this population.

Feature-level analysis of a smoking cessation smartphone app that uses a positive psychology approach (Preprint)

Background

Smoking cessation smartphone apps have emerged as highly accessible tools to support smoking cessation efforts. It is unknown how specific app features contribute to user engagement over time and relate to smoking outcomes.

Objective

To provide a feature-level analysis of the Smiling Instead of Smoking app (version 2) and to link feature use to subsequent smoking cessation.

Methods

Nondaily smokers (N=100) used the app for a period of 49 days (1 week before quitting and 6 weeks after quitting). Participants self-reported 30-day point-prevalence abstinence at the end of this period and at a 6-month follow up (the survey response rate was 94% and 89% at these points, respectively). Self-reported 30-day point prevalence abstinence rates were 40% at the end of treatment and 56% at the 6-month follow up. The app engaged users in both positive psychology content and traditional behavioral smoking cessation content. The app sent push notifications to prompt participants to complete prescribed content (ie, a “happiness exercise” every day and a “behavioral challenge” to use the app’s smoking cessation tools on 15 out of 49 days). Actions that participants took within the app were timestamped and recorded.

Results

Participants used the app on 24.7 (SD 13.8) days out of the 49 prescribed days, interacting with the happiness content on more days than the smoking content (23.8, SD 13.8 days vs 17.8, SD 10.3 days; t₉₉=9.28 [2-tailed]; P<.001). The prescribed content was frequently completed (45% of happiness exercises; 57% of behavioral challenges) and ad libitum tools were used on ≤7 days. Most participants used each ad libitum smoking cessation tool at least once, with higher use of personalized content (≥92% used “strategies,” “cigarette log,” “smoke alarms,” and “personal reasons”) than purely didactic content (79% viewed “benefits of quitting smoking”). The number of days participants used the app significantly predicted 30-day point-prevalence abstinence at the end of treatment (odds ratio [OR] 1.05, 95% CI 1.02-1.09; P=.002) and at the 6-month follow up (OR 1.04, 95% CI 1.008-1.07; P=.01). The number of days participants engaged with the happiness content significantly predicted smoking abstinence at the end of treatment (OR 1.05, 95% CI 1.02-1.08; P=.002) and at the 6-month follow up (OR 1.04, 95% CI 1.007-1.07; P=.02). This effect was not significant for the number of days participants engaged with the smoking cessation content of the app, either at the end of treatment (OR 1.04, 95% CI 0.996-1.08, P=.08) or at the 6-month follow up (OR 1.02, 95% CI 0.98-1.06; P=.29).

Conclusions

Greater app usage predicted greater odds of self-reported 30-day point-prevalence abstinence at both the end of treatment and over the long term, suggesting that the app had a therapeutic benefit. Positive psychology content and prescriptive clarity may promote sustained app engagement over time.

Trial Registration

ClinicalTrials.gov NCT03951766; https://clinicaltrials.gov/ct2/show/NCT03951766

Using Virtual Reality to Induce and Assess Objective Correlates of Nicotine Craving: Paradigm Development Study

Background

Craving is a clinically important phenotype for the development and maintenance of nicotine addiction. Virtual reality (VR) paradigms are successful in eliciting cue-induced subjective craving and may even elicit stronger craving than traditional picture-cue methods. However, few studies have leveraged the advances of this technology to improve the assessment of craving.

Objective

This report details the development of a novel, translatable VR paradigm designed to both elicit nicotine craving and assess multiple eye-related characteristics as potential objective correlates of craving.

Methods

A VR paradigm was developed, which includes three Active scenes with nicotine and tobacco product (NTP) cues present, and three Neutral scenes devoid of NTP cues. A pilot sample (N=31) of NTP users underwent the paradigm and completed subjective measures of nicotine craving, sense of presence in the VR paradigm, and VR-related sickness. Eye-gaze fixation time (“attentional bias”) and pupil diameter toward Active versus Neutral cues, as well as spontaneous blink rate during the Active and Neutral scenes, were recorded.

Results

The NTP Cue VR paradigm was found to elicit a moderate sense of presence (mean Igroup Presence Questionnaire score 60.05, SD 9.66) and low VR-related sickness (mean Virtual Reality Sickness Questionnaire score 16.25, SD 13.94). Scene-specific effects on attentional bias and pupil diameter were observed, with two of the three Active scenes eliciting greater NTP versus control cue attentional bias and pupil diameter (Cohen d=0.30-0.92). The spontaneous blink rate metrics did not differ across Active and Neutral scenes.

Conclusions

This report outlines the development of the NTP Cue VR paradigm. Our results support the potential of this paradigm as an effective laboratory-based cue-exposure task and provide early evidence of the utility of attentional bias and pupillometry, as measured during VR, as useful markers for nicotine addiction.

Assessment of Social Support and Quitting Smoking in an Online Community Forum: Study Involving Content Analysis

Background

A key factor in successfully reducing and quitting smoking, as well as preventing smoking relapse is access to and engagement with social support. Recent technological advances have made it possible for smokers to access social support via online community forums. While community forums associated with smoking cessation interventions are now common practice, there is a gap in understanding how and when the different types of social support identified by Cutrona and Suhr (1992) (emotional, esteem, informational, tangible, and network) are exchanged on such forums. Community forums that entail “superusers” (a key marker of a successful forum), like QuitNow, are ripe for exploring and leveraging promising social support exchanges on these platforms.

Objective

The purpose of this study was to characterize the posts made on the QuitNow community forum at different stages in the quit journey, and determine when and how the social support constructs are present within the posts.

Methods

A total of 506 posts (including original and response posts) were collected. Using conventional content analysis, the original posts were coded inductively to generate categories and subcategories, and the responses were coded deductively according to the 5 types of social support. Data were analyzed using Microsoft Excel software.

Results

Overall, individuals were most heavily engaged on the forum during the first month of quitting, which then tapered off in the subsequent months. In relation to the original posts, the majority of them fit into the categories of sharing quit successes, quit struggles, updates, quit strategies, and desires to quit. Asking for advice and describing smoke-free benefits were the least represented categories. In relation to the responses, encouragement (emotional), compliment (esteem), and suggestion/advice (informational) consistently remained the most prominent types of support throughout all quit stages. Companionship (network) maintained a steady downward trajectory over time.

Conclusions

The findings of this study highlight the complexity of how and when different types of social support are exchanged on the QuitNow community forum. These findings provide directions for how social support can be more strategically employed and leveraged in these online contexts to support smoking cessation.

Increasing cessation motivation and treatment engagement among smokers in pain: A pilot randomized controlled trial

Tobacco smokers with co-occurring pain report greater difficulty quitting, face unique cessation challenges, and may benefit from targeted smoking interventions. We developed and tested a brief motivational intervention aimed at increasing knowledge of pain-smoking interrelations, motivation to quit, and cessation treatment engagement among smokers in pain. Nontreatment seeking daily cigarette smokers with chronic pain (N = 76, 57.9% women, 52.6% White) were randomized to the targeted or ask, advise, refer (AAR) intervention. The targeted intervention included personalized feedback and pain-smoking psychoeducation to help participants develop discrepancy between continued smoking and desired pain outcomes. At postintervention, the targeted intervention (vs. AAR) increased knowledge of pain-smoking interrelations and several indices of motivation to quit smoking (ps < .01). Participants who received the targeted intervention were also more likely to accept information about and report intention to engage evidence-based cessation treatments (ps < .05). Increased knowledge of pain-smoking interrelations mediated postintervention effects on motivation to quit and willingness to learn about treatments. At 1-month follow up, gains in knowledge of pain-smoking interrelations were maintained (p = .009). Participants who received the targeted intervention were more likely to report having subsequently engaged cessation treatment (p = .019), but this was not mediated by increased knowledge of pain-smoking interrelations. Smokers with chronic pain may benefit from targeted interventions that address smoking in the context of pain. Smokers in pain may become increasingly motivated to quit and engage cessation treatment as they become aware of how smoking may exacerbate their pain. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

One view of the next decade of research on behavioral and biobehavioral approaches to cancer prevention and control: intervention optimization

As a new decade begins, we propose that the time is right to reexamine current methods and procedures and look for opportunities to accelerate progress in cancer prevention and control. In this article we offer our view of the next decade of research on behavioral and biobehavioral interventions for cancer prevention and control. We begin by discussing and questioning several implicit conventions. We then briefly introduce an alternative research framework: the multiphase optimization strategy (MOST). MOST, a principled framework for intervention development, optimization, and evaluation, stresses not only intervention effectiveness, but also intervention affordability, scalability, and efficiency. We review some current limitations of MOST along with future directions for methodological work in this area, and suggest some changes in the scientific environment we believe would permit wider adoption of intervention optimization. We propose that wider adoption of intervention optimization would have a positive impact on development and successful implementation of interventions for cancer prevention and control and on intervention science more broadly, including accumulation of a coherent base of knowledge about what works and what does not; establishment of an empirical basis for adaptation of interventions to different settings with different levels and types of resources; and, in the long run, acceleration of progress from Stage 0 to Stage V in the National Institutes of Health Model of Stages of Intervention Development.

Evaluating four motivation-phase intervention components for use with primary care patients unwilling to quit smoking: a randomized factorial experiment

AIMS

To assess the effectiveness of intervention components designed to increase quit attempts and promote abstinence in patients initially unwilling to quit smoking.

DESIGN

A four-factor, randomized factorial experiment.

SETTING

Sixteen primary care clinics in southern Wisconsin.

PARTICIPANTS

A total of 577 adults who smoke (60% women, 80% White) recruited during primary care visits who were currently willing to reduce their smoking but unwilling to try to quit. Interventions Four factors contrasted intervention components administered over a 1-year period: (i) nicotine mini-lozenge versus none; (ii) reduction counseling versus none; (iii) behavioral activation (BA) counseling versus none; and (iv) motivational 5Rs counseling versus none. Participants could request cessation treatment at any time.

MEASUREMENTS

The primary outcome was 7-day point-prevalence abstinence at 52 weeks post enrollment; secondary outcomes were point-prevalence abstinence at 26 weeks and making a quit attempt by weeks 26 and 52.

FINDINGS

No abstinence main effects were found but a mini-lozenge × reduction counseling × BA interaction was found at 52 weeks; P = 0.03. Unpacking this interaction showed that the mini-lozenge alone produced the highest abstinence rate (16.7%); combining it with reduction counseling produced an especially low abstinence rate (4.1%). Reduction counseling decreased the likelihood of making a quit attempt by 52 weeks relative to no reduction counseling (P = 0.01).

CONCLUSIONS

Nicotine mini-lozenges may increase smoking abstinence in people initially unwilling to quit smoking, but their effectiveness declines when used with smoking reduction counseling or other behavioral interventions. Reduction counseling decreases the likelihood of making a quit attempt in people initially unwilling to quit smoking.

Cognitive-Affective Transdiagnostic Factors Associated With Vulnerability to Alcohol and Prescription Opioid Use in the Context of Pain

The use of alcohol and prescription opioids is common among people in pain and poses significant public health burdens. This review identifies factors associated with motivation to use alcohol and prescription opioids in the context of pain. Pain-relevant, cognitive-affective, transdiagnostic vulnerability factors-expectancies/motives, pain catastrophizing, pain-related anxiety, distress intolerance, anxiety sensitivity, and perceived interrelations-were selected from theoretical conceptualizations of pain and substance use. Searches conducted in PubMed, PsycINFO, and Embase returned 25 studies that examined associations between identified variables of interest and the use of alcohol and prescription opioids in the context of pain. Consistent with a larger literature on pain and substance use, the studies included in this review demonstrated that people with chronic pain are motivated to use alcohol and opioids in response to negative affect and hold expectancies/motives for coping with pain. Vulnerabilities that engender difficulty managing aversive internal states (distress intolerance and anxiety sensitivity) and maladaptive responses to pain (pain-related anxiety and pain catastrophizing) also were implicated in motivation for alcohol and opioid use. Although one study found that pain-related anxiety was associated with co-use of alcohol and opioids, no studies examined simultaneous use. Future research directions that can explicate causal associations, identify patterns of alcohol and opioid co-use, clarify the role of pain in cessation processes, and inform treatment development are discussed.

The impact of menthol cigarette use on quit attempts and abstinence among smokers with opioid use disorder

An exceedingly high proportion of persons with opioid use disorder (OUD) smoke cigarettes. Smokers with OUD face multiple barriers to smoking cessation. While menthol cigarette use has been associated with low cessation rates, research has not explored the impact of menthol cigarette use on tobacco use outcomes among smokers with OUD. Participants were current smokers, in methadone treatment for OUD, participating in randomized controlled trials of smoking cessation therapies. We examined the use of menthol cigarettes, and the association between menthol cigarette use and achieving 24-hour quit attempts and seven-day point prevalence abstinence. Of 268 participants, 237 (88.4%) reported menthol use. A similar proportion of menthol and non-menthol smokers achieved a 24-hour quit attempt (83.1% vs. 83.8%, p = 0.92). Though fewer menthol smokers (vs. non-menthol smokers) achieved abstinence (12.7% vs. 22.6%), this did not reach statistical significance (p = 0.14). In this sample of smokers with OUD, menthol smoking was nearly ubiquitous. Menthol smoking was not associated with differences in quit attempts, but was associated with differences in cessation that were not statistically significant. Menthol smoking may contribute to the challenges in achieving abstinence among smokers with OUD.

Smoking Treatment: A Report Card on Progress and Challenges

The impact of tobacco smoking treatment is determined by its reach into the smoking population and the effectiveness of its interventions. This review evaluates the reach and effectiveness of pharmacotherapy and psychosocial interventions for smoking. Historically, the reach of smoking treatment has been low, and therefore its impact has been limited, but new reach strategies such as digital interventions and health care system changes offer great promise. Pharmacotherapy tends to be more effective than psychosocial intervention when used clinically, and newer pharmacotherapy strategies hold great promise of further enhancing effectiveness. However, new approaches are needed to advance psychosocial interventions; progress has stagnated because research and dissemination efforts have focused too narrowly on skill training despite evidence that its core content may be inconsequential and the fact that its mechanisms are either unknown or inconsistent with supporting theory. Identifying effective psychosocial content and its mechanisms of action could greatly enhance the effectiveness of counseling, digital, and web interventions.

Comparative effects of varenicline or combination nicotine replacement therapy versus patch monotherapy on candidate mediators of early abstinence in a smoking cessation attempt

BACKGROUND AND AIMS

The phase-based model of smoking cessation treatment suggests that treatment needs may vary across phases (e.g. pre-cessation, cessation). This study tested the comparative effects of varenicline and combination nicotine replacement therapy (C-NRT) relative to nicotine patch monotherapy on pre-cessation and cessation phase candidate withdrawal, expectancy and motivation mediators; relations between mediators and abstinence; and indirect effects of enhanced treatments on abstinence via candidate mediators.

DESIGN

Secondary mediation analysis of data from the open-label, randomized Wisconsin Smokers' Health Study 2, a comparative effectiveness trial of varenicline or C-NRT, versus patch monotherapy, in adults who smoked, recruited via media and community outreach.

SETTING

Research clinics in Madison and Milwaukee, Wisconsin, USA.

PARTICIPANTS

A total of 1051 daily smokers motivated to quit smoking (52.5% female; mean age = 48.1, standard deviation = 11.6).

INTERVENTIONS

Twelve weeks of varenicline (n = 407) or 12 weeks of combination nicotine patch and nicotine lozenge therapy (n = 421), both compared with 12 weeks of patch control condition (n = 230), with individual smoking cessation counseling.

MEASUREMENTS

The primary abstinence outcome was biochemically verified 7-day point-prevalence abstinence 4 weeks post-target quit day (TQD). Candidate mediators (craving, positive smoking expectancies, withdrawal symptoms, and quitting motivation) were assessed via ecological momentary assessment from 1 week prior (pre-cessation phase) to 4 weeks after (cessation phase) the TQD.

FINDINGS

Pre-cessation and cessation mean levels and slopes of craving [adjusted odds ratio (aOR) = 0.34-0.79], smoking expectancies (aOR = 0.46-0.79) and quitting motivation (aOR = 1.35-7.21) significantly predicted 4-week post-TQD abstinence (P < 0.05). Significant varenicline mediation occurred via greater suppression in pre-cessation craving [mediated effect (ab) = 0.09, standard error (SE) = 0.03, 95% confidence interval (CI) = 0.04-0.14] and smoking expectancies (ab = 0.06, SE = 0.02, 95% CI = 0.02-0.12). C-NRT mediation occurred via greater reduction in pre-post-TQD changes in craving (ab = 0.04, SE = 0.02, 95% CI = 0.01-0.08) and expectancies (ab = 0.03, SE = 0.02, 95% CI = 0.001-0.07), relative to patch monotherapy.

CONCLUSION

Among adult smokers seeking to quit, varenicline seems to work through its effects on suppression of craving and smoking expectancies pre-cessation while combination nicotine replacement therapy mediation seems to work through cessation-related reduction in craving and smoking expectancies changes.

An adapted smoking-cessation intervention for Turkish-speaking migrants in Switzerland: Predictors of smoking outcomes at one-year follow-up

BACKGROUND

Migrant populations usually report higher smoking rates. Among those migrant populations, Turkish- and Kurdish-speaking migrants are often overrepresented. Providing equal access to health services is one of the major challenges of our time. The need for adapted smoking-cessation treatments for Turkish-speaking populations to achieve equity in health led, in 2006, to the development and implementation of the Tiryaki-Kukla smoking-cessation program. The aims of the current study were to evaluate one-year quit rates for smoking-cessation courses held from 2006-2018 and investigate whether certain characteristics predict long-term smoking cessation or reduction.

METHODS

Program evaluation included a pre/post questionnaire (session 1/ 3 months after the quit day) and a follow-up telephone call twelve months after the quit day. To elucidate factors associated with long-term smoking cessation and reduction, Cox regression analysis and Weighted Generalized Equation Models were used.

RESULTS

Of the 478 who participated in smoking-cessation courses, 45.4% declared themselves non-smokers at one-year follow-up. This quit rate is higher than that achieved during the preliminary evaluation of the program involving 61 participants (37.7%). Predictors of long-term smoking cessation were course length (eight vs. six sessions) (95% CI = 1.04-1.36, p = .01), adherence to the course (95% CI = 0.98-0.99, p<0.01), use of pharmacotherapy or nicotine replacement therapy products (95% CI = 0.74-0.98, p = .02), and time passed in the morning until the first cigarette is smoked (95% CI5min = 1.17-1.77, p<0.001; 95% CI30min = 1.09-1.65, p<0.01). Predictors of change in cigarettes smoked per day among smokers were-the time passed until the first cigarette in the morning (5min p < .001; 30min p < .001; 60min p < .01)-, gender (p < .001), and level of motivation to quit at baseline (p = .04).

CONCLUSIONS

Our findings are consistent with existing evidence supporting adapted smoking cessation interventions to reduce health inequity in migrant populations. However, achieving harm reduction in smokers with higher dependence scores remains challenging.

Time-varying effects of 'optimized smoking treatment' on craving, negative affect and anhedonia

AIMS

To identify when smoking cessation treatments affect craving, negative affect and anhedonia, and how these symptoms relate to abstinence, to help evaluate the effects of particular intervention components in multi-component treatments and accelerate treatment refinement.

DESIGN

Secondary analysis of data from a two-arm randomized controlled trial.

SETTING

Seven primary care clinics in Wisconsin, United States.

PARTICIPANTS

Adult primary care patients who smoked daily (n = 574).

INTERVENTION AND COMPARATOR

Intervention was abstinence-optimized treatment (A-OT, n = 276) comprising 3 weeks of nicotine mini-lozenges pre-target quit day (TQD), 26 weeks of combination nicotine patch and mini-lozenges post-TQD and extensive psychosocial support. The comparator was recommended usual care (RUC, n = 298), comprising brief counseling and 8 weeks of nicotine patch post-TQD.

MEASUREMENTS

Time-varying effect models examined dynamic effects of A-OT (versus RUC) on the primary outcomes of nightly cigarette craving, negative affect and anhedonia from 1 week pre- to 2 weeks post-TQD. Exploratory models examined within-person relations between nicotine medication use and same-day symptom ratings. Secondary logistic regression analyses examined associations between post-TQD craving, negative affect and anhedonia and 1-month post-TQD abstinence.

FINDINGS

A-OT significantly suppressed pre- and post-TQD craving (β = -0.27 to -0.46 across days) and post-TQD anhedonia (β = -0.24 to -0.38 across days), relative to RUC. Within individuals, using patches was associated with lower negative affect in RUC (β = -0.42 to -0.52), but not in A-OT. Using more mini-lozenges was associated with greater craving (β = 0.04-0.07) and negative affect (β = 0.03-0.05) early, and with lower anhedonia (β = -0.06 to -0.12) later. Greater post-TQD craving (OR = 0.68) and anhedonia (OR = 0.85) predicted lower odds of abstinence 1 month post-TQD.

CONCLUSION

Time-varying effect models showed that a multi-component treatment intervention for smoking cessation suppressed significant withdrawal symptoms more effectively than recommended usual care among daily adult smokers motivated to quit. The intervention reduced craving pre- and post-target quit day (TQD) and anhedonia post-TQD.

Associations between alcohol consumption and smoking variables among Latinx daily smokers

INTRODUCTION

Accumulating evidence demonstrates a strong link between alcohol consumption and smoking status among Latinx individuals. However, there is a need to evaluate the cognitive processes and experiences related to quitting smoking among Latinx smokers. The purpose of the current paper was to examine the association between alcohol consumption and smoking expectancies, barriers to cessation, cigarette dependence, quit problems, and intentions and confidence to quit.

METHODS

Data were taken from a sample of Spanish-speaking Latinx daily smokers (N = 359; 59% female; Mage = 33.20, SD = 9.71) who completed an online survey. The alcohol consumption subscale of the Alcohol Use Disorders Identification Test (AUDIT; Babor, Higgins-Biddle, Saunders, & Monteiro, & World Health Organization, 2001) was used to predict smoking variables.

RESULTS

Consistent with our prediction, alcohol consumption significantly predicted smoking variables indicative of poorer smoking cessation ability. Specifically, greater alcohol consumption was associated with greater positive and negative smoking expectancies, barriers to cessation, and quit problems experienced during prior cessation attempts. Unexpectedly, greater alcohol consumption was also associated with greater confidence to quit smoking.

CONCLUSIONS

The current research suggests that alcohol consumption should be considered in the context of smoking cessation among Latinx individuals. The findings confirm and extend previous research by demonstrating that alcohol consumption is associated with proximal predictors of smoking outcomes that can be targeted during treatment. Implications for future research include addressing alcohol consumption during intervention and treatment of Latinx daily smokers.

Network analysis reveals the associations of past quit experiences on current smoking behavior and motivation to quit

INTRODUCTION

Smoking is a leading cause of morbidity and mortality in the United States. While most smokers endorse a desire to quit, achieving abstinence is notoriously difficult. Network analysis is a method for understanding the complex relationships of factors that maintain smoking behavior and impact motivation to quit.

METHODS

This study examined self-report prescreen data from treatment-seeking smokers (N = 3913). The number of prior quit attempts and withdrawal symptoms experienced, as well as current smoking behavior and motivation to quit were modeled as interconnected nodes in a network. Two key network metrics were examined: 1) edge weights, which quantify the strength and direction of the associations of interest, and 2) the sum of each node's edge weights, which quantifies the expected influence of a node on the overall network.

RESULTS

The withdrawal symptom of craving, r = 0.10, 95% CI [0.07, 0.13] and digestive problems, r = -0.06, 95% CI [-0.09, -0.03], had the strongest positive and negative association with daily cigarettes, respectively. The number of prior quit attempts, r = 0.17, 95% CI [0.14, 0.20], concentration problems, r = -0.04, 95% CI [-0.027, -0.01], showed the strongest positive and negative associations, respectively, with current motivation to quit. Nodes with significant links to current smoking and motivation to quit were also among the most influential in the overall network.

CONCLUSIONS

Findings suggest prior quit experiences and consequences associated with withdrawal symptoms may differentially relate to maintenance of smoking behavior and motivation to quit in treatment-seeking smokers. Interventions targeting key withdrawal symptoms may enhance motivation to quit.

Predictors of Smoking Cessation Attempts and Success Following Motivation-Phase Interventions Among People Initially Unwilling to Quit Smoking

INTRODUCTION

Most people who smoke cigarettes are not willing (ie, not ready) to make a quit attempt (QA) at any given time. Unfortunately, interventions intended to increase QAs and the success of QAs are only modestly effective. Identifying processes leading to QAs and quitting success could guide intervention development.

AIMS AND METHODS

This is a secondary analysis of a randomized factorial trial of 6 weeks of motivation-phase interventions among primary care patients (N = 517) who were initially unwilling to quit but were willing to reduce their smoking. Using logistic regression, we controlled for treatment condition and tested whether baseline or change in smoking-related constructs after 6 weeks of treatment predicted (1) making an at least 24 h QA between weeks 6 and 26 and (2) quitting success at week 26 (7-day point-prevalence abstinence among those who made a QA). Predictors included cigarettes/day, time to first cigarette, motivation to quit, quitting self-efficacy, anticipated urges to smoke if quit, positive affect, negative affect, and time spent around others who smoke.

RESULTS

In multivariable models that included all smoking-related constructs, changes in the following variables predicted initiating a QA above and beyond other variables: greater baseline time to first cigarette (odds ratio [OR] = 1.60), increases in time to first cigarette (OR = 1.27), and increases in quitting self-efficacy (OR = 1.14). Increased motivation to quit predicted conversion of a QA into quitting success at 26 weeks (OR = 1.36).

CONCLUSION

Predictors of making a QA differed from predictors of quitting success. Predictors of QAs and success could each serve as important treatment targets of motivation-phase interventions.

IMPLICATIONS

Motivation-phase interventions for people initially unwilling to quit smoking cigarettes may be improved by striving to increase their (1) time to first cigarette and quitting self-efficacy to promote QAs and (2) motivation to quit to promote quit success. Future experimental tests of such interventions are needed to identify causal determinants of QAs and quitting success.

Stress, Depression and Quit Attempt Outcomes among Unmotivated Smokers

INTRODUCTION

Stress and depressive symptoms have been linked to a reduced likelihood of sustaining smoking cessation. Because stress and depressive symptoms may negatively affect motivation to quit, stress and depression may also be important for whether or not smokers make a quit attempt.

OBJECTIVE

To examine the relationship between perceived stress and depressive symptoms and initiating a quit attempt in a smoking cessation induction trial.

METHODS

We conducted a secondary analysis of existing data from a randomized clinical trial (N = 255) comparing motivational interviewing to health education and brief advice for smoking cessation induction in smokers with low motivation to quit.

RESULTS

We observed positive associations between baseline predictors and quit attempts at week 12 (r = 0.192, p < 0.01 for depressive symptoms and r = 0.136, p < 0.05 for perceived stress). Logistic regression models revealed similar significant positive associations between baseline perceived stress and baseline depressive symptoms and making a quit attempt by week 12 (OR = 1.5, CI:1.03, 2.19 and OR = 1.03, 95% CI: 1.01, 1.06; respectively).

CONCLUSION

Unexpectedly, this study found generally small but consistently positive associations between baseline depressive symptoms and baseline perceived stress and making a quit attempt by week 12. The results can be viewed as encouraging in that interventions to encourage quit attempts do not appear counter-productive for individuals higher in stress and depressive symptoms, but these patients very likely will need additional supports to sustain abstinence.

A time-varying model of the dynamics of smoking lapse

OBJECTIVE

The majority of smokers who make a quit attempt experience their first lapse within the first week of quitting, yet limited research to date has examined how the strength and direction of the relationship between smoking risk factors and lapse may change over longer periods of time. Time-varying effect modeling (TVEM) was used to address this gap.

METHOD

A diverse sample (N = 325) of adult smokers completed ecological momentary assessments of risk factors for lapse for 28 days after quitting. TVEM was used to examine the relationship between risk factors (abstinence self-efficacy, positive affect, positive coping expectancies, smoking expectancies, motivation, negative affect, stress, and urge) and lapse for 28 days postquit.

RESULTS

Some associations were stable (e.g., negative affect, motivation), whereas others varied over time. Abstinence self-efficacy, positive affect, and positive coping expectancies were most strongly associated with lapse between Days 3 and 8 postquit. The association of urge with lapse was strongest between Days 4 and 10, as well as near the end of the quit attempt. Stress was also most strongly associated with lapse near the beginning and end of the postquit period and was the only predictor associated with lapse on quit date. The strength of the association between smoking expectancies and lapse increased over time.

CONCLUSION

There may be periods during a quit attempt when certain risk factors are more strongly related to lapse. This work has relevance for tailoring interventions designed to deliver intervention components in particular contexts or times of need. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Health Risk Factors in American Indian and Non-Hispanic White Homeless Adults

Objectives: American Indians (AIs) are over-represented among homeless populations, but are understudied regarding their unique risk and resilience factors relative to non-Hispanic white (NHW) adults experiencing homelessness. In the current study, we aimed to address this gap. Methods: We recruited participants (108 AIs and 307 NHWs) from 6 homeless serving agencies in Oklahoma City, OK. Participants completed standard assessments of health, health behaviors, including alcohol and drug use, readiness to change endorsed health behaviors (eg, unsafe sex, fruit and vegetable intake, happiness with weight, physical activity), sleep location and quality, personal victimization, and discrimination. Results: Compared to NHWs, AIs endorsed greater alcohol use problems and were more likely to report having been arrested/booked for disorderly conduct or public drunkenness; however, AIs were less likely to report smoking cigarettes and reported greater readiness to change unsafe/unprotected sexual behaviors. Furthermore, compared to NHWs, AIs reported experiencing greater discrimination and were more likely to report sleeping outside or on the streets, versus in shelters; however, AIs reported fewer days of inadequate sleep. Conclusions: Findings suggest AI-specific risk and resilience factors for homelessness. This information can aid in treatment, service, and housing planning for this under-studied group who experiences some of the greatest health disparities.

Age and pre quit-day attrition during smoking cessation treatment

The present study aimed to replicate the finding that younger age predicts higher pre quit-day attrition. Our second aim was to explain this relation by examining empirically and theoretically informed age-related risk factors for low smoking cessation treatment engagement. 136 participants (Mage = 44.2 years, SD = 11.3 years; age = 22-64 years) were randomized to 15-weeks of either 1) an exercise intervention (n = 72) or 2) a wellness education control condition (n = 64). First, a logistic regression analysis was employed to test whether younger adults were more likely than older adults to drop prior to quit date. Next, we assessed whether smoking related health concerns, social expectancies, and/or perceived severity of craving affected the strength of the relation between age and attrition, by adding these three variables to the logistic regression along with age. The logistic regression model indicated that younger age and treatment condition were significantly related to the odds of dropping from treatment prior to the scheduled quit date. Further, health concerns, social expectancies, and/or perceived severity of cravings did not account for the effect of age on pre quit-day attrition. These findings highlight the importance of identifying empirically and theoretically informed variables associated with the pre quit-day attrition problem of young smokers.

Effectiveness of Mindfulness-Based Relapse Prevention Program as an Adjunct to the Standard Treatment for Smoking: A Pragmatic Design Pilot Study

INTRODUCTION

Posttreatment relapse is a major roadblock to stemming the global epidemic of tobacco-related illness. This article presents results from a pilot trial evaluating the feasibility and initial efficacy of Mindfulness-Based Relapse Prevention (MBRP) as an adjunct to standard relapse prevention treatment (ST) for smoking cessation.

AIMS AND METHODS

Smokers (n = 86) in the maintenance phase of treatment were randomized to receive either ST plus MBRP (MBRP) (n = 44) or ST alone (ST) (n = 42). Data were collected at baseline and at 4-, 12-, and 24-week follow-up points. We evaluated the feasibility of the protocol with frequency analysis, and the efficacy with both intention to treat and complete case analyses of the effects of MBRP on abstinence. Secondary outcomes included mindfulness, craving, depression, anxiety, and positive/negative affect.

RESULTS

High adherence suggested MBRP is acceptable and feasible. Participants in the MBRP group reported increases in mindfulness (M = -7.833, p = .016), and reductions in craving (M = 17.583, p = .01) compared with the ST group. Intention to treat analysis found that, compared with MBRP (36.4%), ST (57.1%) showed trend-level superiority in abstinence at Week 4 (Prevalence Ratio = 0.63, p = .06); however at Week 24, the ST group (14.3%) demonstrated a twofold greater decrease in abstinence, compared with the MBRP group (20.1%) (Prevalence Ratio = 2.25, p = .08). Therefore, the MBRP group maintained a higher abstinence rate for longer. Reported effects were greater in the complete case analysis.

CONCLUSIONS

MBRP holds promise for preventing relapse after aided tobacco quit attempts.

IMPLICATIONS

Findings suggest that MBRP is acceptable, feasible, and valued by participants. At 24-week follow-up, there was a large effect size and a statistical trend toward fewer MBRP patients relapsing compared with ST patients. MBRP conferred ancillary benefits including reductions in craving and increases in levels of mindfulness. MBRP for tobacco cessation is highly promising and merits further research.

TRIAL REGISTRATION

clinicaltrials.gov.

IDENTIFIER

NCT02327104.

Patterns of lapses and recoveries during a quit attempt using varenicline and behavioral counseling among smokers with and without HIV

Addressing tobacco use among HIV+ smokers is a priority. Lack of knowledge about how HIV+ smokers respond to tobacco use treatments limits our ability to effectively treat this population of smokers. Using data from 2 clinical trials that provided 12 weeks of varenicline and behavioral counseling, 1 with smokers with HIV (n = 89) and 1 with smokers without HIV (n = 179), we used mixed logistic regression modeling to compare point-prevalence abstinence rates and adherence to the initial target quit date (TQD) and Cox regression for repeated outcomes to evaluate lapse and recovery dynamics between the groups. Sixty percent of HIV- smokers refrained from smoking at the TQD while only 33% of HIV+ smokers did (odds ratio [OR] = 0.32, 95% CI [0.18, 0.56], p < .001). The point-prevalence abstinence rates at Week 12 were 31% (HIV-) and 28% (HIV+; OR = 0.7, 95% CI [0.42, 1.16], p = .16) and the point prevalence abstinence rates at Week 24 were 22% (HIV-) and 15% (HIV+; OR = 0.87, 95% CI [0.49, 1.57], p = .65). Although there was no interaction between HIV status and lapse risk, χ2(3) < 1, there was a significant interaction for the recovery model, (χ2(3) = 20.4, p < 0.001): as the number of events increased, the time to the next recovery became longer among smokers with HIV, compared to smokers without HIV. Although HIV+ smokers were treated effectively with varenicline, compared to HIV- smokers, they showed significantly lower initial cessation at the TQD and took increasingly longer to recover following lapses. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Exploring positive expectancies and quit status among adult electronic cigarette users

Initial research on electronic cigarette (e-cigarette) use suggests differences exist in levels of use, beliefs, and cessation difficulties among users. However, little research has explored how these factors interact to confer worse e-cigarette outcomes. The current study examined the association between positive expectancies of e-cigarette use and e-cigarette processes among 544 (51.1% female; M_age = 35.4 years, SD = 10.12) adult e-cigarette users who had and had not attempted to quit e-cigarettes, a defining characteristic believed to distinguish those with and without greater e-cigarette quit difficulty. Results indicated that greater positive outcome expectancies of e-cigarette use were significantly related to increased perceived risks, benefits, and barriers to quitting. The strength of the associations was stronger for those who reported past quit attempts compared to those who never attempted quitting. Overall, the current study highlights the potentially important role that positive expectancies for e-cigarette use and quit attempt status play in e-cigarette processes. Findings suggest a possible need to contextualize positive expectancies for e-cigarette use within future e-cigarette cessation tactics and tailoring treatments based on quit attempt status.

Anxiety Sensitivity and Distress Tolerance in Smokers: Relations With Tobacco Dependence, Withdrawal, and Quitting Success†

INTRODUCTION

This study examined relations of two affective vulnerabilities, high anxiety sensitivity (AS) and low distress tolerance (DT), with tobacco dependence, withdrawal, smoking cessation, and pharmacotherapy response.

METHODS

Smokers interested in quitting (N = 1067; 52.2% female, 28.1% African American) were randomized to 12 weeks of nicotine patch, nicotine patch plus nicotine lozenge, or varenicline. Baseline questionnaires assessed AS, DT, negative affect, anxiety, and dependence. Withdrawal was assessed the first-week post-quit via ecological momentary assessment.

RESULTS

DT, but not AS, predicted biochemically confirmed point-prevalence abstinence at multiple endpoints: weeks 4, 12, 26, and 52 post-quit (ps < .05); relations remained after controlling for pharmacotherapy treatment, AS, baseline negative affect, anxiety, and anxiety disorder history (ps < .05). Additional exploratory analyses examining week 4 abstinence showed DT predicted abstinence (p = .004) even after controlling for baseline dependence, post-quit withdrawal (craving and negative affect), and treatment. DT moderated treatment effects on abstinence in exploratory analyses (interaction p = .025); those with high DT were especially likely to be abstinent at week 4 with patch plus lozenge versus patch alone.

CONCLUSIONS

DT, but not AS, predicted abstinence over 1 year post-quit (higher DT was associated with higher quit rates), with little overlap with other affective measures. DT also predicted early abstinence independent of dependence and withdrawal symptoms. Results suggest low DT may play a meaningful role in motivation to use tobacco and constitute an additional affective risk factor for tobacco cessation failure beyond negative affect or clinical affective disorders.

IMPLICATIONS

People in a stop-smoking study who reported a greater ability to tolerate distress were more likely to quit smoking and remain smoke-free 1 year later. Smokers with high DT were more likely to be smoke-free 4 weeks after their target quit day if they received nicotine patch plus nicotine lozenge rather than nicotine patch alone.

TRIAL REGISTRATION

NCT01553084.

Reach out behavioral intervention for hypertension initiated in the emergency department connecting multiple health systems: study protocol for a randomized control trial

Background

Hypertension is the most important modifiable risk factor for cardiovascular disease, the leading cause of mortality in the United States. The Emergency Department represents an underutilized opportunity to impact difficult-to-reach populations. There are 136 million visits to the Emergency Department each year and nearly all have at least one blood pressure measured and recorded. Additionally, an increasing number of African Americans and socioeconomically disadvantaged patients are overrepresented in the Emergency Department patient population. In the age of electronic health records and mobile health, the Emergency Department has the potential to become an integral partner in chronic disease management. The electronic health records in conjunction with mobile health behavior interventions can be leveraged to identify hypertensive patients to impact otherwise unreached populations.

Methods

Reach Out is a factorial trial studying multicomponent, behavioral interventions to reduce blood pressure in the Emergency Department patient population. Potential participants are identified by automated alerts from the electronic health record and, following consent, receive a blood pressure cuff to take home. During the initial screening phase, they are prompted to submit weekly blood pressure readings. Responders with persistent hypertension are then randomized into one of three component arms, consisting of varying intensity levels: (1) healthy behavior text messaging (daily vs. none), (2) blood pressure self-monitoring (daily vs. weekly), and (3) facilitated primary care provider appointment scheduling and transportation (yes vs. no). If participants are randomized to receive facilitated primary care provider appointment scheduling and are not established with a primary care provider, care will be established at a local Federally Qualified Health Center. Participants are followed for 12 months.

Discussion

The Reach Out study is designed to determine which behavioral intervention components or ‘dose’ of components contributes to a reduction in systolic blood pressure after 1 year (Aim 1). The study will also assess the effect of primary care provider appointment assistance on total primary care follow-up visits of hypertensive patients treated in an urban, safety net Emergency Department (Aim 2). Ideally, the Reach Out system will contribute to hypertension management, serving as a model for safety net hospitals and Federally Qualified Health Centers to improve chronic disease management in underserved communities.

Trial registration

This study was registered at clinicaltrials.gov, identifier NCT03422718. The record was first available to the public on January 30, 2018 prior to the enrollment of patients on March 25, 2019.

The 'Take a Break' game: Randomized trial protocol for a technology-assisted brief abstinence experience designed to engage lower-motivated smokers

BACKGROUND

While smoking continues to be the most preventable cause of mortality in the United States, most current smokers remain not ready to quit at any given time. Engaging these 'motivation phase' smokers with brief experiences to build confidence and practice skills related to cessation could lead to sooner and more successful quit attempts. Increasingly available mobile technology and gamification can be used to provide smokers with accessible and engaging support.

METHODS

We describe our protocol for conducting a randomized controlled trial evaluating Take a Break, an mHealth-based smoking pre-cessation challenge designed for smokers not ready to quit. Participants in the intervention receive 1) Motivational Messages, 2) text message Challenge Quizzes, 3) Goal-setting with tobacco treatment specialist, 4) Coping Mini-Games apps, and 5) Recognition and Rewards for participation during a 3-week challenge. Access to coping mini-games and motivational messaging continues for 6-months. Both intervention and comparison group participants receive brief Nicotine Replacement Therapy (NRT) sampling and daily smoking assessment text messages for three weeks. Primary outcomes include number of days abstinent during the challenge, change in patient-reported self-efficacy after the challenge, time to first quit attempt following the challenge, and 7-day point prevalent smoking cessation at six months.

CONCLUSION

Take a Break is an innovative approach to engage those not prepared for a quit attempt. Take a Break provides motivation phase smokers with tools and a brief experience to prepare them for a quit attempt, filling a gap in tobacco cessation support and current research.

The Effect of Positive and Negative Affect on Early Treatment Milestones in the Context of Integrated Smoking Treatment

: Smoking is the leading cause of preventable death in the United States. Efforts have been made to develop effective, integrated smoking-cessation treatments for individuals with greater difficulty quitting, including individuals with elevated anxiety sensitivity (AS). Despite initial evidence for the efficacy of these treatments, little is understood about pretreatment predictors of early treatment milestones, including treatment initiation and response. Positive affectivity (PA) and negative affectivity (NA) are unique mood traits that may be related to early treatment milestones. Indeed, PA and NA are related to smoking and mood outcomes generally. Yet, it is presently unknown if pretreatment PA or NA predict early treatment milestones within the context of an integrated smoking-cessation treatment. The current study sought to evaluate the independent effect of PA and NA on early treatment milestones within the context of an integrated smoking-AS treatment protocol. Smoking and AS outcomes were evaluated independently. Participants included 288 (50% female; Mage = 38.66, SD = 13.67) treatment-seeking adult daily cigarette users. Results indicated that higher pretreatment NA was associated with an increased likelihood of early dropout versus responding to treatment across both outcomes (smoking: odds ratio [OR] 0.93, 95% confidence interval [CI] 0.88-0.99; AS: OR 0.92, 95% CI 0.88-0.98). Pretreatment PA did not significantly differentiate any of the groups. Overall, the present study serves as an initial investigation of the role of pretreatment NA in identifying those at greatest risk for dropping out of treatment (cf. responding to treatment).

Effects of smoking cessation treatment attendance on abstinence: The moderating role of psychologically based behavioral health conditions

Available smoking cessation treatments have shown only modest quit success. Presence of a psychologically based behavioral health condition (PBHC), such as depression, anxiety, or addiction, can impact smoking cessation treatment engagement and quit success; however, the differential effect of treatment engagement on smoking cessation outcomes across smokers with and without a PBHC is unknown. The current study examined the moderating effect presence (versus absence) of a PBHC on the relation between treatment attendance and early smoking abstinence following a 4-session smoking cessation treatment. Participants included 529 (45.9% male; Mage = 38.23 years, SD = 13.56; 75.4% White) smokers enrolled in a large randomized controlled trial evaluating the efficacy of a transdiagnostic smoking cessation treatment. A repeated-measures latent class analysis (RMLCA) was conducted to examine treatment attendance. The effects of treatment attendance, PBHC (present/absent), and their interaction were modeled on biochemically-verified point prevalence abstinence using a latent growth curve from 1-week to 1-month post-quit. The RMLCA provided evidence for three classes: Drop-outs (n = 197), Titrators (n = 89), and Completers (n = 243). A significant interaction emerged such that Completers without a PBHC were significantly more likely to be abstinent relative to Completers with a PBHC (b = 2.69, SE = 0.67, p < .001) and Titrators without a PBHC (b = 3.36, SE = 0.80, p < .001). These results provide novel data that implicate the clinical importance of treatment attendance and PBHC status on smoking abstinence.

Simulation and minimization: technical advances for factorial experiments designed to optimize clinical interventions

BACKGROUND

The Multiphase Optimization Strategy (MOST) is designed to maximize the impact of clinical healthcare interventions, which are typically multicomponent and increasingly complex. MOST often relies on factorial experiments to identify which components of an intervention are most effective, efficient, and scalable. When assigning participants to conditions in factorial experiments, researchers must be careful to select the assignment procedure that will result in balanced sample sizes and equivalence of covariates across conditions while maintaining unpredictability.

METHODS

In the context of a MOST optimization trial with a 2x2x2x2 factorial design, we used computer simulation to empirically test five subject allocation procedures: simple randomization, stratified randomization with permuted blocks, maximum tolerated imbalance (MTI), minimal sufficient balance (MSB), and minimization. We compared these methods across the 16 study cells with respect to sample size balance, equivalence on key covariates, and unpredictability. Leveraging an existing dataset to compare these procedures, we conducted 250 computerized simulations using bootstrap samples of 304 participants.

RESULTS

Simple randomization, the most unpredictable procedure, generated poor sample balance and equivalence of covariates across the 16 study cells. Stratified randomization with permuted blocks performed well on stratified variables but resulted in poor equivalence on other covariates and poor balance. MTI, MSB, and minimization had higher complexity and cost. MTI resulted in balance close to pre-specified thresholds and a higher degree of unpredictability, but poor equivalence of covariates. MSB had 19.7% deterministic allocations, poor sample balance and improved equivalence on only a few covariates. Minimization was most successful in achieving balanced sample sizes and equivalence across a large number of covariates, but resulted in 34% deterministic allocations. Small differences in proportion of correct guesses were found across the procedures.

CONCLUSIONS

Based on the computer simulation results and priorities within the study context, minimization with a random element was selected for the planned research study. Minimization with a random element, as well as computer simulation to make an informed randomization procedure choice, are utilized infrequently in randomized experiments but represent important technical advances that researchers implementing multi-arm and factorial studies should consider.

Developing more efficient, effective, and disseminable treatments for eating disorders: an overview of the multiphase optimization strategy

The present manuscript describes the multiphase optimization strategy (MOST) and its potential applications to treatments for eating disorders (EDs). The manuscript describes the three phases of MOST, discusses a hypothetical case example of how MOST could be applied to developing a disseminable ED treatment, and reviews the pros and cons of the MOST approach. Outcomes from treatments for EDs leave room for improvement. However, traditional methods of treatment development and evaluation (i.e., the treatment package approach) make it challenging to determine how best to improve ED treatments. For example, testing full treatment packages in open trials and RCTs without systematic testing of each component is inefficient (as it is unknown which components are effective), and often does not provide concrete future directions for optimization of the treatment. Much stands to be gained by optimizing treatments in the early stages before testing them in open trials or RCTs. MOST is an alternative, engineering-inspired research framework that is well-suited to address the issues of inefficiency associated with the treatment package approach. MOST entails identifying the most promising treatment components for inclusion in interventions, then eliminating or deemphasizing less efficacious/inert components. This strategy results in a treatment comprised of only effective components that can then be tested via RCT. Though the MOST approach has limitations, it has the potential to greatly benefit ED treatment research and is worthy of application in the field.

Pain characteristics and nicotine deprivation as predictors of performance during a laboratory paradigm of smoking cessation

Although smokers with co-occurring pain report expectations for experiencing greater nicotine withdrawal and difficulty quitting, limited work has examined the role of pain in cessation-related outcomes. The goal of this study was to examine clinically relevant pain characteristics (pain persistence, pain intensity, pain-related disability) as predictors of withdrawal and smoking lapse/relapse outcomes using a laboratory paradigm of cessation. Participants (N = 120 daily cigarette smokers; 48% male; M_age = 36.17, SD = 12.16; M_{Cigarettes Per Day} = 20.51, SD = 6.99) were randomized to either nondeprived or 12-hr nicotine deprivation conditions prior to an experimental study visit. Upon arrival to the laboratory, participants completed measures of pain characteristics and nicotine withdrawal symptoms. Primary outcomes included nicotine withdrawal scores and analogues of smoking lapse (latency to initiating smoking) and relapse (number of cigarettes smoked). We hypothesized that smokers with greater pain persistence, pain intensity, and pain-related disability would endorse more severe nicotine withdrawal and greater lapse/relapse behavior, and that these positive associations would be stronger among those who were nicotine deprived. Results indicated that, above and beyond the effect of nicotine deprivation, persistent pain predicted more severe nicotine withdrawal, and that greater pain-related disability predicted quicker latency to lapse during the laboratory paradigm. Contrary to expectation, nicotine deprivation did not moderate effects of pain characteristics on withdrawal or lapse/relapse outcomes. Clinical implications include that different pain processes may influence different cessation outcomes, and that smokers in pain may benefit from the provision of pharmacological aids to better control withdrawal symptoms. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

A Randomized Controlled Trial of an Optimized Smoking Treatment Delivered in Primary Care

Background

The effectiveness of smoking cessation treatment is limited in real-world use, perhaps because we have not selected the components of such treatments optimally nor have treatments typically been developed for and evaluated in real-world clinical settings.

Purpose

To validate an optimized smoking cessation treatment package that comprises intervention components identified as effective in factorial screening experiments conducted as per the Multiphase Optimization Strategy (MOST).

Methods

Adult smokers motivated to quit were recruited from primary care clinics (N = 623). Participants were randomized to receive either recommended usual care (R-UC; 10 min of in-person counseling, 8 weeks of nicotine patch, and referral to quitline services) or abstinence-optimized treatment (A-OT; 3 weeks of prequit mini-lozenges, 26 weeks of nicotine patch + mini-lozenges, three in-person and eight phone counseling sessions, and 7-11 automated calls to prompt medication use). The key outcomes were self-reported and biochemically confirmed (carbon monoxide, CO <6 ppm) 7-day point-prevalence abstinence.

Results

A-OT participants had significantly higher self-reported abstinence rates than R-UC participants at 4, 8, 16, and 26 weeks (ORs: 1.91-3.05; p <. 001). The biochemically confirmed 26-week abstinence rates were lower than the self-reported 26-week rates, but revealed a similar treatment effect size (OR = 2.94, p < .001). There was no moderation of treatment effects on 26-week abstinence by demographic, psychiatric, or nicotine dependence variables. A-OT had an incremental cost-effectiveness ratio for 26-week CO-confirmed abstinence of $7,800.

Conclusions

A smoking cessation treatment that is optimized via MOST development meaningfully enhances cessation rates beyond R-UC smoking treatment in smokers seen in primary care.

Clinical Trial Registration

NCT02301403.

Effect of Intensive Personalized "5As+5Rs" Intervention on Smoking Cessation in Hospitalized Acute Coronary Syndrome Patients Not Ready to Quit Immediately: A Randomized Controlled Trial

Introduction

The acute coronary syndrome (ACS) patients who are not ready to quit smoking immediately have an extremely low rate of cessation. This study aims to investigate the efficacy of intensive personalized '5As+5Rs'intervention (IPANR intervention) on smoking cessation in this population.

Methods

A parallel-group randomized controlled trial was carried out, which compared IPANR intervention with routine 5Rs (control) at Fu Xing Hospital, Capital Medical University, Bei Jing, China. Three hundred and twenty hospitalized ACS smokers who were not ready to quit were randomly distributed to IPANR intervention group comprising three individual counseling during hospitalization and 15 intensive follow-up sessions (weekly during months 1, 2, 3, and monthly thereafter until month 6) or 5Rs group in a 1:1 fashion by 8 cardiologists who were blinded to the allocation sequence. Primary end point was carbon monoxide-confirmed continuous abstinence rate (CAR) through week 9 to week 12. Secondary outcome included abstinence rate at 24 weeks.

Results

Overall, 97.5% (312/320) participants completed the trial. An intention-to-treat analysis showed statistically significant advantage of IPANR compared with control group at 4 weeks CAR (27.5% vs. 17.5%, RR = 1.571, 95% CI = 1.032-2.392, p = 0.032, number needed to treat (NNT) = 10), and abstinence rate at 24 weeks (23.8% vs.15.0%, RR 1.583, 95% CI = 0.998-2.512, p = 0.048, NNT: 11.36). At 24 weeks, cigarettes smoked per day by the patients who failed to quit were significant lower in IPANR group than 5Rs group (13.21 ± 8.23 vs. 17.45 ± 10.71; p < 0.001).

Conclusions

The IPANR initiated during hospitalization, is a feasible and effective approach for smoking cessation in ACS patients not ready to quit immediately.

Implications

Smoking has a major impact on acute stages of ACS for recurrent ischemic events and long-term outcomes. However, there are few evidence-based treatments for smokers who are not ready to quit. This study described a cessation intervention initiated during hospitalization and included 15 intensive follow-up aimed at enabling ACS smokers who were not ready to quit immediately to deliver adequate motivational and behavior change counseling. Given its effectiveness demonstrated in this prospective study, this intervention in hospitalized ACS smokers might have the potential to substantially improve the cessation rate of ACS patients who are not ready to quit smoking immediately.

Understanding quit patterns from a randomized clinical trial: Latent classes, predictors, and long-term abstinence

OBJECTIVE

Tobacco dependence treatment is recognized as a dynamic, chronic process comprised of several specific phases. Of these phases, the Cessation phase is the most critical as it has demonstrated the strongest relation to quit success. Yet, little is understood about smoking trajectories during this period. The current study aimed to address gaps in the smoking research literature and advance understanding of the dynamic quit process unique to completing an integrated smoking treatment by evaluating quit behavior during the Cessation phase.

METHOD

Two hundred and sixty-seven treatment seeking smokers enrolled in a clinical trial to evaluate the efficacy of a novel, integrated smoking cessation treatment (46.1% male; Mage = 39.25, SD = 13.70) were included in the present study. Repeated-measure latent class analysis was employed to evaluate quit patterns from quit day through day 14 post-quit.

RESULTS

Results supported a four-class solution: Consistent Quitters, Non-Quitters, Relapsers, and Delayed Quitters. Predictors of class membership included age, number of prior quit attempts, motivation to quit smoking, and quit day smoking urges. Moreover, class membership was significantly associated with 6-month abstinence.

CONCLUSION

Results suggest that there are four relevant classes of quit behavior, each with specific predictor variables including age, motivation to quit, smoking urges, and number of quit attempts, and that these classes relate to long-term abstinence. These results have the potential to inform manualized smoking cessation treatment interventions based on relevant subgroups of quit behavior.