Development of a Behavioral Activation–Based Intervention for Cigarette-Smoking Young Adults

Individual Predictors of Response to A Behavioral Activation-Based Digital Smoking Cessation Intervention: A Machine Learning Approach

Background: Depression is prevalent among individuals who smoke cigarettes and increases risk for relapse. A previous clinical trial suggests that Goal2Quit, a behavioral activation-based smoking cessation mobile app, effectively increases smoking abstinence and reduces depressive symptoms. Objective: Secondary analyses were conducted on these trial data to identify predictors of success in depression-specific digitalized cessation interventions. Methods: Adult who smoked cigarettes (age = 38.4 ± 10.3, 53% women) were randomized to either use Goal2Quit for 12 weeks (N = 103), paired with a 2-week sample of nicotine replacement therapy (patch and lozenge) or to a Treatment-As-Usual (TAU) control (N = 47). The least absolute shrinkage and selection operator was utilized to identify a subset of baseline variables predicting either smoking or depression intervention outcomes. The retained predictors were then fitted via linear regression models to determine relations to each intervention outcome. Results: Relative to TAU, only individuals who spent significant time using Goal2Quit (56 ± 46 min) were more likely to reduce cigarette use by at least 50% after 12 weeks, whereas those who spent minimal time using Goal2Quit (10 ± 2 min) did not exhibit significant changes. An interaction between educational attainment and treatment group revealed that, as compared to TAU, only app users with an educational degree beyond high school exhibited significant reductions in depression. Conclusions: The findings highlight the importance of tailoring depression-specific digital cessation interventions to individuals' unique engagement needs and educational level. This study provides a potential methodological template for future research aimed at personalizing technology-based treatments for cigarette users with depressive symptoms.

Depression Severity Moderates Reward Learning Among Smokers With Current or Past Major Depressive Disorder in a Smoking Cessation Randomized Clinical Trial

INTRODUCTION

Behavioral and pharmacological smoking cessation treatments are hypothesized to increase patients' reward learning to reduce craving. Identifying changes in reward learning processes that support effective tobacco-dependence interventions among smokers who experience depression may guide patients toward efficient treatment strategies. The objective was to investigate the extent to which adult daily cigarette smokers with current or past major depressive disorder (MDD) learned to seek reward during 12 weeks of treatment combining behavioral activation and varenicline. We hypothesized that a decline in reward learning would be attenuated (least to most) in the following order: (1) behavioral activation integrated with ST (BASC) + varenicline, (2) BASC + placebo, (3) standard behavioral cessation treatment (ST) + varenicline, (4) ST + placebo.

METHODS

We ran a phase IV, placebo-controlled, randomized clinical trial with 300 participants receiving 12 weeks of one of four conditions across two urban medical centers. Depressive symptoms were measured using the Beck Depression Inventory-II (BDI). Reward learning was ascertained at weeks 1, 7, and 14 using the Probabilistic Reward Task (PRT), a laboratory task that uses an asymmetric reinforcement schedule to assess (a) learning to seek reward (response bias), (b) differentiate between stimuli, and (c) time to react to cues.

RESULTS

There was a significant interaction of BDI group × PRT response bias. Response bias declined from weeks 7 to 14 among participants with high baseline depression symptoms. The other two BDI groups showed no change in response bias.

CONCLUSIONS

Controlling for baseline depression, participants showed a decrease in response bias from weeks 1 to 14, and from weeks 7 to 14. Treatment condition and abstinence status were unassociated with change in reward learning.

IMPLICATIONS

Smokers who report greater depression severity show a decline in reward learning despite their participation in smoking cessation treatments, suggesting that depressed populations pose unique challenges with standard smoking cessation approaches.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02378714.

Behavioral Activation-Based Digital Smoking Cessation Intervention for Individuals With Depressive Symptoms: Randomized Clinical Trial

BACKGROUND

Depression is common among adults who smoke cigarettes. Existing depression-specific cessation interventions have limited reach and are unlikely to improve smoking prevalence rates among this large subgroup of smokers.

OBJECTIVE

This study aimed to determine whether a mobile app-based intervention tailored for depression paired with a mailed sample of nicotine replacement therapy (NRT) is efficacious for treating depression and promoting smoking cessation.

METHODS

A 2-arm nationwide remote randomized clinical trial was conducted in the United States. Adults (N=150) with elevated depressive symptoms (Patient Health Questionnaire-8≥10) who smoked were enrolled. The mobile app ("Goal2Quit") provided behavioral strategies for treating depression and quitting smoking based on Behavioral Activation Treatment for Depression. Goal2Quit participants also received a 2-week sample of combination NRT. Treatment as usual participants received a self-help booklet for quitting smoking that was not tailored for depression. Primary end points included Goal2Quit usability, change in depression (Beck Depression Inventory-II) across 12 weeks, and smoking cessation including reduction in cigarettes per day, incidence of 24-hour quit attempts, floating abstinence, and 7-day point prevalence abstinence (PPA).

RESULTS

In total, 150 participants were enrolled between June 25, 2020, and February 23, 2022, of which 80 were female (53.3%) and the mean age was 38.4 (SD 10.3) years. At baseline, participants on average reported moderate depressive symptoms and smoked a mean of 14.7 (SD 7.5) cigarettes per day. Goal2Quit usability was strong with a mean usability rating on the System Usability Scale of 78.5 (SD 16.9), with 70% scoring above the ≥68 cutoff for above-average usability. Retention data for app use were generally strong immediately following trial enrollment and declined in subsequent weeks. Those who received Goal2Quit and the NRT sample reported lower mean depressive symptoms over the trial duration as compared to treatment as usual (difference of mean 3.72, SE 1.37 points less; P=.01). Across time points, all cessation outcomes favored Goal2Quit. Regarding abstinence, Goal2Quit participants reported significantly higher rates of 7-day PPA at weeks 4 (11% vs 0%; P=.02), 8 (7-day PPA: 12% vs 0%; P=.02), and 12 (16% vs 2%; P=.02).

CONCLUSIONS

A mobile app intervention tailored for depression paired with a sample of NRT was effective for depression treatment and smoking cessation. Findings support the utility of this intervention approach for addressing the currently unmet public health treatment need for tailored, scalable depression-specific cessation treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03837379; https://clinicaltrials.gov/ct2/show/NCT03837379.

A pilot trial of behavioural activation with a contingency management component: Preliminary examination of changes in smoking and alternative rewards among low-income individuals

The heaviest smoking and burden of tobacco-related illness occurs among low-income individuals. Using a behavioural economics framework, this non-randomised pilot study examined the preliminary efficacy of behavioural activation (BA) with a contingency management (CM) component designed to encourage continued use of BA skills and reductions in cigarettes smoked. Eighty-four participants were recruited from a community centre. Data were collected at the start of every other group and at four different follow-up time points. Domains assessed included number of cigarettes smoked, activity level, and environmental rewards (i.e. alternative environmental reinforcers). Over time, cigarette smoking decreased (p < .001), environmental reward increased (p = .03), and reward probability and activity level were associated over time with cigarette smoking (p ≤ .03) above and beyond the effect of nicotine dependence. The continued use of BA skills was associated with greater environmental rewards (p = .04). While further research is needed to replicate this work, results suggest initial evidence for the utility of this intervention in a traditionally underserved community.

Engagement with Activity Monitoring During a Behavioral Activation Intervention: A Randomized Test of Monitoring Format and Qualitative Evaluation of Participant Experiences

Behavioural activation (BA) is an efficacious treatment approach. Activity monitoring is a key component of brief BA treatments; however, no studies have examined the most efficacious format for monitoring. The present pilot study tested brief versus intensive activity monitoring approaches during a BA intervention administered in a college orientation course. Outcomes characterised (1) engagement with the treatment protocol via activity monitoring and (2) participant qualitative experiences with monitoring and the intervention as reported during focus group interviews. Four course sections were randomly assigned to receive monitoring forms that were brief (assessed activities three times daily) or intensive (assessed activities hourly). Forms were provided electronically to students via a web-based platform which tracked completion. There were no significant differences in monitoring frequency (38.0 vs. 23.0 days; p = .154) or the duration of monitoring engagement (62.0 vs. 36.0 days; p = .054) between the brief and intensive conditions. Qualitative findings suggested that participants in both conditions found utility in activity monitoring, particularly during the first month as they transitioned to college. Overall, findings indicated that participants may find utility in monitoring during the first month of a BA intervention using either brief or intensive monitoring forms.

Modifying outcome expectancies and behavioral reinforcers to induce quit attempts among young adult smokers

Research has shown that outcome expectancies predict smoking behavior, and expectancy challenge interventions can reduce smoking. This study tested the hypothesis that supplementing expectancy challenge with a behavioral activation intervention promoting increased exposure to alternative reinforcers would help increase motivation to quit and induce actual quit attempts within the following month among young adult smokers. Smokers, aged 18-35 (N = 159, of whom 93 provided one-month follow-up data) and not required to be interested in quitting at the point of enrollment, were randomized to (a) the combined cognitive-behavioral intervention, (b) a cognitive-only expectancy challenge, or (c) a neutral reading (control) task. There were no significant between-group effects on motivation, but the conditions differed significantly in likelihood of leading to a quit attempt. Post hoc comparisons showed the combined condition participants (52 % of completers) to be significantly more likely than control group participants (25 %) to make a quit attempt, with the cognitive-only group (43 %) intermediate and not significantly different from the other conditions. These data provide preliminary evidence of utility for the brief cognitive-behavioral intervention in promoting smoking cessation attempts; more research is needed to test various possible explanations of how and for whom the intervention is effective, as well as whether it would significantly exceed expectancy challenge alone in larger samples.

Measurement of substance-free reinforcement in addiction: A systematic review

A robust body of theoretical and experimental work highlights the influence of alternative, substance-free rewards on decisions to use alcohol and other drugs. However, translational applications have been limited in part by the lack of consensus on how to measure substance-free reinforcement in applied and clinical settings. The current study summarizes extant research utilizing self-report reinforcement or reward methodologies, and critically reviews the psychometric properties of the available measures. These studies (N = 50) fell into three categories: measures of recent substance-related and substance-free activity participation and enjoyment (n = 32), measures of time or monetary resource allocation (n = 15), and rating scale measures of reward availability and experience (n = 8). The available research suggests that, consistent with experimental laboratory research and with behavioral economic predictions, there is an inverse relation between substance-free reinforcement and substance use. These studies also support the clinical utility of these measures in predicting substance use severity and course. Reinforcement measures could be improved by enhancing content validity, multimethod convergent validity, and generalizability.

Behavioral activation for children and adolescents: a systematic review of progress and promise

Behavioral activation (BA) effectively treats depression in adults, and shows promise in treating anxiety. Research into its application to children and adolescents is emerging. This review aimed to explore the scope of studies, current evidence of effectiveness and how the intervention has been delivered and adapted, to inform future research. A systematic review was undertaken searching PsycInfo, PubMed including Medline, EMBASE, and Scopus for terms relating to BA and children and adolescents. Two researchers scored abstracts for inclusion. Data extraction was completed by one researcher and checked by another. 19 studies were identified, across 21 published articles. 12 were case studies, with three pre-post pilot designs and four randomized-controlled trials. Case studies found early support for the feasibility and potential effectiveness of BA to address both anxiety and depression. The RCTs reported largely positive outcomes. Meta-analysis of depression scores indicated that BA may be effective; however, high heterogeneity was observed. Sample sizes to date have been small. BA has been delivered by trained therapists, doctoral trainee psychologists, social workers, or psychology graduates. Studies are uniquely in high-income settings. Adaptations include flexibility in content delivery, youth friendly materials, and parental involvement. There is some limited evidence to support BA as effective for young people. Feasibility and acceptability are supported. Fully powered trials are now required, with expansion to delivery in low- and middle-income settings, and detailed consideration of implementation issues that consider culture and environment.