Real-Time Readiness to Quit and Peer Smoking within a Text Message Intervention for Adolescent Smokers: Modeling Mechanisms of Change

Treating young adult cannabis use disorder with text message-delivered peer network counseling

BACKGROUND

Approximately 16.5% of U.S. young adults have a cannabis use disorder (CUD) and are at risk for negative outcomes. Treatment can reduce cannabis use, but young adults are less likely to seek help than older adults. Peer Network Counseling-txt (PNC-txt) is a brief, text-delivered, Motivational Interviewing-informed substance use intervention focusing on peer relations and activity spaces as mechanisms for behavioral change. PNC-txt has shown evidence of reducing tobacco and cannabis use with adolescents and young adults, but it has not been tested in the context of legal cannabis use. The current randomized controlled trial sought to expand the evidence regarding the context of PNC-txt effects, comparing one state in which cannabis is legal (Colorado) and one state in which it is not (Tennessee). We hypothesized that participants randomized to PNC-txt would show significant reductions in cannabis use compared to controls, with larger reductions for females and those in Colorado, and that peer relations and activity space would mediate effects.

METHODS

One thousand, seventy eight 18-25 year olds (CO: 551; TN: 527) who met screening criteria for CUD and biologically-verified cannabis use were randomly assigned to PNC-txt or waitlist control condition. Every other day for 4 weeks, participants assigned to PNC-txt received pre-programmed text conversations, tailored via data from the baseline assessment. Self-report and biological indicators of cannabis use were measured at 1-, 3-, and 6-months.

DISCUSSION

Data analysis is underway. Results will provide evidence regarding whether, and how, PNC-txt reduces cannabis use in young adults with CUD.

TRIAL REGISTRATION

This trial was prospectively registered on September 28, 2020 with ClinicalTrials.gov (NCT04567394).

Reducing Risk for Adolescent Substance Misuse with Text-Delivered Counseling to Adolescents and Parents

Background: Text-delivered prevention programs provide unique opportunities to deliver substance use prevention interventions to at-risk populations. Methods: A pilot randomized controlled trial was conducted to test the feasibility, acceptability, and preliminary efficacy of a 4-week, automated personalized text-messaging prevention program, designed to reduce risk factors and increase protective factors associated with adolescent substance use and misuse. Sixty-nine adolescents were recruited from a Federally Qualified Health Care clinic and randomized to a text-delivered intervention, or a wait-list control condition. Simultaneously, fifty-two parents of adolescent participants were enrolled into a parenting skills text-delivered intervention. Participants completed a baseline assessment and three follow-up surveys over three-months. Adolescent saliva specimens for drug testing were collected. Results: All intervention-allocated adolescents implemented at least one of the text-based counseling recommendations and 79% indicated that they found the texts helpful. Significant intervention effects were found on risk and protective factors for substance misuse. Adolescents in the intervention group reported reduced depression symptoms (d = -.63) and anxiety symptoms (d = -.57). Relative to controls, adolescents in the intervention group maintained a higher quality of parental relationship (d = .41) and parenting skills (d = .51), suggesting a prophylactic effect. Marginal decrease in the odds of positive drug tests were found for youth in intervention group (77.1% decrease, p = 0.07) but not with controls (54.3% decrease, p = 0.42,). Conclusions: Results provide preliminary evidence in the feasibility, acceptability, and efficacy of targeting risk and protective factors that are implicated in substance use via text-delivered interventions for high-risk populations.

Mobile phone text messaging and app-based interventions for smoking cessation

BACKGROUND

Mobile phone-based smoking cessation support (mCessation) offers the opportunity to provide behavioural support to those who cannot or do not want face-to-face support. In addition, mCessation can be automated and therefore provided affordably even in resource-poor settings. This is an update of a Cochrane Review first published in 2006, and previously updated in 2009 and 2012.

OBJECTIVES

To determine whether mobile phone-based smoking cessation interventions increase smoking cessation rates in people who smoke.

SEARCH METHODS

For this update, we searched the Cochrane Tobacco Addiction Group's Specialised Register, along with clinicaltrials.gov and the ICTRP. The date of the most recent searches was 29 October 2018.

SELECTION CRITERIA

Participants were smokers of any age. Eligible interventions were those testing any type of predominantly mobile phone-based programme (such as text messages (or smartphone app) for smoking cessation. We included randomised controlled trials with smoking cessation outcomes reported at at least six-month follow-up.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures described in the Cochrane Handbook for Systematic Reviews of Interventions. We performed both study eligibility checks and data extraction in duplicate. We performed meta-analyses of the most stringent measures of abstinence at six months' follow-up or longer, using a Mantel-Haenszel random-effects method, pooling studies with similar interventions and similar comparators to calculate risk ratios (RR) and their corresponding 95% confidence intervals (CI). We conducted analyses including all randomised (with dropouts counted as still smoking) and complete cases only.

MAIN RESULTS

This review includes 26 studies (33,849 participants). Overall, we judged 13 studies to be at low risk of bias, three at high risk, and the remainder at unclear risk. Settings and recruitment procedures varied across studies, but most studies were conducted in high-income countries. There was moderate-certainty evidence, limited by inconsistency, that automated text messaging interventions were more effective than minimal smoking cessation support (RR 1.54, 95% CI 1.19 to 2.00; I² = 71%; 13 studies, 14,133 participants). There was also moderate-certainty evidence, limited by imprecision, that text messaging added to other smoking cessation interventions was more effective than the other smoking cessation interventions alone (RR 1.59, 95% CI 1.09 to 2.33; I² = 0%, 4 studies, 997 participants). Two studies comparing text messaging with other smoking cessation interventions, and three studies comparing high- and low-intensity messaging, did not show significant differences between groups (RR 0.92 95% CI 0.61 to 1.40; I² = 27%; 2 studies, 2238 participants; and RR 1.00, 95% CI 0.95 to 1.06; I² = 0%, 3 studies, 12,985 participants, respectively) but confidence intervals were wide in the former comparison. Five studies compared a smoking cessation smartphone app with lower-intensity smoking cessation support (either a lower-intensity app or non-app minimal support). We pooled the evidence and deemed it to be of very low certainty due to inconsistency and serious imprecision. It provided no evidence that smartphone apps improved the likelihood of smoking cessation (RR 1.00, 95% CI 0.66 to 1.52; I² = 59%; 5 studies, 3079 participants). Other smartphone apps tested differed from the apps included in the analysis, as two used contingency management and one combined text messaging with an app, and so we did not pool them. Using complete case data as opposed to using data from all participants randomised did not substantially alter the findings.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that automated text message-based smoking cessation interventions result in greater quit rates than minimal smoking cessation support. There is moderate-certainty evidence of the benefit of text messaging interventions in addition to other smoking cessation support in comparison with that smoking cessation support alone. The evidence comparing smartphone apps with less intensive support was of very low certainty, and more randomised controlled trials are needed to test these interventions.

A Systematic Review on Effect of Electronic Media among Children and Adolescents on Substance Abuse

Background:

Substance abuse is one of the most significant global public health issues among youths. Electronic media has become a part of day-to-day life for all. This systematic review is undertaken to comprehensively explore the effect of electronic media on substance abuse among children and adolescents.

Methodology:

Two review authors independently searched various electronic databases and other sources.

Selection Criteria:

Randomized control trials that assessed the effect of exposure of electronic media (defined as television, internet, gaming, mobile phones/phones, and radio) among participants in the age range of 5–19 years on substance abuse were included in the review.

Data Collection and Analysis:

Two reviewers independently extracted data. We used an approach proposed by the Cochrane Collaboration. We used GRADE profiler to assess the overall quality of the evidence.

Main Results:

We retrieved 6003 studies and found 15 studies that fulfilled our inclusion criteria. Since included studies differed in the type of intervention and reporting of outcomes, we did not undertake meta-analysis and choose to describe studies narratively. Quality of evidence was rated as “very low” due to too little information or too few data to be able to reach any conclusions.

Authors' Conclusions:

Clinicians, policymakers, and educators to partner with caregivers and youth to support electronic media use that promotes positive outcome in these areas.

Registration of Systematic Review:

This systematic review has been registered at PROSPERO International prospective register of systematic reviews (Registration number: PROSPERO 2018 CRD42018086935) available at https://www.crd.york.ac.uk/prospero/display_record.php?RecordID = 86935.

Tobacco cessation interventions for young people

BACKGROUND

Most tobacco control programmes for adolescents are based around prevention of uptake, but teenage smoking is still common. It is unclear if interventions that are effective for adults can also help adolescents to quit. This is the update of a Cochrane Review first published in 2006.

OBJECTIVES

To evaluate the effectiveness of strategies that help young people to stop smoking tobacco.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register in June 2017. This includes reports for trials identified in CENTRAL, MEDLINE, Embase and PsyclNFO.

SELECTION CRITERIA

We included individually and cluster-randomized controlled trials recruiting young people, aged under 20 years, who were regular tobacco smokers. We included any interventions for smoking cessation; these could include pharmacotherapy, psycho-social interventions and complex programmes targeting families, schools or communities. We excluded programmes primarily aimed at prevention of uptake. The primary outcome was smoking status after at least six months' follow-up among those who smoked at baseline.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of candidate trials and extracted data. We evaluated included studies for risk of bias using standard Cochrane methodology and grouped them by intervention type and by the theoretical basis of the intervention. Where meta-analysis was appropriate, we estimated pooled risk ratios using a Mantel-Haenszel fixed-effect method, based on the quit rates at six months' follow-up.

MAIN RESULTS

Forty-one trials involving more than 13,000 young people met our inclusion criteria (26 individually randomized controlled trials and 15 cluster-randomized trials). We judged the majority of studies to be at high or unclear risk of bias in at least one domain. Interventions were varied, with the majority adopting forms of individual or group counselling, with or without additional self-help materials to form complex interventions. Eight studies used primarily computer or messaging interventions, and four small studies used pharmacological interventions (nicotine patch or gum, or bupropion). There was evidence of an intervention effect for group counselling (9 studies, risk ratio (RR) 1.35, 95% confidence interval (CI) 1.03 to 1.77), but not for individual counselling (7 studies, RR 1.07, 95% CI 0.83 to 1.39), mixed delivery methods (8 studies, RR 1.26, 95% CI 0.95 to 1.66) or the computer or messaging interventions (pooled RRs between 0.79 and 1.18, 9 studies in total). There was no clear evidence for the effectiveness of pharmacological interventions, although confidence intervals were wide (nicotine replacement therapy 3 studies, RR 1.11, 95% CI 0.48 to 2.58; bupropion 1 study RR 1.49, 95% CI 0.55 to 4.02). No subgroup precluded the possibility of a clinically important effect. Studies of pharmacotherapies reported some adverse events considered related to study treatment, though most were mild, whereas no adverse events were reported in studies of behavioural interventions. Our certainty in the findings for all comparisons is low or very low, mainly because of the clinical heterogeneity of the interventions, imprecision in the effect size estimates, and issues with risk of bias.

AUTHORS' CONCLUSIONS

There is limited evidence that either behavioural support or smoking cessation medication increases the proportion of young people that stop smoking in the long-term. Findings are most promising for group-based behavioural interventions, but evidence remains limited for all intervention types. There continues to be a need for well-designed, adequately powered, randomized controlled trials of interventions for this population of smokers.

Using Mobile-Technology-Based Ecological Momentary Assessment (EMA) Methods With Youth: A Systematic Review and Recommendations

Ecological momentary assessment (EMA) methods are increasingly used in social and health sciences, but the feasibility and best practices for using EMA with youth are not yet clear. We conducted a systematic review of studies that used self-report EMA methods with youth; the goal was to identify common approaches and challenges to implementation and develop recommendations for future research. We examined 54 peer-reviewed papers that reported on 24 unique studies. Papers were evaluated using a standardized, three-dimensional coding scheme focused on the following: (1) sample characteristics; (2) EMA data collection methods (sampling duration, frequency, hardware/software); (3) study implementation methods (technical/logistical challenges, training participants, compliance). Overall, the research suggests EMA can be successfully implemented with youth (age ∼ ≥7) from diverse backgrounds, but protocol adaptations may be necessary for younger children. Study design and implementation challenges and recommendations for research on youth are provided.

Positive and Negative Peer Influence in Residential Care

The potential for negative peer influence has been well established in research, and there is a growing interest in how positive peer influence also impacts youth. No research, however, has concurrently examined positive and negative peer influence in the context of residential care. Clinical records for 886 residential care youth were used in a Hierarchical Linear Model analysis to examine the impact of negative and positive peer influence on naturally occurring patterns of serious problem behavior over time. Negative peer influence, where the majority of youth in a home manifested above the average number of serious behavior problems, occurred 13.7% of the time. Positive peer influence, where the majority of youth manifested no serious problem behaviors for the month, occurred 47.7% of the time. Overall, youth problem behavior improved over time. There were significantly lower rates of serious problem behavior in target youth during positive peer influence months. Conversely, there were significantly higher rates of serious problem behaviors in target youth during negative peer influence months. Negative peer influence had a relatively greater impact on target peers' serious behavior problems than did positive peer influence. Caregiver experience significantly reduced the impact of negative peer influence, but did not significantly augment positive peer influence. Months where negative peer influence was combined with inexperienced caregivers produced the highest rates of serious problem behavior. Our results support the view that residential programs for troubled youth need to create circumstances that promote positive and control for negative peer influence.

The role of tobacco outlet density in a smoking cessation intervention for urban youth

This study investigates the role of tobacco outlet density in a randomized controlled trial of a text messaging-based smoking cessation intervention conducted among a sample of 187 primarily African American youth in a midsize U.S. city. A moderated mediation model was used to test whether the indirect effect of residential tobacco outlet density on future smoking was mediated by the intention to smoke, and whether this indirect effect differed between adolescents who received the intervention and those who did not. Results indicated that tobacco outlet density is associated with intention to smoke, which predicts future smoking, and that the indirect effect of tobacco outlet density on future smoking is moderated by the intervention. Tobacco outlet density and the intervention can be viewed as competing forces on future smoking behavior, where higher tobacco outlet density acts to mitigate the sensitivity of an adolescent to the intervention's intended effect. Smoking cessation interventions applied to youth should consider tobacco outlet density as a contextual condition that can influence treatment outcomes.

Time-varying effects of a text-based smoking cessation intervention for urban adolescents

INTRODUCTION

Craving to smoke is understood as an important mechanism for continued smoking behavior. Identifying how smoking interventions operate on craving with particular populations is critical for advancing intervention science. This study's objective was to investigate the time-varying effect of a text-delivered smoking cessation intervention.

METHODS

Toward this end, we used ecological momentary assessment (EMA) data collected from a five-day, automated text-messaging smoking cessation randomized clinical trial with 200 urban adolescents. We employed a time-varying effect model (TVEM) to estimate the effects of stress (time-varying covariate) and baseline nicotine dependence level (time-invariant covariate) on craving over six months by treatment condition. The TVEM approach models behavioral change and associations of coefficients expressed dynamically and graphically represented as smooth functions of time.

RESULTS

Controlling for gender, age, and current smoking, differences in trajectories of craving between intervention and control conditions were apparent over the course of the study. During months 2 to 3, the association between stress and craving was significantly stronger among the control group, suggesting treatment dampens this association during this time period. The intervention also reduced the salience of baseline dependence among treatment adolescents, with craving being reduced steadily over time, while the control group increased craving over time.

CONCLUSIONS

These results provide insight into the time-varying nature of treatment effects for adolescents receiving a text-based smoking cessation intervention. The ability to specify when in the course of an intervention the effect is strongest is important in developing targeted and adaptive interventions that can adjust strategically with time.