The 2016 Ferno Award Address: Three Things

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.

Randomized factorial experiment of components of the SmokeFree Baby smartphone application to aid smoking cessation in pregnancy

Smartphone applications (apps) might be able to reach pregnant smokers who do not engage with face-to-face support. However, we do not know how far pregnant smokers will engage with smoking cessation apps or what components are likely to be effective. This study aimed to assess pregnant smokers' engagement with the SmokeFree Baby app (v1) and to assess the short-term efficacy of selected components ("modules") for smoking abstinence. Positive outcomes would provide a basis for further development and evaluation. SmokeFree Baby was developed drawing on behavior change theories and relevant evidence. Pregnant smokers (18+) who were interested in quitting and set a quit date were recruited. Following multiphase optimization development principles, participants (N = 565) were randomly allocated to one of 32 (2 × 2 × 2 × 2 × 2) experimental groups in a full factorial design to evaluate five modules (each in minimal and full version: identity, health information, stress management, face-to-face support, and behavioral substitution). Measures of engagement included duration and frequency of engagement with the app. Smoking abstinence was measured by self-reported number of smoke-free days up to 4 weeks from the quit date. Participants engaged with the app for a mean of 4.5 days (SD = 8.5) and logged in a mean of 2.9 times (SD = 3.1). Main effects of the modules on the number of smoke-free days were not statistically significant (identity: p = .782, health information: p = .905, stress management: p = .103, face-to-face support: p = .397, behavioral substitution: p = .945). Despite systematic development and usability testing, engagement with SmokeFree Baby (v1) was low and the app did not appear to increase smoking abstinence during pregnancy.

Effects of motivation phase intervention components on quit attempts in smokers unwilling to quit: A factorial experiment

BACKGROUND

Smoking reduction treatment is a promising approach to increase abstinence amongst smokers initially unwilling to quit. However, little is known about which reduction treatment elements increase quit attempts and the uptake of cessation treatment amongst such smokers.

METHODS

This study is a secondary analysis of a 4-factor randomized factorial experiment conducted amongst primary care patients (N = 517) presenting for regular healthcare visits in Southern Wisconsin who were unwilling to quit smoking but willing to cut down. We evaluated the main and interactive effects of Motivation-phase intervention components on whether participants: 1) made a quit attempt (intentional abstinence ≥24 h) by 6- and 26-weeks post-study enrollment and, 2) used cessation treatment. We also evaluated the relations of quit attempts with abstinence. The four intervention components evaluated were: 1) Nicotine Patch vs. None; 2) Nicotine Gum vs. None; 3) Motivational Interviewing (MI) vs. None; and 4) Behavioral Reduction Counseling (BR) vs. None. Intervention components were administered over 6 weeks, with an option to repeat treatment; participants could request cessation treatment at any point.

RESULTS

Nicotine gum significantly increased the likelihood of making a quit attempt by 6 weeks (23% vs. 15% without gum; p < .05). Conversely, nicotine patch reduced quit attempts when used with BR. Patch also discouraged use of cessation treatment (15.8% vs. 23% without patch; p < .05). Aided vs. unaided quit attempts produced abstinence in 42% vs. 10% of participants, respectively.

CONCLUSION

Nicotine gum is a promising Motivation-phase intervention that may spur quit attempts amongst smokers initially unwilling to quit.

Collecting outcome data of a text messaging smoking cessation intervention with in-program text assessments: How reliable are the results?

BACKGROUND

Text messaging interventions have shown promise in helping people quit smoking. Texting programs periodically survey participants about their smoking status. This study examined the consistency of participant self-reported smoking between external surveys and internal program text message assessments.

METHODS

Participants in Text2Quit program were surveyed about their past 7-day smoking at one, three, and six months post-enrollment using different survey modes (external surveys and internal program text message assessments) and responses were compared for consistency. The first set of analyses was conducted for participants responding on both modes (n = 45 at one month; n = 50 at three months; n = 42 at six months). Additional analyses, assuming missing = smoking, were conducted with the full sample of 262 smokers (68.7% female, mean age = 35.8 years) and compared to saliva-confirmed abstinence rates.

RESULTS

Participants responding to both modes consistently reported smoking status at one (88.9%), three (88.0%) and six (88.1%) months post-enrollment, with fair to substantial levels of agreement (one month: κ = 0.24; three months: κ = 0.63; six months: κ = 0.66). Participants responding to both modes reported high rates of abstinence. In missing = smoking analyses, significant differences in abstinence rates reported across modes were detected at each timepoint (one month: external = 30.5%, internal = 16.4%; three months: external = 33.2%, internal = 16.0%; six months: external = 31.7%, internal = 12.2%; all p < .001). Moderate levels of agreement were found between the two modes. At 6 months, abstinence rates obtained via internal data were closer to those biochemically verified (15.7%) compared to external surveys.

CONCLUSIONS

Results provide initial support for the use of internal program assessments in text messaging programs with missing = smoking assumptions in order to gather outcome data on smoking behavior.

Reducing Smoking Among People With Schizophrenia: Perspectives on Priorities for Advancing Research

Although tobacco smoking is very common among people with schizophrenia and has devastating effects on health, strategies to ameliorate the risk are lacking. Some studies have reported promising results yet quit rates are much lower than in the general population. There is a need to advance research into smoking cessation efforts among people with schizophrenia. We posed the following question to five leading international experts in the field: "What are the top three research ideas we need to prioritize in order to advance the field of reducing smoking amongst people with schizophrenia?" They identified three broad priorities: (i) deeper understanding about the relationship between smoking, smoking cessation and symptomatology; (ii) targeted, adaptive and responsive behavioral interventions evaluated with smarter methodologies; and (iii) improvements in delivery of interventions. Efforts should be made to establish a collaborative international research agenda.

Two brief valid measures of therapeutic alliance in counseling for tobacco dependence

Behavioral counseling is effective for smoking cessation and the psychotherapy literature indicates therapeutic alliance is key to counseling effectiveness. However, no tobacco-counseling specific measures of alliance exist that are suitable in most tobacco counseling contexts. This hinders assessment of counseling components in research and clinical practice. Based on the Working Alliance Inventory, and external expert review, we developed two alliance instruments: the 12-item and 3-item Working Alliance Inventory for Tobacco (WAIT-12 and WAIT-3). Two samples of 226 daily smokers via Amazon Mechanical Turk completed measures including demographics, tobacco characteristics, working alliance scales, and quit attempts. Both WAIT-12 and WAIT-3 had good to excellent internal consistency (0.92 and 0.88 for the WAIT-3 and 0.96 for the WAIT-12). The WAIT-12 1-factor model indicated poor fit (CFI=0.83, TLI=0.79, RMSEA=0.19, SRMR=0.09). The WAIT-12 3-factor model (CFI=0.94, TLI=0.93, RMSEA=0.11, SRMR=0.04) was indicative of acceptable fit. Both the WAIT-12 and the WAIT-3 were significantly associated with participants' self-reported cigarettes per day, quit attempts, and cessation. Initial validation of the WAIT-12 and WAIT-3 indicates they are psychometrically sound measures of tobacco dependence counseling alliance. The WAIT-3 provides brevity; it can be administered in under 1min. The WAIT-12 allows for assessment of specific components of therapeutic alliance. Overall, these instruments should allow for better measurement of alliance in clinical services and research.

Offering smoking treatment to primary care patients in two Wisconsin healthcare systems: Who chooses smoking reduction versus cessation?

Smokers unwilling to make a quit attempt can still benefit from smoking intervention. However, it is unclear what proportion of smokers will enter such a Motivation phase intervention, and whether such an intervention attracts different types of smokers than does abstinence oriented treatment. We conducted a study from June 2010 to October 2013 based on a chronic care model of tobacco treatment among study eligible primary care patients (N=1579; 58% women, 89% White) presenting for regular health care visits in southern Wisconsin, U.S. Medical assistants, prompted via the electronic health record (EHR), invited smokers (n=10,242) to learn more about treatment options to help them either reduce their smoking or quit. Of those invited to learn more who were then reached by study staff, 10.2% (n=1046) reported interest in reduction treatment and 24% (n=2465) reported interest in cessation treatment. Patients who selected and ultimately entered reduction (n=492) versus cessation (n=1087) were more likely to report: older age; a history of anxiety; lower motivation to quit; lower primary dependence motives; more close friends or family who smoke; and a greater interval since their last quit attempt. Results suggest that Motivation phase treatment aimed at smoking reduction may increase the proportion and range of smokers inducted into tobacco treatment.