Structural Components of Integrated Behavioral Health Care: A Comparison of National Programs

Initiatives that support and incentivize the integration of behavioral health and general medical care have become a focus of government strategies to achieve the triple aim of improved health, better patient experience, and reduced costs. The authors describe the components of four large-scale national initiatives aimed at integrating care for a wide range of behavioral health needs. Commonalities across these national initiatives highlight health care and social services needs that must be addressed to improve care for people with co-occurring behavioral health and general medical conditions. These findings can inform how to design, test, select, and align the most promising strategies for integrated care in a variety of settings.

Primary and Behavioral Health Care Integration Program: Impacts on Health Care Utilization, Cost, and Quality

This article describes an extension of the RAND Corporation's evaluation of the Substance Abuse and Mental Health Services Administration's Primary and Behavioral Health Care Integration (PBHCI) grants program. PBHCI grants are designed to improve the overall wellness and physical health status of people with serious mental illness or co-occurring substance use disorders by supporting the integration of primary care and preventive PH services into community behavioral health centers where individuals already receive care. From 2010 to 2013, RAND conducted a program evaluation of PBHCI, describing the structure, process, and outcomes for the first three cohorts of grantee programs (awarded in 2009 and 2010). The current study extends previous work by investigating the impact of PBHCI on consumers' health care utilization, total costs of care to Medicaid, and quality of care in three states. The evidence suggests that PBHCI was successful in reducing frequent use of emergency room and inpatient services for physical health conditions, reducing costs of care, and improving follow-up after hospitalization for a mental illness. However, PBHCI evidence does not suggest that PBHCI had a consistent effect on quality of preventive care and health monitoring for chronic physical conditions. These findings can guide the design of future cohorts of PBHCI clinics to build on the strengths with respect to shifting emergency department and inpatient care to less costly and more effective settings and address the continuing challenge of integrating care between specialty behavioral health providers and general medical care providers.

Prioritizing quality measure concepts at the interface of behavioral and physical healthcare

Objective

Integrated healthcare models can increase access to care, improve healthcare quality, and reduce cost for individuals with behavioral and general medical healthcare needs, yet there are few instruments for measuring the quality of integrated care. In this study, we identified and prioritized concepts that can represent the quality of integrated behavioral health and general medical care.

Design

We conducted a literature review to identify candidate measure concepts. Experts then participated in a modified Delphi process to prioritize the concepts for development into specific quality measures.

Setting

United States.

Participants

Expert behavioral health and general medical clinicians, decision-makers (policy, regulatory and administrative professionals) and patient advocates.

Main outcome measures

Panelists rated measure concepts on importance, validity and feasibility.

Results

The literature review identified 734 measures of behavioral or general medical care, which were then distilled into 43 measure concepts. Thirty-three measure concepts (including a segmentation strategy) reached a predetermined consensus threshold of importance, while 11 concepts did not. Two measure concepts were 'ready for further development' ('General medical screening and follow-up in behavioral health settings' and 'Mental health screening at general medical healthcare settings'). Among the 31 additional measure concepts that were rated as important, 7 were rated as valid (but not feasible), while the remaining 24 concepts were rated as neither valid nor feasible.

Conclusions

This study identified quality measure concepts that capture important aspects of integrated care. Researchers can use the prioritization process described in this study to guide healthcare quality measures development work.

Measuring Efficiency at the Interface of Behavioral and Physical Health Care

BACKGROUND

Measures of efficiency in healthcare delivery, particularly between different parts of the healthcare system could potentially improve health resource utilization. We use a typology adapted from the Agency for Healthcare Research and Quality to characterize current measures described in the literature by stakeholder perspective (payer, provider, patient, policy-maker), type of output (reduced utilization or improved outcomes) and input (physical, financial or both).

AIMS OF THE STUDY

To systematically describe measures of healthcare efficiency at the interface of behavioral and physical healthcare and identify gaps in the literature base that could form the basis for further measure development.

METHODS

We searched the Medline database for studies published in English in the last ten years with the terms 'efficiency', 'inefficiency', 'productivity', 'cost' or 'QALY' and 'mental' or 'behavioral' in the title or abstract. Studies on healthcare resource utilization, costs of care, or broader healthcare benefits to society, related to the provision of behavioral health care in physical health care settings or to people with physical health conditions or vice versa were included.

RESULTS

85 of 6,454 studies met inclusion criteria. These 85 studies described 126 measures of efficiency. 100 of these measured efficiency according to the perspective of the purchaser or provider, whilst 13 each considered efficiency from the perspective of society or the consumer. Most measures counted physical resources (such as numbers of therapy sessions) rather than the costs of these resources as inputs. Three times as many measures (95) considered service outputs as did quality outcomes (31).

DISCUSSION

Measuring efficiency at the interface of behavioral and physical care is particularly difficult due to the number of relevant stakeholders involved, ambiguity over the definition of efficiency and the complexity of providing care for people with multimorbidity. Current measures at this interface concentrate on a limited range of outcomes.

LIMITATIONS

We only searched one database and did not review the gray literature, nor solicit a call for relevant but unpublished work. We did not assess the methodological quality of the studies identified.

IMPLICATION FOR HEALTH CARE PROVISION AND USE

Most measures of healthcare efficiency are currently viewed from the perspective of payers and providers, with very few studies addressing the benefits of healthcare to society or the individual interest of the consumer. One way this imbalance could be addressed is through much stronger involvement of consumers in measurement-development, for example, by an expansion in patient-reported outcome measures in assessing quality of care.

IMPLICATIONS FOR HEALTH POLICIES

Integrating behavioral and physical care is a major area of implementation as health systems in high income countries move from volume to value based care delivery. Measuring efficiency at this interface has the potential to incentivize and also evaluate integration efforts.

IMPLICATIONS FOR FURTHER RESEARCH

There has been only one previous systematic review of efficiency measurement and none at the interface of behavioral and physical care. We identify gaps in the evidence base for efficiency measurement which could inform further research and measurement development.

The Air Force Deployment Transition Center: Assessment of Program Structure, Process, and Outcomes

It is often accepted as common knowledge that military personnel benefit from decompression time between a war zone and the home station. To capitalize on the potential benefits of a decompression period paired with support services, the U.S. Air Force established the Deployment Transition Center (DTC) at Ramstein Air Base in Germany in July 2010. The DTC provides airmen returning from combat missions with an opportunity to decompress and share lessons learned before returning to their home stations. The authors of this study evaluate the structure, processes, and outcomes of the DTC program. They find that, although a majority of participants found the DTC program worthwhile, a comparison of DTC participants and similar airmen who did not participate the program shows no evidence that the program helps reduce posttraumatic stress disorder symptoms, depressive symptoms, binge drinking, or social conflicts with family and coworkers. In addition, one of the DTC program elements appears to be similar to posttraumatic debriefing interventions, which several studies have found to be either ineffective or harmful. For these reasons, if the main goals of the DTC program are to improve behavioral health and social conflict outcomes, the authors recommend that the DTC program be discontinued or redesigned and Air Force resources invested in alternative programs. However, if the DTC program has other goals, such as providing rest and relaxation to airmen after a difficult deployment or capturing after-action information, then the authors recommend that these goals be documented and the DTC program be more specifically tailored to them.

Enrollment of Specialty Mental Health Clinics in a State Medicaid Program to Promote General Medical Services

OBJECTIVE

To promote integrated general medical care for individuals with serious mental illness, the New York State Office of Mental Health (OMH) established regulations allowing specialty mental health clinics to provide Medicaid-reimbursable health monitoring (HM) and health physicals (HP). This study examined clinics' enrollment in this program to understand its potential to reach individuals with serious mental illness.

METHODS

Information on enrollment and characteristics of clinics (N=500) was obtained from OMH administrative databases. Clinic enrollment in the HM/HP program was examined for the program's first five years (2010-2015). Logistic regression models accounting for the clustering of multiple clinics within agencies were used to examine characteristics associated with enrollment.

RESULTS

A total of 291 of 500 (58%) licensed clinics in New York State in 2015 enrolled in the HM/HP program, potentially reaching 62% of all Medicaid enrollees with serious mental illness seen in specialty mental health clinics in the state. State-operated clinics were required to participate, and had 91% enrollment. Over half of hospital-affiliated and freestanding mental health clinics elected to enroll (53% and 54%, respectively). In adjusted models, enrollment was higher among freestanding clinics compared with hospital-affiliated clinics, higher in larger than smaller clinics, and higher in county-operated than in private nonprofit clinics.

CONCLUSIONS

The high level of enrollment in the HM/HP program indicates strong interest among mental health clinics in providing general medical care services. However, supplemental policies may be needed to extend the program to areas of the mental health system where barriers to general medical care services are highest.

General Medical Outcomes From the Primary and Behavioral Health Care Integration Grant Program

OBJECTIVE

Primary and Behavioral Health Care Integration (PBHCI) grants aim to improve the health of people with serious mental illness by integrating primary and preventive general medical services into behavioral health settings. This report describes the general medical outcomes of persons served by early cohorts of programs, funded in 2009 or 2010, that participated in this national demonstration project.

METHODS

A quasi-experimental, difference-in-differences design was used to compare changes in general medical health among consumers served at three PBHCI clinics (N=322) and three clinics that were selected as matched control sites (N=469). Propensity-score weighting was used to adjust for baseline differences between PBHCI and control clinic populations. Baseline data were collected between 2010 and 2012; follow-up data were collected approximately one year later. General medical outcomes included blood pressure; body mass index; cholesterol, triglyceride, and blood glucose or HbA1c levels; and self-reported tobacco smoking.

RESULTS

Compared with consumers served at control clinics, PBHCI consumers had better outcomes for cholesterol: mean reductions in total cholesterol were greater by 36 mg/dL (p<.01), mean reductions in low-density lipoprotein cholesterol were greater by 35 mg/dL (p<.001), and mean increases in high-density lipoprotein cholesterol were greater by 3 mg/dL (p<.05). No significant PBHCI effects were observed for the other health indicators.

CONCLUSIONS

Approximately one year of PBHCI treatment resulted in statistically and potentially clinically significant improvements in cholesterol but not in other general medical outcomes examined. More rigorous implementation of integrated care in community behavioral health settings may be needed to further improve the health of adults with serious mental illness.

Integrating Primary Care Into Community Mental Health Centers: Impact on Utilization and Costs of Health Care

OBJECTIVE

This evaluation was designed to assess the impact of providing integrated primary and mental health care on utilization and costs for outpatient medical, inpatient hospital, and emergency department treatment among persons with serious mental illness.

METHODS

Two safety-net, community mental health centers that received a Substance Abuse and Mental Health Services Administration Primary and Behavioral Health Care Integration (PBHCI) grant were the focus of this study. Clinic 1 had a ten-year history of providing integrated services whereas clinic 2 began integrated services with the PBHCI grant. Difference-in-differences (DID) analyses were used to compare individuals enrolled in the PBHCI programs (N=373, clinic 1; N=389, clinic 2) with propensity score-matched comparison groups of equal size at each site by using data obtained from medical records.

RESULTS

Relative to the comparison groups, a higher proportion of PBHCI clients used outpatient medical services at both sites following program enrollment (p<.003, clinic 1; p<.001, clinic 2). At clinic 1, PBHCI was also associated with a reduction in the proportion of clients with an inpatient hospital admission (p=.04) and a trend for a reduction in inpatient hospital costs per member per month of $217.68 (p=.06). Hospital-related cost savings were not observed for PBHCI clients at clinic 2 nor were there significant differences between emergency department use or costs for PBHCI and comparison groups at either clinic.

CONCLUSIONS

Investments in PBHCI can improve access to outpatient medical care for persons with severe mental illness and may also curb hospitalizations and associated costs in more established programs.

SimCoach Evaluation: A Virtual Human Intervention to Encourage Service-Member Help-Seeking for Posttraumatic Stress Disorder and Depression

This article describes RAND Corporation researchers' assessment of SimCoach, a computer program featuring a virtual human that speaks and gestures in a video game-like interface, designed to encourage service members, especially those with signs or symptoms of posttraumatic stress disorder (PTSD) or depression, to seek help to improve their psychological health. The assessment included a formative component assessing SimCoach's design, development, and implementation approaches and a summative component assessing outcomes among participants in a user experience survey and a randomized controlled trial (RCT). Results of the formative evaluation identified both strengths and opportunities for improvement. For example, although SimCoach development processes were well-aligned with best practices for software engineering, SimCoach content development and evaluation processes could have been more tightly coupled to best practices in psychological health. The summative evaluation RCT did not show any SimCoach-related benefit in intent to seek help compared with that of control users not exposed to any intervention. However, secondary outcomes indicated that SimCoach users had satisfying experiences without distress. If SimCoach development is continued, greater attention to clinical processes and outcomes is needed so that the program can have its intended impact on help-seeking for PTSD and depression.

Public-Private Partnerships for Providing Behavioral Health Care to Veterans and Their Families: What Do We Know, What Do We Need to Learn, and What Do We Need to Do?

American veterans and their family members struggle with behavioral health problems, yet few engage in treatment to address these problems. Barriers to care include trouble accessing treatment and limited communication between civilian and military health care systems, which treat veterans and their family members separately. Even though the Department of Veterans Affairs (VA) is making efforts to address barriers to care, more work is needed to effectively serve veterans and their families. Public-private partnerships have been discussed as a potential solution and could include collaborations between a public agency, such as the VA, and a private organization, such as a veteran service organization, private industry, or private hospital. Despite the call for such partnerships, not much is known about what a public-private partnership would entail for addressing behavioral health concerns for veterans and their families. The health care literature is sparse in this area, and published examples and recommendations are limited. Thus, the authors wrote this article to inform the creation of public-private partnerships to better serve veterans and their families. The article outlines nine key components for public-private partnerships addressing veteran behavioral health care. These components are supported by qualitative interview data from five successful public-private partnerships that serve veterans and their families. This study will assist policymakers in the VA and other federal agencies in developing and fostering public-private partnerships to address the behavioral health care needs of veterans and their families. The article also discusses next steps for research and policymaking efforts with regard to these partnerships.

Care Transitions to and from the National Intrepid Center of Excellence (NICoE) for Service Members with Traumatic Brain Injury

Improvised explosive devices (IEDs) have been one of the leading causes of death and injury among U.S. troops. Those who survive an IED blast or other injuries may be left with a traumatic brain injury (TBI) and attendant or co-occurring psychological symptoms. In response to the need for specialized services for these populations, the U.S. Department of Defense (DoD) established the National Intrepid Center of Excellence (NICoE) in Bethesda, Maryland, in 2010. The NICoE's success in fulfilling its mission is impacted by its relationships with home station providers, patients, and their families. The RAND Corporation was asked to evaluate these relationships and provide recommendations for strengthening the NICoE's efforts to communicate with these groups to improve patients' TBI care. Through surveys, site visits, and interviews with NICoE staff, home station providers, service members who have received care at the NICoE, and the families of these patients, RAND's evaluation examined the interactions between the NICoE and the providers responsible for referring patients and implementing treatment plans.

Evaluation of the SAMHSA Primary and Behavioral Health Care Integration (PBHCI) Grant Program: Final Report

Excess morbidity and mortality in persons with serious mental illness is a public health crisis. Numerous factors contribute to this health disparity, including illness and treatment-related factors, socioeconomic and lifestyle-related factors, and limited access to and poor quality of general medical care. Primary and Behavioral Health Care Integration (PBHCI), one of the Substance Abuse and Mental Health Services Administration's service grant programs, is intended to improve the overall wellness and physical health status of people with serious mental illness, including individuals with co-occurring substance use disorders, by making available an array of coordinated primary care services in community mental health and other community-based behavioral health settings where the population already receives care. This article describes the results of a RAND Corporation evaluation of the PBHCI grants program. The evaluation was designed to understand PBHCI implementation strategies and processes, whether the program leads to improvements in outcomes, and which program models and/or model features lead to better program processes and consumer outcomes. Results of the evaluation showed that PBHCI grantee programs were diverse, varying in their structures, procedures, and the extent to which primary and behavioral health care was integrated at the program level. Overall, PBHCI programs also served many consumers with high rates of physical health care needs, although total program enrollment was lower than expected. The results of a small, comparative effectiveness study showed that consumers served at PBHCI clinics (compared to those served at matched control clinics) showed improvements on some (e.g., markers of dyslipidemia, hypertension, diabetes) but not all of the physical health indicators studied (e.g., smoking, weight). Finally, we found that program features, such as clinic hours, regular staff meetings, and the degree of service integration, increased consumer access to integrated care, but that access to integrated care was not directly associated with improvements in physical health. Implications of the study results for programs and the broader field, plus options for future PBHCI-related research are discussed.

An Examination of New York State's Integrated Primary and Mental Health Care Services for Adults with Serious Mental Illness

The poor physical health of adults with serious mental illnesses is a public health crisis. Greater integration of mental health and primary medical care services at the clinic and system levels could address this need. In New York state, there are several ongoing initiatives that promote integrated care for adults with serious mental illness, provided or coordinated by community mental health center staff. This study examines three initiatives. Data were collected by RAND through site visits and surveys of mental health clinic administrators and associated professionals. Results showed that Primary and Behavioral Health Care Integration grantees developed infrastructure that supported a broad scope of primary and preventive health care services; these broad changes appeared to contribute to clinic-wide culture shifts toward integration and shared accountability for consumers' "whole person" health. Clinics participating in the Medicaid Incentive tended to implement only those services for which they could bill, which resulted in newly identified consumer physical health care needs but did not help consumers to connect to physical health care services. Finally, while administrators and providers were optimistic that Medicaid Health Homes have potential to improve access to care for adults with serious mental illness, the newness of the initiative made it difficult to assess the degree to which Health Home networks would meet these goals. We conclude with recommendations to state policymakers, clinical providers, and technical assistance providers and recommendations for future research, all designed to strengthen New York state's integrated care initiatives for adults with serious mental illness.

The effects of prior authorization policies on medicaid-enrolled children's use of antipsychotic medications: evidence from two mid-Atlantic states

OBJECTIVE

The purpose of this study was to examine the impact of prior authorization policies on the receipt of antipsychotic medication for Medicaid-enrolled children.

METHODS

Using de-identified administrative Medicaid data from two large, neighboring, mid-Atlantic states from November 2007 through June 2011, we identified subjects <18 years of age using antipsychotics, from the broader group of children and adolescents receiving behavioral health services or any psychotropic medication. Prior authorization for antipsychotics was required for children in State A <6 years of age from September 2008, and for children <13 years of age from August 2009. No such prior authorizations existed in State B during that period. Filled prescriptions were identified in the data using national drug codes. Using a triple-difference strategy (using differences among the states, time periods, and differences in antidepressant prescribing rates among states over the same time periods), we examined the effect of the prior authorization policy on the rate at which antipsychotic prescriptions were filled for Medicaid-enrolled children and adolescents.

RESULTS

The impact of prior authorization policies on antipsychotic medication use varied by age: Among 6-12 year old children, the impact of the prior authorization policy on antipsychotic medication prescribing was a modest but statistically significant decrease of 0.47% after adjusting for other factors; there was no effect of the prior authorization among children 0-5 years.

CONCLUSIONS

Prior authorization policies had a modest but statistically significant effect on antipsychotic use in 6-12 year old children, but had no impact in younger children. Future research is needed to understand the utilization and clinical effects of prior authorization and other policies and interventions designed to influence antipsychotic use in children.

Quantifying the persistence of pro-smoking media effects on college students' smoking risk

PURPOSE

To quantify the persistence of pro-smoking media exposure effects on college students' intentions to smoke and smoking refusal self-efficacy.

METHOD

A total of 134 college students (ages 18-24 years) were enrolled in an ecological momentary assessment study in which they carried handheld data collection devices for 3 weeks and reported their exposures to pro-smoking media as they occurred in the real world. Smoking intentions and smoking refusal self-efficacy were assessed after each exposure to pro-smoking media and at random prompts during each day of the 3-week assessment period. A generalized additive model was used to determine how long the effect of an exposure to pro-smoking media persisted.

RESULTS

The effect of pro-smoking media exposures persisted for 7 days. After exposure, smoking intentions immediately increased (.56; 95% confidence interval [CI]: [.26, .87]) and then steadily decreased (-.12; 95% CI: [-.19, -.05]) each day for 7 days, while smoking refusal self-efficacy immediately decreased (-.42; 95% CI: [-.75, -.10]) and then steadily increased (.09; 95% CI: [.02, .16]) each day for 7 days. Daily changes occurring after 7 days were not statistically significant, suggesting that smoking intentions and refusal self-efficacy had stabilized and were no longer affected by pro-smoking media exposure.

CONCLUSIONS

Exposures to pro-smoking media may have strong implications for emerging young adults smoking risk as the impact of an individual exposure appears to persist for at least a week.

Integrating primary care into community behavioral health settings: programs and early implementation experiences

OBJECTIVE

This article describes the characteristics and early implementation experiences of community behavioral health agencies that received Primary and Behavioral Health Care Integration (PBHCI) grants from the Substance Abuse and Mental Health Services Administration to integrate primary care into programs for adults with serious mental illness.

METHODS

Data were collected from 56 programs, across 26 states, that received PBHCI grants in 2009 (N=13) or 2010 (N=43). The authors systematically extracted quantitative and qualitative information about program characteristics from grantee proposals and semistructured telephone interviews with core program staff. Quarterly reports submitted by grantees were coded to identify barriers to implementing integrated care.

RESULTS

Grantees shared core features required by the grant but varied widely in terms of characteristics of the organization, such as size and location, and in the way services were integrated, such as through partnerships with a primary care agency. Barriers to program implementation at start-up included difficulty recruiting and retaining qualified staff and issues related to data collection and use of electronic health records, licensing and approvals, and physical space. By the end of the first year, some problems, such as space issues, were largely resolved, but other issues, including problems with staffing and data collection, remained. New challenges, such as patient recruitment, had emerged.

CONCLUSIONS

Early implementation experiences of PBHCI grantees may inform other programs that seek to integrate primary care into behavioral health settings as part of new, large-scale government initiatives, such as specialty mental health homes.

Middle and high school students' exposure to alcohol- and smoking-related media: a pilot study using ecological momentary assessment

The goals of this study were to assess the feasibility of using Ecological Momentary Assessment (EMA) to measure adolescents' exposure to alcohol and smoking-related media. A sample of 20 middle and high school students completed a 2-week EMA protocol in which they monitored exposures to alcohol and smoking-related media. Results showed that adolescents were highly compliant with the study protocol. A total of 255 exposures to alcohol (67%) and smoking (33%) were captured, representing an average of 8.50 (SD = 5.82) alcohol-related media exposures and 4.25 (SD = 3.67) smoking-related media exposures per participant, during the study period. Exposures tended to occur in the afternoon (52% alcohol; 54% smoking), at point of sale (44% alcohol; 65% smoking), and on days leading up to the weekend (57% alcohol; 57% smoking). Exposures were also likely in the presence of family (69% alcohol; 56% smoking). Overall, results of this small pilot provide preliminary evidence that EMA is a useful tool for tracking and characterizing middle and high school students' real-world exposures to alcohol- and smoking-related media. Future studies may suggest mechanisms by which media exposures lead to youth uptake of drinking and smoking behaviors.

Programs Addressing Psychological Health and Traumatic Brain Injury Among U.S. Military Servicemembers and Their Families

Over the last decade, U.S. military forces have been engaged in extended conflicts that are characterized by increased operational tempo, most notably in Iraq and Afghanistan. While most military personnel cope well across the deployment cycle, many will experience difficulties handling stress at some point; will face psychological health challenges, such as post-traumatic stress disorder or major depression; or will be affected by the short- and long-term psychological and cognitive consequences of a traumatic brain injury (TBI). Over the past several years, the Department of Defense (DoD) has implemented numerous programs that address various components of psychological health along the resilience, prevention, and treatment continuum and focus on a variety of clinical and nonclinical concerns. This article provides detail from an evaluation of 211 programs currently sponsored or funded by DoD to address psychological health and TBI, along with descriptions of how programs relate to other available resources and care settings. It also provides recommendations for clarifying the role of programs, examining gaps in routine service delivery that could be filled by programs, and reducing implementation barriers. Barriers include inadequate funding and resources, concerns about the stigma associated with receiving psychological health services, and inability to have servicemembers spend adequate time in programs. The authors found that there is significant duplication of effort, both within and across branches of service. As each program develops its methods independently, it is difficult to determine which approaches work and which are ineffective. Recommendations include strategic planning, centralized coordination, and information-sharing across branches of service, combined with rigorous evaluation. Programs should be evaluated and tracked in a database, and evidence-based interventions should be used to support program efforts.

Friends moderate the effects of pro-smoking media on college students' intentions to smoke

Exposure to prosmoking media (e.g., smoking in movies, advertising in magazines) contributes to smoking in young people. However, the extent to which the impact of exposure depends on the social context in which those exposures occur has not been investigated. This study used ecological momentary assessment to examine the moderating role of social context in the relationship between college students' exposure to prosmoking media and their smoking refusal self-efficacy and intention to smoke. College students (n = 134) carried handheld computers for 21 days, recording their exposure to all forms of prosmoking media during the assessment period. They also responded to three investigator-initiated control prompts (programmed to occur randomly) each day of the assessment. After each exposure to prosmoking media and after each control prompt, participants answered questions about smoking refusal self-efficacy and their intentions to smoke; they also indicated whether they were with friends, with family, with a romantic partner, or alone (i.e., their social context). When participants were with friends, prosmoking media exposures were associated with stronger smoking intentions and lower smoking refusal self-efficacy; these associations were not present when participants were alone. Being with family members or with a romantic partner did not moderate the impact of prosmoking media exposure on either dependent variable. These results suggest a new role for peers in the development of youth smoking.

Measuring exposure to protobacco marketing and media: a field study using ecological momentary assessment

INTRODUCTION

The aims of this study were to validate ecological momentary assessment (EMA) as a method for measuring exposure to tobacco-related marketing and media and to use this method to provide detailed descriptive data on college students' exposure to protobacco marketing and media.

METHODS

College students (n = 134; ages 18-24 years) recorded their exposures to protobacco marketing and media on handheld devices for 21 consecutive days. Participants also recalled exposures to various types of protobacco marketing and media at the end of the study period.

RESULTS

Retrospectively recalled and EMA-based estimates of protobacco marketing exposure captured different information. The correlation between retrospectively recalled and EMA-logged exposures to tobacco marketing and media was moderate (r = .37, p < .001), and EMA-logged exposures were marginally associated with the intention to smoke at the end of the study, whereas retrospective recall of exposure was not. EMA data showed that college students were exposed to protobacco marketing through multiple channels in a relatively short period: Exposures (M = 8.24, SD = 7.85) occurred primarily in the afternoon (42%), on weekends (35%), and at point-of-purchase locations (68%) or in movies/TV (20%), and exposures to Marlboro, Newport, and Camel represented 56% of all exposures combined and 70% of branded exposures.

CONCLUSIONS

Findings support the validity of EMA as a method for capturing detailed information about youth exposure to protobacco marketing and media that are not captured through other existing methods. Such data have the potential to highlight areas for policy change and prevention in order to reduce the impact of tobacco marketing on youth.

Patterns of intermittent smoking: An analysis using Ecological Momentary Assessment

Non-daily smokers comprise a substantial proportion of US smokers, but there has been little study of their patterns of smoking, which are often assumed to reflect "social smoking." We used Ecological Momentary Assessment methods to study smoking patterns in 27 non-daily smoking adults who recorded each cigarette smoked over three weeks by leaving a voice mail message indicating their circumstances at the time of smoking. All told, 689 cigarettes were recorded over 589 person-days of observation. On average, participants smoked on 67% of days, averaging 2.1 (SD=0.91) cigarettes per day on days they smoked; 22% of all cigarettes were smoked in bouts (within an hour of another cigarette). Altogether, 19% of cigarettes were smoked when drinking alcohol and 29% when participants were socializing. Smoking patterns varied widely across participants. A pair of hierarchical cluster analyses distinguished three groups: Those who smoked primarily (81% of cigarettes) in the daytime (Early smokers; n=15, 58% of total sample), those who smoked primarily (75% of cigarettes) at night (Late smokers; n=7, 27%), and a distinct, classic "Social smoking" group (n=4, 15% of total sample), who smoked mostly at night but also primarily when socializing or drinking (86% of their cigarettes), in the evening (71% of their cigarettes), on weekends (65% of their cigarettes), and in bouts (71% of their cigarettes). Overall, results suggest that non-daily smoking patterns are quite heterogeneous, and that many non-daily smokers may not be primarily social smokers.

Smoking during the night: prevalence and smoker characteristics

We report on the smoking patterns and characteristics of individuals who smoke at night. We also explore the relationship between night smoking, nicotine dependence, and cessation outcomes. Participants (N = 691) were heavy smokers enrolled in cessation research clinics. Data were from three studies. Using ecological momentary assessment, participants monitored their smoking (ad libitum, day and night) on electronic diaries (EDs) during a 2-week baseline period and for 4 weeks following a target quit day. A total of 41% of smokers recorded at least one episode of night smoking. Within this group, night smoking occurred on 26% of nights, averaging two episodes per night. ED data correlated with a single self-report item assessing the frequency of night smoking. Night smoking was associated with greater nicotine dependence and daily caffeine consumption. It also predicted risk for lapsing beyond traditional measures of nicotine dependence. Night smoking is common, is associated with nicotine dependence, and it represents additional risk for cessation failure. People who smoke at night may need nicotine replacement therapy overnight. Future research should determine whether treatments that improve sleep quality also improve cessation outcomes in night smokers.

Daily smoking patterns, their determinants, and implications for quitting

In this article, the authors examine daily temporal patterns of smoking in relation to environmental restrictions on smoking and cessation outcomes. Time-series methods were used for analyzing cycles in 351 smokers who monitored their smoking in real time for 2 weeks. The waking day was divided into 8 "bins" of approximately 2 hr, cigarette counts were tallied for each bin, and temporal patterns of smoking and restriction were analyzed. Cluster analyses of smoking patterns by time of day resulted in 4 clusters: daily decline (n = 30; 9%), morning high (n = 43; 12%), flatline (n = 247; 70%), and daily dip-evening incline (n = 31; 9%). Clusters differed in baseline demographic, smoking, and psychosocial variables. Results suggest that smoking behavior can be characterized by regular patterns of smoking frequency during the waking day: Smoking in the flatline cluster was within +/-0.5 standard deviation at all times. For the other clusters, smoking was high in the morning (daily dip-evening incline: +1.7 standard deviations; morning high: +2.8 standard deviations; daily decline: +1.7 standard deviations); moderate (morning high: -0.8 standard deviations; daily decline: +0.3 standard deviations) or low (daily dip-evening incline: -1.0 standard deviations) midday; and high (daily dip-evening incline: +2.0 standard deviations), moderate (morning high: +0.5 standard deviations), or low (daily decline: -1.5 standard deviations) in the evening. Daily smoking patterns were related to environmental smoking restrictions, but the strength of this relationship differed among clusters and by time of day. Clusters differed in lapse risk.

Analyzing milestones in smoking cessation: illustration in a nicotine patch trial in adult smokers

Tests of addiction treatments seldom reveal where treatment exercises its effect (i.e., promoting initial abstinence, preventing lapses, and/or impeding progression from lapse to relapse). The authors illustrate analyses distinguishing effects on these milestones in a randomized trial of high-dose nicotine patch (35 mg; n = 188) versus placebo (n = 136) in adult smokers, who used electronic diaries to monitor smoking in real time during 5 weeks of treatment. High-dose patch promoted initial abstinence (hazard ratio [HR] = 1.3) and decreased the risk of lapsing among those who achieved abstinence (HR = 1.6). The biggest effect of treatment was to prevent progression to relapse among those who had lapsed (HR = 7.1). Analysis of effects by milestones may enhance understanding of cessation treatments and their mechanisms of action.