A Deposit Contract Method to Deliver Abstinence Reinforcement for Cigarette Smoking

Eight smokers were randomly assigned to a deposit contract ($50.00) or to a no-deposit group. Using a reversal design, participants could recoup their deposit (deposit group) or earn vouchers (no-deposit group) for smoking reductions and abstinence (breath carbon monoxide [CO] ≤ 4 parts per million) during treatment phases. Treatment was delivered via a novel Internet-based method to monitor smoking status. Although equivalent decreases in breath CO and abstinence were observed during treatment in both groups, $178.50 in vouchers were distributed to participants in the no-deposit group, whereas a small surplus remained in the deposit group. A deposit contract method may represent a cost-effective model to deliver abstinence reinforcement for cigarette smoking.     

Effects of internet-based voucher reinforcement and a transdermal nicotine patch on cigarette smoking

Nicotine replacement products are commonly used to promote smoking cessation, but alternative and complementary methods may increase cessation rates. The current experiment compared the short-term effects of a transdermal nicotine patch to voucher-based reinforcement of smoking abstinence on cigarette smoking. Fourteen heavy smokers (7 men and 7 women) completed the four 5-day phases of the study: baseline, patch treatment, voucher treatment, and return to baseline. The order of the two treatment phases was counterbalanced across participants. In the patch treatment condition, participants wore a 14-mg transdermal nicotine patch every day. In the voucher treatment condition, participants received vouchers contingent on abstinence from smoking, defined as producing carbon monoxide (CO) readings of < or =4 parts per million. Participants e-mailed two video clips per day showing them breathing into a CO monitor and the resulting CO reading to clinic staff. In the voucher treatment, 24% of samples were negative, and 5% of samples were negative in the patch treatment. Results suggest that contingent vouchers were more effective than transdermal nicotine patches in promoting abstinence.     

Effects of an Internet-based voucher reinforcement program for smoking abstinence: a feasibility study

The present study tested the feasibility of an Internet-based method to obtain objective evidence of smoking abstinence and to deliver vouchers for evidence of abstinence. Four heavy smokers participated in this 4-week study. Twice daily, participants made video recordings of themselves providing a breath carbon monoxide (CO) sample with a Web camera. The video was sent electronically to the smoking clinic. Participants could earn vouchers for gradual reductions in breath CO during an initial shaping condition, and then for achieving abstinence (CO < or = 4 ppm). Vouchers could be exchanged for merchandise at select Internet vendors. Relative to baseline conditions, participants substantially reduced their smoke intake, and 3 achieved sustained periods of abstinence. The study suggests that an Internet-based voucher reinforcement program is a feasible method to promote abstinence from cigarette smoking.     

CONTINGENT PAYMENT PROCEDURES FOR SMOKING REDUCTION AND CESSATION

We assessed the ability of a combined contingent reinforcement and intensive monitoring procedure to promote and sustain temporary smoking cessation among 34 hired research volunteers, and the ability of a smoking reduction test to predict the subsequent initiation of abstinence. During the 5-day cutdown test, subjects were paid from $0 to $6 per day depending on the extent of reduction from baseline CO levels. During the abstinence test, breath samples were obtained three times daily and subjects were paid $4 for each CO reading ≤11 ppm. Sixty-eight percent of subjects initiated abstinence. Of the breath samples collected during the abstinence test (91% of scheduled samples), 96.5% were ≤11 ppm and 80.5% were ≤8 ppm. Subjects who earned more money during the cutdown test were more likely to abstain (r = ?0.51, p < .001). Contingent reinforcement and intensive monitoring procedures appear to have usefulness for analog studies of smoking reduction and cessation.     

Technology‐based contingency management and e‐cigarettes during the initial weeks of a smoking quit attempt

Contingency management (CM) interventions are among the most effective behavioral interventions for smoking. This study assessed the effects of CM and electronic cigarettes (ECs) on smoking reductions and abstinence for durations of 30‐36 days. Twelve participants were exposed to Baseline, EC alone, and EC + CM conditions. An internet‐based platform was used to monitor smoking via breath carbon monoxide (CO) and deliver CM for smoking abstinence (CO ≤4 ppm). A Bluetooth‐enabled EC monitored daily EC puffs. Abstinence rates were equivalent between EC (34.4%) and EC + CM (30.4%) conditions. Both conditions promoted smoking reductions. We observed an inverse correlation between smoking and EC puffs (r = ‐.62, p < .05). Results suggest the use of electronic cigarettes can promote smoking reductions and abstinence, and CM did not improve these outcomes. Larger magnitude consequences or tailoring EC characteristics (e.g., flavor) may have improved outcomes. Technology‐based methods to collect intensive, longitudinal measures of smoking and electronic cigarette use may be useful to characterize their environmental determinants.     

Effects of biochemical validation of self-reported cigarette smoking on treatment success and on misreporting abstinence

Many investigators have reported that cigarette smokers who are trying to quit often falsely report being abstinent at the end of treatment. Unfortunately, much of the previous research designed to investigate this problem has been flawed, making the results difficult to interpret. We attempted to avoid these flaws and to investigate the measurement of alveolar carbon monoxide (CO) levels to validate self-reported smoking rates at the end of treatment. Participants in behavioral cessation clinics were randomly assigned to one of three conditions that varied in timing of exposure to information regarding CO measurement: at the beginning of treatment (demonstration of CO measurement, discussion of smoking effects on CO levels, and notification that individual CO levels would be measured at the conclusion of the clinic), at the end of treatment (demonstration, discussion, and notification of CO measurement prior to self-reports of smoking levels), or at the end of treatment (demonstration and discussion of CO measurement subsequent to self-reports of smoking levels). CO levels of all participants were measured at the end of treatment after they reported their current smoking levels. Only 16% of self-reports of abstinence were not verified by CO measurement. Smokers who observed the CO demonstration at the beginning of treatment were significantly more likely than the other two groups to achieve abstinence at the end of treatment and significantly less likely to misreport abstinence. Clinical and research implications of these results are discussed.     

A randomized controlled trial of contingency management for smoking cessation in substance use treatment patients

Background/ObjectiveContingency management (CM) is one of the most effective interventions for smokers with substance use disorder (SUD), and no empirical assessment of its long-term efficacy has been conducted so far in a real-world context. The objectives were: (1) examine the additive effectiveness of CM on cognitive-behavioral treatment (CBT) for smoking cessation, and (2) examine the relationship between smoking cessation and substance use abstinence.MethodA total of 80 participants (75.8% males; M_age = 45.31; SD = 9.64) were assigned to two smoking cessation treatments: CBT or CBT+CM. A set of generalized estimating equations were conducted to examine the effect of treatment condition on smoking outcomes, as well as the effect of smoking status on substance abstinence.ResultsAdding CM to CBT for smoking cessation improved tobacco abstinence rates at the end-of-treatment (p = .049). Tobacco abstinence rates declined over time (p = .012), but no significant effects of treatment condition were observed across follow-ups (p = .260). Smoking cessation was not significantly related to substance abstinence (p ≥ .488).ConclusionsCM facilitates early abstinence in smokers with SUD, although effects subside after treatment termination. The lack of association between smoking abstinence and substance use suggests no jeopardizing effects as a result of quitting smoking.     

Attendance Rates in A Workplace Predict Subsequent Outcome of Employment-Based Reinforcement of Cocaine Abstinence in Methadone Patients

This study assessed whether attendance rates in a workplace predicted subsequent outcome of employment-based reinforcement of cocaine abstinence. Unemployed adults in Baltimore methadone programs who used cocaine (N  =  111) could work in a workplace for 4 hr every weekday and earn $10.00 per hour in vouchers for 26 weeks. During an induction period, participants provided urine samples but could work independent of their urinalysis results. After the induction period, participants had to provide urinalysis evidence of cocaine abstinence to work and maintain maximum pay. A multiple regression analysis showed that induction period attendance was independently associated with urinalysis evidence of cocaine abstinence under the employment-based abstinence reinforcement contingency. Induction period attendance may measure the reinforcing value of employment and could be used to guide the improvement of employment-based abstinence reinforcement.     

CONTINGENCY MANAGEMENT PROMOTES SMOKING REDUCTIONS IN RESIDENTIAL SUBSTANCE ABUSE PATIENTS

Rates and consequences of cigarette smoking are more severe in substance abusers. In this 12‐week pilot study, residential substance abuse treatment patients received standard care for smoking cessation (n = 12) or prize contingency management (n = 12) for expired carbon monoxide (CO) tests ≤ 8 ppm and salivary cotinine < 10 ng/ml, which are indicative of smoking abstinence. Percentage of negative CO tests and the highest number of consecutive negative CO tests were greater in contingency management compared to standard care.     

VOUCHER‐BASED CONTINGENT REINFORCEMENT OF SMOKING ABSTINENCE AMONG METHADONE‐MAINTAINED PATIENTS: A PILOT STUDY

This study evaluated the efficacy of a contingency management (CM) intervention to promote smoking cessation in methadone‐maintained patients. Twenty participants, randomized into contingent (n = 10) or noncontingent (n = 10) experimental conditions, completed the 14‐day study. Abstinence was determined using breath carbon monoxide and urine cotinine levels. Contingent participants received voucher‐based incentives for biochemical evidence of smoking abstinence. Noncontingent participants earned vouchers independent of smoking status. Contingent participants achieved significantly more smoking abstinence and longer durations of continuous smoking abstinence than did noncontingent participants. These results support the potential efficacy of using voucher‐based CM to promote smoking cessation among methadone‐maintained patients.     

mMotiv8: A smartphone‐based contingency management intervention to promote smoking cessation

Cigarette smoking is the leading preventable cause of death and illness in the United States. We tested the usability, acceptability, and efficacy of a smartphone‐based contingency management treatment to promote cessation. We used a nonconcurrent multiple‐baseline design. Participants (N = 14) provided breath carbon monoxide (CO) samples by using a CO meter that was connected to the user's smartphone. An app (mMotiv8) housed on participants' smartphones automatically captured pictures of the CO sampling procedure to validate the end user's identity, and it prompted submissions via a push message delivered to participants' smartphones. Participants earned a $10 incentive for daily abstinence, which was added to a reloadable debit card. Overall, 4% of the CO samples were negative during baseline, and 89% were negative during treatment. Self‐reported usability and acceptability were high, and 85% of the prompted samples were submitted. A smartphone intervention could be scalable and reduce the health consequences and costs associated with cigarette smoking, particularly in rural and low‐income populations.     

Positive psychotherapy for smoking cessation: Treatment development,feasibility, and preliminary results

Low positive and high negative affect (NA) predict low rates of smoking abstinence among smokers making a quit attempt. Positive psychotherapy can both increase positive affect (PA) and decrease NA and, therefore, may be a useful adjunct to behavioral smoking counseling. The purpose of the present study was to assess the feasibility and acceptability of a positive psychotherapy for smoking cessation (PPT-S) intervention that integrates standard smoking cessation counseling with nicotine patch and a package of positive psychology interventions. We delivered PPT-S to 19 smokers who were low in PA at baseline. Rates of session attendance and satisfaction with treatment were high, and most participants reported using and benefiting from the positive psychology interventions. Almost one-third of the participants (31.6%) sustained smoking abstinence for six months after their quit date. Future studies to assess the relative efficacy of PPT-S compared to standard smoking cessation treatment are warranted.     

A randomized trial of employment-based reinforcement of cocaine abstinence in injection drug users

High-magnitude and long-duration abstinence reinforcement can promote drug abstinence but can be difficult to finance. Employment may be a vehicle for arranging high-magnitude and long-duration abstinence reinforcement. This study determined if employment-based abstinence reinforcement could increase cocaine abstinence in adults who inject drugs and use cocaine during methadone treatment. Participants could work 4 hr every weekday in a workplace where they could earn about $10.00 per hour in vouchers; they were required to provide routine urine samples. Participants who attended the workplace and provided cocaine-positive urine samples during the initial 4 weeks were invited to work 26 weeks and were randomly assigned to an abstinence-and-work (n = 28) or work-only (n = 28) group. Abstinence-and-work participants had to provide urine samples showing cocaine abstinence to work and maintain maximum pay. Work-only participants could work independent of their urinalysis results. Abstinence-and-work participants provided more (p = .004; OR = 5.80, 95% CI = 2.03-16.56) cocaine-negative urine samples (29%) than did work-only participants (10%). Employment-based abstinence reinforcement can increase cocaine abstinence.     

Pilot Cases of Combined Cognitive Processing Therapy and Smoking Cessation for Smokers With Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) and smoking are often comorbid, and both problems are in need of improved access to evidence-based treatment. The combined approach could address two high-priority problems and increase patient access to both treatments, but research is needed to determine whether this is feasible and has promise for addressing both PTSD and smoking.We collected data from 15 test cases that received a treatment combining two evidence-based treatments: cognitive processing therapy–cognitive version (CPT-C) for PTSD and integrated care for smoking cessation (ICSC). We explored two combined treatment protocols including a brief (six-session) CPT-C with five follow-up in-person sessions focused on smoking cessation (n = 9) and a full 12-session CPT-C protocol with ICSC (n = 6). The combined interventions were feasible and acceptable to patients with PTSD making a quit attempt. Initial positive benefits of the combined treatments were observed. The six-session dose of CPT-C and smoking cessation resulted in 6-month bioverified smoking abstinence in two of nine participants, with clinically meaningful PTSD symptom reduction in three of nine participants. In the second cohort (full CPT-C and smoking treatment), both smoking and PTSD symptoms were improved, with three of six participants abstinent from smoking and four of six participants reporting clinically meaningful reduction in PTSD symptoms. Results suggested that individuals with PTSD who smoke are willing to engage in concurrent treatment of these problems and that combined treatment is feasible.     

Patient-Informed Treatment Development of Behavioral Smoking Cessation for People With Schizophrenia

The objective of this study was to use qualitative methodology to tailor and refine an existing smoking cessation intervention for the population of people who use cigarettes and are diagnosed with schizophrenia, schizoaffective, or psychotic disorder. Successive cohort design methodology was used to iteratively modify the treatment in response to qualitative participant, therapist, and consultant feedback on the intervention. Qualitative methodology for participant feedback included analysis of semistructured interviews with participants, visualization of app utilization data, and stakeholder feedback from study therapists and consultants. Using the successive cohort design, a tailored multicomponent mobile health smoking cessation intervention was developed. The intervention included mobile contingency management (i.e., financial compensation for confirmed abstinence from smoking), pharmacotherapy for smoking cessation, cognitive-behavioral counseling sessions, and the Stay Quit app for relapse prevention. Two cohorts (N = 13) were completed in the study; after each cohort, the treatment protocol was revised. The intervention is described, as well as the qualitative findings from each cohort and subsequent changes made to the intervention based upon patient and provider feedback. Metrics of patient engagement included treatment adherence (40% in Cohort 1 and 63% in Cohort 2). Both participants and therapists reported that the intervention was helpful. Over one third of participants self-reported abstinence at posttreatment. Since qualitative methodology is often underutilized in mental health treatment development, this study demonstrates the utility of the successive cohort design for treatment development of behavior change interventions for at-risk, vulnerable populations.     

Demonstration of an Integrated Treatment for Smoking Cessation and Anxiety Symptoms in People With HIV: A Clinical Case Study

Despite high rates of co-occurring tobacco use and anxiety symptoms and disorders among persons with HIV, evidence-based interventions for these individuals are not yet available. The present study sought to evaluate an integrated treatment model addressing smoking cessation and anxiety sypmtoms among HIV-positive smokers. Treatment was an 8-week intervention integrating a standard smoking cessation protocol (i.e., cognitive-behavioral therapy [CBT], nicotine replacement therapy) with CBT for anxiety. Inclusion criteria were 18–65 years of age, ≥ 10 cigarettes/day, State–Trait Anxiety Inventory [STAI-T] score of > 39, and moderate motivation (i.e., ≥ 5 out of 10 on a 10-point Likert scale) to quit smoking. Primary outcomes included scores on the Anxiety Sensitivity Index (ASI) and cigarettes smoked per day. Self-reported abstinence was biochemically verified by carbon monoxide breath analysis. Three male participants (mean age 49.3, SD = 9.1) completed through 2-month follow-up. At baseline all participants reported smoking an average of 20 cigarettes per day. Two participants quit smoking and maintained abstinence by the 2-month follow-up, and demonstrated a reduction in ASI scores. Participant 3 continued to smoke but at a reduced rate. Participants’ response to cognitive and behavioral strategies (e.g., creating balanced thoughts, interoceptive exposures) will be discussed. Clinical lessons learned include use of a flexible approach to cognitive restructuring, use of imaginal and in vivo exposures in session to better prepare patients for homework practice, and flexibility in delivering the treatment in an individual or group format. This clinical presentation provides preliminary support for the feasibility and initial effectiveness of an integrated treatment to reduce anxiety symptoms and aid in smoking cessation in anxious, HIV-positive smokers.     

Immediate carbon monoxide estimates and self-reported smoking

Because carbon monoxide (CO) is an easily understood danger of cigarette smoking, new breath CO analyzers may be useful in cessation programs. Self-reported cigarette consumption and breath CO correlated .70 using a 90-sec. CO-determination method. Smokers averaging 17 daily cigarettes had average breath CO of 24 parts per million (ppm), falling to 7.71 ppm for smokers claiming at least 24-hr. abstinence. Corresponding carboxyhemoglobin (COHb) estimates were 4.34% (slightly above World Health Organization 4% safety limit) and 1.39%. Smoking clinics can use CO-monitoring devices for feedback or surveillance, although feedback would provide the most benefits for participants.     

Comparing intervention outcomes in smokers treated for single versus multiple behavioral risks.

This study examined treatment outcomes among smokers with single versus multiple behavioral risks. Data were drawn from smokers (N = 2,326) participating in 3 population-based, multibehavioral studies targeting cigarette smoking, high-fat diets, and high-risk sun exposure. Outcomes were compared for participants at risk for smoking only (13%), smoking plus 1 additional risk factor (37%), and smoking plus 2 additional risk factors (50%). The smoking only group tended to be female, older, more educated, lighter smokers, in the preparation stage of change for smoking, with more previous quit attempts and longer periods of abstinence. At 12 and 24 months follow-up, treatment of 1 or 2 coexisting risk factors did not decrease the effectiveness of smoking cessation treatment, and treatment for the coexisting factors was effective.     

Self-efficacy,nicotine-fading/self-monitoring and cigarette-smoking behaviour

An attempt to replicate and extend the successful results of Foxx and Brown's (1979) nicotine-fading, self-monitoring procedure for smoking abstinence or controlled smoking was undertaken using a combination of their procedure and cognitive-behavioural interventions. The latter consisted of: (1) a variation of Meichenbaum's (1977) self-instructional training and (2) a simple, direct manipulation of Bandura's (1977) concept of self-efficacy. Evidence was found to support Foxx and Brown's (1979) procedure with respect to reduced smoking rate and nicotine/tar intake. Combinations of treatments did not result in an enhancement of these effects. However, with respect to smoking abstinence, comparable results were only found in groups receiving specific training in self-efficacy. It was suggested that the variability of findings in this study as well as those in the literature subsequent and relating to Foxx and Brown's (1979) procedure might be accounted for using Bandura's (1977) self-efficacy concept.