A contingency-management intervention to promote initial smoking cessation among opioid-maintained patients.

Prevalence of cigarette smoking among opioid-maintained patients is more than threefold that of the general population and associated with increased morbidity and mortality. Relatively few studies have evaluated smoking interventions in this population. The purpose of the present study was to examine the efficacy of contingency management for promoting initial smoking abstinence. Forty methadone- or buprenorphine-maintained cigarette smokers were randomly assigned to a contingent (n = 20) or noncontingent (n = 20) experimental group and visited the clinic for 14 consecutive days. Contingent participants received vouchers based on breath carbon monoxide levels during Study Days 1 to 5 and urinary cotinine levels during Days 6 to 14. Voucher earnings began at $9.00 and increased by $1.50 with each subsequent negative sample for maximum possible of $362.50. Noncontingent participants earned vouchers independent of smoking status. Although not a primary focus, participants who were interested and medically eligible could also receive bupropion (Zyban). Contingent participants achieved significantly more initial smoking abstinence, as evidenced by a greater percentage of smoking-negative samples (55% vs. 17%) and longer duration of continuous abstinence (7.7 vs. 2.4 days) during the 2 week quit attempt than noncontingent participants, respectively. Bupropion did not significantly influence abstinence outcomes. Results from this randomized clinical trial support the efficacy of contingency management interventions in promoting initial smoking abstinence in this challenging population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contingency management for smoking cessation in adolescent smokers.

This pilot study evaluated the use of contingency management (CM) procedures in combination with cognitive-behavioral therapy (CBT) for smoking cessation in adolescents. Twenty-eight treatment-seeking adolescent smokers participated in a 1-month, school-based smoking cessation program and were randomly assigned to receive either CM with weekly CBT or CBT alone. In the CM+CBT group, biochemical verification of abstinence was obtained twice daily during the first 2 weeks, followed by daily appointments during the 3rd week and once every other day during the 4th week. Participants were monetarily reinforced for abstinence on an escalating magnitude schedule with a reset contingency. At the end of 1 week and 1 month of treatment, abstinence verified using quantitative urine cotinine levels was higher in participants in the CM+CBT group (1 week: 76.7%; 1 month: 53.0%) when compared with the CBT-alone group (1 week: 7.2%; 4 weeks: 0%). These preliminary results provide a strong initial signal supporting the utility of CM techniques for smoking cessation in adolescents and demonstrate the feasibility of implementing such a program in a school setting. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contingency management to enhance naltrexone treatment of opioid dependence: A randomized clinical trial of reinforcement magnitude.

Fifty-five detoxified opioid-dependent individuals were randomly assigned to 1 of 3 treatments delivered over 12 weeks: standard naltrexone maintenance, standard naltrexone plus low-value contingency management (CM), or standard naltrexone plus high-value CM. Results suggest that (a) assignment to either CM condition was associated with significant reductions in opioid use over time compared with standard naltrexone treatment; (b) contrasts of high- versus low-value reinforcement magnitude were not significant, suggesting no relative benefit of higher over lower value incentives in this population; (c) participants assigned to either CM group reported significant reductions in readiness to change compared with participants assigned to standard naltrexone treatment. These findings suggest that targeted behavioral therapies can play a substantial role in broadening the utility of available pharmacotherapies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Shaping smoking cessation in hard-to-treat smokers.

Objective: Contingency management (CM) effectively treats addictions by providing abstinence incentives. However, CM fails for many who do not readily become abstinent and earn incentives. Shaping may improve outcomes in these hard-to-treat (HTT) individuals. Shaping sets intermediate criteria for incentive delivery between the present behavior and total abstinence. This should result in HTT individuals having improving, rather than poor, outcomes. We examined whether shaping improved outcomes in HTT smokers (never abstinent during a 10-visit baseline). Method: Smokers were stratified into HTT (n = 96) and easier-to-treat (ETT [abstinent at least once during baseline]; n = 50) and randomly assigned to either CM or CM with shaping (CMS). CM provided incentives for breath carbon monoxide (CO) levels OR = 42, 95% CI [5.9, 307]) than with CMS, in which the difference between HTT and ETT participants was not significant. Assignment to CMS predicted membership in the improving (p = .002) as compared with the poor outcomes cluster. Conclusion: Shaping can increase CM’s effectiveness for HTT smokers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Motivational interviewing for smoking cessation: A meta-analytic review.

Objective: Motivational interviewing (MI) is a treatment approach that has been widely examined as an intervention for tobacco dependence and is recommended in clinical practice guidelines. Previous reviews evaluating the efficacy of MI for smoking cessation noted effects that were modest in magnitude but included few studies. The current study is a comprehensive meta-analysis of MI for smoking cessation. Method: The meta-analysis included 31 controlled trials with an abstinence outcome variable. Studies with nonpregnant (N = 23) and pregnant samples (N = 8) were analyzed separately. Results: For nonpregnant samples, combined results suggest that MI significantly outperformed comparison conditions at long-term follow-up points (dc = .17). The magnitudes of this result represented a 2.3% difference in abstinence rates between MI and comparison groups. All analyses investigating the impact of moderating participant, intervention, and study design characteristics on outcome were nonsignificant, with the exception of studies including international, non-U.S. samples, which had larger effects overall. Several subgroups of studies had significant combined effect sizes, pointing to potentially promising applications of MI, including studies that had participants with young age, medical comorbidities, low tobacco dependence, and, consistent with clinical practice guidelines, low motivation or intent to quit. Effects were smaller among pregnant samples. In addition, significant combined effect sizes were observed among subgroups of studies that administered less than 1 hr of MI and among studies that reported high levels of treatment fidelity. Conclusions: The results are interpreted in light of other behavioral approaches to smoking cessation, and the public health implications of the findings are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Motivation for smoking cessation among pregnant women.

The authors evaluated an expanded measure of intrinsic and extrinsic motivation for smoking cessation in a population-based sample of 897 pregnant smokers (500 current smokers and 397 recent quitters). The measure assessed motivation related to pregnancy and parenthood in addition to general intrinsic and extrinsic dimensions. Current smokers at baseline who quit smoking by 28 weeks of pregnancy (n?=?102) had significantly higher baseline levels of pregnancy-related motivation than continuing smokers. Extrinsic and pregnancy motivation dropped between baseline and 28 weeks of pregnancy among continuing smokers. Higher levels of intrinsic relative to extrinsic motivation at baseline were associated with sustained abstinence during the first 2 months postpartum. Results suggest that both general and pregnancy-specific motivation are important for smoking cessation and relapse prevention during pregnancy. Interventions to enhance the salience of health benefits over and above those related to pregnancy and other intrinsic benefits of a greater sense of self-control could protect against postpartum relapse. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contingency management in cocaine abusers: A dose-effect comparison of goods-based versus cash-based incentives.

Goods-based contingency management interventions (e.g., those using vouchers or prizes as incentives) have demonstrated efficacy in reducing cocaine use, but cost has limited dissemination to community clinics. Recent research suggests that development of a cash-based contingency management approach may improve treatment outcomes while reducing operational costs of the intervention. However, the clinical safety of providing cash-based incentives to substance abusers has been a concern. The present 16-week study compared the effects of goods-based versus cash-based incentives worth $0, $25, $50, and $100 on short-term cocaine abstinence in a small sample of cocaine-dependent methadone patients (N = 12). A within-subject design was used; a 9-day washout period separated each of 8 incentive conditions. Higher magnitude ($50 and $100) cash-based incentives (checks) produced greater cocaine abstinence compared with the control ($0) condition, but a magnitude effect was not seen for goods-based incentives (vouchers). A trend was observed for greater rates of abstinence in the cash-based versus goods-based incentives at the $50 and $100 magnitudes. Receipt of $100 checks did not increase subsequent rates of cocaine use above those seen in control conditions. The efficacy and safety data provided in this and other recent studies suggest that use of cash-based incentives deserves consideration for clinical applications of contingency management, but additional confirmation in research using larger samples and more prolonged periods of incentive delivery is needed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Extended treatment with bupropion SR for cigarette smoking cessation.

The authors present results of a randomized clinical trial of the efficacy of extended treatment with bupropion SR in producing longer term cigarette smoking cessation. Adult smokers (N = 362) received open-label treatment (11 weeks) that combined relapse prevention training, bupropion SR, and nicotine patch followed by extended treatment (14 weeks) with bupropion SR or matching placebo. Abstinence percentages were relatively high (week 11: 52%; week 25: bupropion, 42%; placebo, 38%; week 52: bupropion, 33%; placebo, 34%), but bupropion SR did not surpass placebo. Gender and baseline craving level were identified as significant, independent moderators of treatment response. Men were more likely to abstain than women (week 11: 59% vs. 43%, p = .001; week 25: 48% vs. 31%, p = .001; week 52: 39% vs. 27%, p = .01). Because most smokers suffer relapse with any current cessation treatment, the comparatively high abstinence percentages achieved in this trial are of interest. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive–behavioral therapy to promote smoking cessation among African American smokers: A randomized clinical trial.

Objective: The health consequences of tobacco smoking disproportionately affect African Americans, but research on whether efficacious interventions can be generalized to this population is limited. This study examined the efficacy of group-based cognitive–behavioral therapy (CBT) for smoking cessation among African Americans. Method: Participants (N = 154; 65% female, M = 44 years old, mean cigarettes/day = 13) were randomly assigned to either (a) group CBT or (b) group general health education (GHE). Participants in both conditions received 6 sessions of counseling and 8 weeks of transdermal nicotine patches. The primary outcome variable was 7-day point prevalence abstinence (ppa), assessed at the end of counseling (2 weeks) and at 3- and 6-month follow-ups. Secondary outcomes included 24-hr ppa and 28-day continuous abstinence (assessed at 3 and 6 months). Results: Intent-to-treat analyses demonstrated the hypothesized effects, such that 7-day ppa was significantly greater in the CBT than the GHE condition at the end of counseling (51% vs. 27%), at 3 months (34% vs. 20%), and at 6 months (31% vs. 14%). Results of a generalized linear mixed model demonstrated a significant effect of CBT versus GHE on 7-day ppa (odds ratio = 2.57, 95% CI [1.40, 4.71] and also an effect of time (p     

Monetary incentives promote smoking abstinence in adults with attention deficit hyperactivity disorder (ADHD).

Individuals with attention deficit hyperactivity disorder (ADHD) smoke at rates significantly higher than the general population and have more difficulty quitting than nondiagnosed individuals. Currently, there are no evidence-based approaches for reducing smoking specifically in individuals with ADHD. Adult regular smokers with or without ADHD participated in a study of extended smoking withdrawal where monetary incentives were used to promote abstinence. Participants were paid according to an escalating schedule for maintaining abstinence measured as self-report of no smoking and an expired air carbon monoxide (CO) level of ≤4 parts per million. Sixty-four percent (14/22) of smokers with ADHD and 50% (11/22) of smokers without ADHD maintained complete abstinence for the 2-week duration of the study. Twenty-two percent (5/22) and 9% (2/22) of smokers with ADHD and without ADHD, respectively, maintained continued abstinence for up to 10 days following the removal of the contingencies. Though abstinence rates were higher for the smokers with ADHD, the group differences were not statistically significant. Results suggest that monetary incentives may be a useful approach for promoting abstinence in adult smokers with ADHD, perhaps owing to altered reinforcement processes in these individuals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparable efficacy of contingency management for cocaine dependence among African American, Hispanic, and White methadone maintenance clients.

Cocaine use is a significant problem among methadone maintenance clients. Contingency management (CM) is a reinforcement-based approach with demonstrated efficacy for reducing cocaine use. This study examines whether the efficacy of CM treatment for cocaine-dependent individuals receiving methadone maintenance for opioid dependence differs by ethnicity. Participants were 191 African American, Hispanic, and White cocaine-dependent methadone maintenance clients, randomly assigned to standard methadone treatment or standard methadone treatment plus CM for 12 weeks. Hispanic participants were younger, less educated, and reported fewer years of cocaine use than did African American and White participants and reported fewer years of heroin use than did African American participants. African American participants were less likely to report a history of psychiatric symptoms or treatment in comparison with Hispanic and White participants. While CM was associated with longer duration of continuous cocaine abstinence and a greater proportion of submitted urine samples negative for cocaine, ethnicity was not related to treatment outcomes, and there was no significant interaction between treatment and ethnicity. CM appears to be an efficacious treatment for cocaine dependence among methadone maintenance clients, regardless of ethnicity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prize Reinforcement Contingency Management for Cocaine Dependence: Integration With Group Therapy in a Methadone Clinic.

In this study, the authors evaluated a low-cost contingency management (CM) procedure for reducing cocaine use and enhancing group therapy attendance in 77 cocaine-dependent methadone patients. Patients were randomly assigned to 12 weeks of standard treatment or standard treatment with CM, in which patients earned the opportunity to win prizes ranging from $1 to $100 for submitting cocainenegative samples and attending therapy. Patients in the CM condition submitted more cocaine-negative samples and attended more groups than patients in standard treatment. The best predictor of cocaine abstinence at follow-up was duration of abstinence during treatment. On average, patients in the CM condition earned $117 in prizes. Data from this study suggest that some aspects of reinforcement can be implemented in group therapy in community-based clinics. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pretreatment task persistence predicts smoking cessation outcome.

R. Eisenberger's (1992) learned industriousness theory states that individuals display differing degrees of persistence depending on their history of reinforcement for effortful behavior. These differences may influence the development, maintenance, and cessation of addictive behaviors. In cross-sectional studies, E. P. Quinn, T. H. Brandon, and A. L. Copeland (1996) found that cigarette smokers were less persistent than nonsmokers, and R. A. Brown, C. W. Lejuez, C. W. Kahler, and D. R. Strong (2002) found that smokers who had previously abstained for 3 months were more persistent than those who had never quit. The present study extended these findings by using a prospective design. A pretreatment measure of task persistence (mirror tracing) completed by 144 smokers predicted sustained abstinence throughout 12 months of follow-up. Moreover, persistence predicted outcome independent of other significant predictors: gender, nicotine dependence, negative affect, and self-efficacy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Self-efficacy and smoking cessation: A meta-analysis.

According to relapse models, self-efficacy (SE), or confidence in one's ability to abstain, should predict the outcome of an attempt to quit smoking. We reviewed 54 studies that prospectively examined this relationship. The relationship between SE and future smoking depended upon the population studied and the timing of the SE assessment. The relationship between SE and future smoking was modest when SE was assessed prior to a quit attempt; SE scores were .21 standard deviation units (SD) higher for those not smoking at follow-up than for those who were smoking. The relationship was stronger (.47 SD) when SE was assessed post-quit. However, this effect was diminished when only abstainers at the time of the SE assessment were included in analysis (.28 SD). Controlling for smoking status at the time of SE assessment substantially reduced the relationship between SE and future smoking. Although SE has a reliable association with future abstinence, it is less robust than expected. Many studies may overestimate the relationship by failing to appropriately control for smoking behavior at the time of the SE assessment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship between in-treatment abstinence and post-treatment abstinence in a smoking cessation treatment.

Previous research has indicated that abstinence early in a smoking cessation program is predictive of successful posttreatment abstinence. However, it has not been established whether or not this effect is independent of other in-treatment abstinence patterns. In this paper the relationship between three potentially important aspects of in-treatment smoking abstinence and posttreatment smoking abstinence are examined: early abstinence, extended abstinence, and end-of-treatment abstinence. We examined the relationship between smoking behavior measured each weekday over 70 visits (approximately 14 weeks) of a contingency management smoking cessation program and at a follow-up visit 6 months after study entry (3 months after the scheduled end of treatment). Ninety-five of 102 participants were successfully followed-up. Seven of these 95 participants were confirmed abstinent. Early abstinence, defined as abstinence during the first 10 treatment visits, was significantly and independently related to follow-up abstinence (OR = 56.67 [7.29–440.63]). Extended abstinence and end-of-treatment abstinence were related to follow-up abstinence, but not independent of early abstinence based on multiple regression models. Inclusion of a variety of demographic and environmental characteristics did not significantly alter this relationship. Thus, consistent with the previous literature, the establishment of early abstinence appears to be crucial to establishing longer-term abstinence, independent of other in-treatment abstinence patterns. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Baseline reaction time predicts 12-month smoking cessation outcome in formerly depressed smokers.

Burgeoning evidence points to a positive association between cigarette smoking and depression. Moreover, depressive symptomatology, whether historical, current, or subsyndromal, appears to negatively influence smoking cessation efforts. Whereas depression is typically assessed via clinical interview or self-report, rarely are the known neurocognitive deficits linked to depression (e.g., global slowing) assessed in the context of smoking cessation research. Hence, this study examined whether simple reaction time--color naming of affectively neutral words--is predictive of 12-month smoking cessation outcome among a sample of formerly depressed smokers (N = 28). Results revealed a significant, positive correlation between reaction time and depressive symptoms such that those who exhibited slower reaction times were at heightened risk to relapse. Baseline depressive symptoms, as assessed via self-report, neither correlated with nor predicted smoking cessation outcome. Results from logistic regression analyses further showed that reaction time added incremental variance to the prediction of smoking cessation outcome. Therefore, simple reaction time may capture aspects of depression not typically assessed in self-report questionnaires. These results are discussed in terms of their theoretical and clinical implications for smoking cessation research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The use of contingency management to reduce cigarette smoking among college students.

The current study tested the feasibility of using contingency management to reduce cigarette smoking among college students. Eighty-eight undergraduate smokers were enrolled in a 3-week ABA study. During the baseline weeks, participants earned noncontingent monetary payments for attending data collection sessions. During the intervention week, participants earned monetary payments contingent on demonstrating recent abstinence. Participants were randomly assigned to either a low- or a high-reinforcer magnitude condition that controlled the amount of money that could be earned during the intervention week. Cigarette smoking was significantly reduced during the intervention week relative to the baseline weeks, and greater reductions were achieved under the high-reinforcer magnitude condition. These results suggest that cigarette smoking among college students is responsive to contingency management procedures. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evidence for clinical smoking cessation for adolescents.

Objective: This report reviews the evidence that informs the role of health and mental health care providers in addressing youth smoking cessation. Design: Qualitative literature review. Results: Physicians do not consistently screen adolescents for tobacco use and fail to provide recommended cessation advice. Challenges to addressing smoking cessation include the need for procedures to ensure confidentiality and the existence of competing demands to provide other services. Few published studies have specifically addressed the effectiveness of clinical interventions. Interventions that require return visits or follow-up phone contacts are technically difficult to implement in this population. Successful interventions may require resources not available in nonresearch settings. Most studies have used brief clinical intervention as a control condition, making it impossible to evaluate its effectiveness. Conclusion: There is little evidence that supports current clinical smoking cessation guidelines for adolescents. More research is needed to develop inexpensive, efficient clinical interventions that can provide youths access to smoking cessation help. Future challenges include reorganizing clinical systems to offer greater counseling by support staff or in electronic formats and to provide effective booster messages and follow-up care in a population that is difficult to track. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Implicit and explicit attitudes predict smoking cessation: Moderating effects of experienced failure to control smoking and plans to quit.

The current study tested implicit and explicit attitudes as prospective predictors of smoking cessation in a Midwestern community sample of smokers. Results showed that the effects of attitudes significantly varied with levels of experienced failure to control smoking and plans to quit. Explicit attitudes significantly predicted later cessation among those with low (but not high or average) levels of experienced failure to control smoking. Conversely, however, implicit attitudes significantly predicted later cessation among those with high levels of experienced failure to control smoking, but only if they had a plan to quit. Because smoking cessation involves both controlled and automatic processes, interventions may need to consider attitude change interventions that focus on both implicit and explicit attitudes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Specifying the determinants of the initiation and maintenance of behavior change: An examination of self-efficacy, satisfaction, and smoking cessation.

Using data from smokers (N = 591) who enrolled in an 8-week smoking cessation program and were then followed for 15 months, the authors tested the thesis that self-efficacy guides the decision to initiate smoking cessation but that satisfaction with the outcomes afforded by quitting guides the decision to maintain cessation. Measures of self-efficacy and satisfaction assessed at the end of the program, 2 months, and 9 months were used to predict quit status at 2, 9, and 15 months, respectively. At each point, participants were categorized as either initiators or maintainers on the basis of their pattern of cessation behavior. Across time, self-efficacy predicted future quit status for initiators, whereas satisfaction generally predicted future quit status for maintainers. Implications for models of behavior change and behavioral interventions are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)