The primary goal of the study is to evaluate the effectiveness of a combined tele-health and contingency management (CM) intervention that the investigators call mobile CM, or mCM, in promoting smoking abstinence in US Veterans. The mCM intervention will combine a mobile system to reward non-smoking, smoking cessation counseling, and smoking cessation medications. The primary aim is to evaluate how effective this intervention is in promoting smoking abstinence compared to telehealth interventions for smoking cessation.
Despite recent efforts to expand reach of smoking cessation treatment options beyond clinic based care, smoking cessation treatment including the use of smoking cessation aids remain greatly underutilized. If cessation programs are to have significant impact (Impact = Reach X Efficacy) on changing health behavior at the population level, there is a fundamental need to develop new and innovative strategies to increase treatment intensity, access, and participation. The use of intensive behavioral therapies, such as contingency management (CM), have demonstrated efficacy for reducing smoking in difficult-to-treat populations, but have had limited reach given the need to verify abstinence multiple times daily via clinic based monitoring. The development of a mobile health (mHealth) platform to provide CM has made the use of intensive CM approaches portable and feasible. The primary goal of the current study is to evaluate the effectiveness of a proactive tele-health intervention that combines evidenced based treatment for smoking cessation with smartphone based, portable contingency management on smoking rates. The central hypothesis is that increasing the intensity of available tele-health smoking approaches through the addition of mobile CM will be an effective way to reduce smoking rates in Veterans returning from the Iraq/Afghanistan wars. Guided by strong preliminary data, this hypothesis will be tested in a comparative effectiveness trial with a two-group design in which 260 Veteran smokers will be randomized to receive either an "mCM" intervention which combines evidence-based cognitive-behavioral telephone counseling (TC), a tele-medicine clinic for access to nicotine replacement (NRT), and mCM administered through a smart phone or to a control condition that will provide controls for therapist, medication, time and attention effects. Specific aims are to evaluate (1) the impact of mCM on rates of abstinence from cigarettes as measured by bio-verified, self-reported prolonged abstinence at 3-month, 6-month, and 12 month post-randomization follow-up, (2) the relative cost-effectiveness of the mCM intervention in quality adjusted life years (QALY), and (3) potential treatment mediators including self-efficacy and treatment process mechanisms. The approach is innovative because it builds upon advances in mHealth technology and will be the first evaluation of smart phone based mobile CM in conjunction with other evidence-based smoking cessation treatment for OEF/OIF/OND Veterans. There is a surprising lack of research aimed at evaluating multi-component smoking cessation interventions that integrate CM with evidence-based cognitive-behavioral treatment and smoking cessation aids such as NRT. Cigarette smoking remains the most lethal substance use disorder in the United States and military veterans are at particular high risk for smoking related morbidity and mortality. The significance of identifying cost-effective approaches to decreasing tobacco use in the relatively young and at-risk cohort of returning Veterans could be tremendous as it will prevent significant morbidity and mortality.
Participants will be prescribed one form of nicotine replacement "rescue" treatment (i.e., gum, lozenge), and may choose nicotine gum as the preferred "rescue" treatment. Participants will be instructed to use the rescue method as needed during the post-quit phase of the study to reduce cigarette cravings.
Participants will be asked to provide video recordings of themselves taking carbon monoxide readings in order to confirm smoking abstinence. Participants are asked to upload these videos to the study's secured server, and are provided reinforcement for videos that suggest smoking abstinence.
Participants receive five sessions of cognitive-behavioral telephone counseling, and a participant manual. The telephone counseling protocol included in this application is based on standard cognitive-behavioral therapy techniques shown to be efficacious for smoking cessation and is informed by behavioral treatment principles .
Duke University Medical Center
Durham, North Carolina, United States
smoking, self-report
Participants' self-report of smoking in the past seven days will be measured at 6-month follow-up study visit.
Time frame: 6 month follow-up (6 months post-quit attempt)
saliva cotinine
For participants reporting smoking abstinence at 6-months post treatment follow-up, the investigators will bio-verify smoking abstinence by collecting saliva samples that will be used to determine salivary cotinine levels.
Time frame: 6 month follow-up (6 months post-quit attempt)
smoking, self-report
Participants' self-report of smoking in the past seven days will be measured at approximately eight weeks after the participant's initial smoking quit attempt.
Time frame: Approx. ten weeks after enrollment (i.e., eight weeks after smoking quit attempt)
saliva cotinine
For participants reporting smoking abstinence eight weeks after their smoking quit attempt, the investigators will bio-verify smoking abstinence by collecting saliva samples that will be used to determine salivary cotinine levels.
Time frame: Approx. ten weeks after enrollment (i.e., eight weeks after smoking quit attempt)
smoking, self-report
Participants' self-report of smoking in the past seven days will be measured at 3-month follow-up study visit.
Time frame: 3 month follow-up (3 months post-quit attempt)
saliva cotinine
For participants reporting smoking abstinence at the 3-month follow-up contact, the investigators will bio-verify smoking abstinence by collecting saliva samples that will be used to determine salivary cotinine levels.
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Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
291
Participants will be prescribed nicotine patches to be used during the post-quit phase of the study.
Participants will be prescribed one form of nicotine replacement "rescue" treatment (i.e., gum, lozenge), and may choose nicotine lozenge as the preferred "rescue" treatment. Participants will be instructed to use the rescue method as needed during the post-quit phase of the study to reduce cigarette cravings.
Participants in the experimental condition will be loaned a smart phone to use during the mobile contingency management intervention period. The phone will be used to record videos of carbon monoxide readings to determine smoking abstinence.
Participants in the experimental condition will be loaned a CO monitor to use during the mobile contingency management intervention period. The monitor will be used to determine carbon monoxide content in the breath as a measurement of smoking.
Time frame: 3 month follow-up (3 months post-quit attempt)