Persons with either a mental disorder or substance abuse disorder (SUD) are twice as likely to smoke as those without (Lasser et al., 2000). Smokers with other drug addictions are heavier smokers (Hughes, 2002; Sobell, 2002), less successful in their attempts to quit smoking (Drobes, 2002; Joseph, Nichol, & Anderson, 1993), and experience greater tobacco-related mortality than the general population (SRNT Subcommittee on Biochemical Verification, 2002). Among individuals who abuse other substances, smoking prevalence is highest among those who received past year drug treatment, ranging from 72.6 percent to 74.5 percent from 2006 to 2011 (Guydish, Yu, Le, Pagano, & Delucchi, 2015).
Quitting smoking while in drug treatment does not jeopardize recovery from other drug use (Kalman, Kim, DiGirolamo, Smelson, & Ziedonis, 2010; Martin et al., 1997; Stuyt, 1997), and has been associated with improved drug use outcomes (Prochaska, Delucchi, & Hall, 2004; Tsoh, Chi, Mertens, & Weisner, 2011). However, smoking cessation interventions achieve only modest quit rates in this population. In general population smokers, smoking abstinence rates at six months were 14.6 percent for counseling interventions, 21.7 percent for medication interventions, and 27.6 percent for interventions using both approaches (Fiore et al., 2008). In comparison, a meta-analysis of studies of smokers who received addiction treatment reported 12 percent posttreatment smoking abstinence (Prochaska et al., 2004). Another review reported six-month tobacco abstinence rates from 2 percent to 18 percent in drug treatment samples (Baca & Yahne, 2009). So there is a need to improve smoking cessation interventions for persons in drug abuse treatment.
At least some smokers in drug abuse treatment are motivated to quit smoking. When asked directly, many clients express interest in quitting (Orleans & Hutchinson, 1993; Saxon, McGuffin, & Walker, 1997), and about half of smokers enrolled in addiction treatment have tried to quit within the past year (Martinez, Guydish, Le, Tajima, & Passalacqua, 2015). One way to improve smoking cessation in this population may be to increase motivation to quit, which for many is already present.
At least three approaches have been used to strengthen motivation to quit smoking. The expert system (ES; Velicer & Prochaska, 1999), an interactive system based on the transtheoretical model, tailors intervention to the smokers’ readiness to quit smoking. Readiness to quit is conceptualized in the stages of precontemplation (not thinking of quitting in the next six months), contemplation (thinking of quitting in the next six months), and preparation (thinking of quitting within the next thirty days). ES delivers a computer-generated feedback report with suggested actions based on individuals’ stages of change. ES has been effective in treating smokers at different stages of readiness to quit (Martinez et al., 2015; Velicer, Prochaska, & Redding, 2006; Velicer, Redding, Sun, & Prochaska, 2007) and in various settings (Hall et al., 2006; J. O. Prochaska et al., 2008).
A second approach is motivational incentives or external rewards contingent on goal-related behaviors. One study in residential addiction treatment provided incentives up to $10 for consecutive negative daily carbon monoxide (CO) tests. Smoking abstinence increased, but voucher costs averaged $526 per participant (Robles et al., 2005). In another study, prize draws escalated with consecutive negative COs, yielding more smoking reduction, but did not increase smoking cessation as compared to controls (Alessi, Petry, & Urso, 2008).
A third approach is the practice quit attempt, as a way to rehearse quitting smoking without the pressure of quitting for good. In a randomized trial, the practice quit attempt in conjunction with nicotine replacement therapy (NRT) achieved higher rates of making a quit attempt—49 percent versus 40 percent—compared to a practice quit attempt without NRT (Carpenter et al., 2011).
The pilot study reported here began in collaboration with HealthRIGHT 360 (HR360), a nonprofit agency providing behavioral health services to low income and uninsured Californians. HR360 program directors wanted to address smoking, but observed that patients were often not ready to quit. We developed a three-session smoking cessation readiness group using ES strategies combined with a practice quit attempt. The aim was to engage smokers in smoking cessation, and the primary outcome was initiation of smoking cessation services. Second, in a pilot randomized trial we assessed whether the addition of incentives for participation in the readiness group would improve initiation of smoking cessation services.
Programs and Participants
HR360 prioritized two women-focused residential programs for this study. One program served women paroling from state prisons who had substance abuse and trauma issues, some of whom were interested in reunifying with their children. The program had capacity to serve sixty-three adult women and fifteen children up to age twelve. The second program was a sixty-four-bed, gender-responsive, trauma-informed program with services designed to address substance use, trauma, mental illness, health and wellness, spirituality, family reunification, and employability. A third site housed a computer lab and group meeting space where most of the readiness groups and smoking cessation groups were held. Eligible participants were women in each of the residential programs who had been in treatment for at least two weeks, self-identified as current and daily smokers, were not pregnant, and were willing to participate in the readiness group.
Participants were enrolled in a total of twelve cohorts according to the time of enrollment. Cohorts were randomly assigned to either the incentive (n = 6 cohorts) or control (n = 6 cohorts) condition. Research staff, the readiness group leader, and clients were blinded to condition until baseline data collection was completed. The day before the readiness group was to begin, the group leader was informed of the condition. Participants learned of the group condition at the first session. Cohorts ranged in size from two to eleven, with a median of seven per cohort. Smoking behavior was measured in a pre-post design, before and after the readiness group.
The Readiness Group Intervention
Each participant completed a computerized ES assessment at baseline, and received a computer-generated personalized feedback report. The readiness group was designed to support participants in working through the ES personalized activities center (PAC) activities and resources. In many residential treatment programs, access to computers and phones is restricted for clinical reasons. For programs in this study, computer access required staff permission as well as coordination of the clients’ clinical schedules and computer availability. Given these considerations, the ES intervention was modified. The ES assessments at baseline and thirty days were completed by patients online. All other ES activities were conducted either in the readiness group or as homework between sessions, using paper printouts of PAC activities. Session one introduced handouts from PAC activities specific to each stage of change (e.g. “Take small steps,” “Change your image,” and “Overcome the cons” for the contemplation stage), and later sessions introduced PAC handouts that were relevant to all stages of change. The second purpose of the readiness group was to support participants in a quit attempt with NRT. Therefore, in addition to materials from ES, participants received handouts with NRT information and instructions.
Session one began with discussion of participant ES personalized feedback reports, including their stage of change for smoking cessation, and ES-recommended goals and strategies for change. NRT use was discussed as a resource for the practice quit attempt. Contraindications to NRT were discussed, preferences for product type were assessed (e.g., patch, gum or lozenges), and dosage was determined per package instructions. At the end of the session, participants were offered PAC activities handouts based on their stage of change, and each participant was asked to select three activities as homework.
In session two, the facilitator reviewed worksheet completion, then elicited discussion of the completed PAC activities. This session focused on preparation for the optional twenty-four-hour practice quit attempt. For homework, participants were asked to read NRT instructions for the type of NRT they requested, as well as PAC handouts on withdrawal symptoms and cravings. Because all medications are controlled in these programs, participants received NRT in an envelope and brought it to the program medication room for storage and distribution.
In session three, the facilitator reviewed homework, participants discussed their experiences with the practice quit attempt, and expired CO was measured for those who made a quit attempt. The group then completed the PAC handout entitled “One Hundred Benefits of Quitting” and discussed how to continue the change process after this final session. The facilitator provided information about the California Quitline, and about the optional smoking cessation group.
In addition to the readiness group components described above, participants in the incentive cohorts received a $5 gift card for participation in each session. In sessions two and three they also received a $5 gift card for completing homework, and a $10 gift card if they made a successful quit attempt. While the standard cutoff to establish smoking abstinence is < 8 parts per million (ppm; SRNT Subcommittee on Biochemical Verification, 2002), we used a relaxed cutoff (< 9 ppm) to define successful practice quit attempts. Participants who met all participation, homework, and quit attempt criteria received a $5 consistency bonus. The total possible incentive was $40 per participant.
The Smoking Cessation Group
The aim of the readiness group was to increase readiness to quit smoking, and the outcome was whether participants would initiate smoking cessation services. The study provided a four-session smoking cessation group based on Hall et al. (2002), in which participants develop a quit plan, monitor cigarette use and factors that trigger smoking, and develop relapse prevention skills. The intervention has been shown to increase cessation compared to brief advice and referral (Hall et al., 2002; Hall et al., 2006). Up to eight weeks of NRT was provided for each participant, and cessation groups were led by a psychologist who was not involved in the readiness group. Both the readiness group and the cessation group were conducted while participants were in residential treatment. Women who left treatment were contacted for follow up assessments, but could not continue participation in either group.
The primary outcome was whether participants did or did not initiate smoking cessation treatment, defined as attending at least one smoking cessation group. In addition, participants reported demographic characteristics and the number of weeks they had been in the treatment program. Participants also reported the number of cigarettes per day (CPD), and number of quit attempts in the past year. The heaviness of smoking index (HSI) was included as a measure of nicotine dependence (Borland, Yong, O’Connor, Hyland, & Thompson, 2010).
Readiness to quit smoking was assessed using the item: “Are you seriously thinking of quitting smoking?” Stage of change was categorized as precontemplation, contemplation, and preparation as previously described (DiClemente et al., 1991). Perceived health risks were assessed using the item: “Given your current smoking status (i.e., the amount you currently smoke), what is the chance (from 0 to 100 percent) that you will get lung cancer?” (Halpern-Felsher, Biehl, Kropp, & Rubinstein, 2004).
Expired CO was measured using the Bedfont Smokerlyzer CO monitor. At the end of the readiness group, seven-day point prevalence abstinence was determined by self-report and expired CO < 4 ppm, a stringent cutoff recommended to confirm recent smoking abstinence (Bandiera, Anteneh, Le, Delucchi, & Guydish, 2015).
At the start of each cohort, research team members met with participants as a group to complete informed consent and baseline measures. Participants then completed the online ES assessment. Following the three readiness group sessions (about thirty days after baseline), participants again completed the online ES assessment, the CO measure, and a follow-up survey. Participants were then asked if they were interested in the four-week smoking cessation group. Those expressing interest were given the time and location of the group, and a binder including cessation group materials.
We assessed whether readiness group attendance differed between incentive and control participants. We report the number of participants who made any practice quit attempt and the number who made a successful practice quit attempt during the readiness group. Using t-test and Chi Square analyses, we compared those who did and did not initiate smoking cessation services. Variables associated with initiating smoking cessation services at p < .10 were included in logistic regression models designed to test whether the number of readiness group sessions attended, and making a practice quit attempt, were independently associated with later attending the smoking cessation group. We report pre-post change in CPD, HIS, and stage of change for participants who completed thirty-day follow up. Last, we report seven-day point prevalence smoking abstinence for all participants at the end of the readiness group.
Participants were evenly assigned by cohorts to the control (n = 36) and incentive (n = 39) conditions. These two groups did not differ significantly on any demographic or smoking variables at baseline, suggesting that the two study groups were generally equivalent.
The Role of Incentives
For incentive participants (n = 39), the amount of incentives received ranged from $0 to $40, with a mean of $21.9 (SD = $14.76). The mean number of readiness group sessions attended was 2.0 (SD = 1.11) for control and 2.2 (SD = 1.19) for incentive participants, and this difference was not statistically significant. This suggests that the addition of incentives did not increase attendance to readiness groups.
Practice Quit Attempts
Overall, thirty-eight participants made a practice quit attempt. Of those, nineteen made a successful practice quit attempt defined as CO < 8 ppm at readiness group three (25 percent of all participants). The remaining nineteen participants registered CO readings > 9 ppm, suggesting they were not successful in quitting for twenty-four hours.
Initiating Smoking Cessation
After the readiness group, twenty-nine participants (38.7 percent) attended at least one session of the smoking cessation group. This proportion did not differ between incentive (30.8 percent) and control (44.2 percent) conditions. Although this difference may appear clinically meaningful, it was not statistically significant (p = 0.14). To identify factors that may be associated with attending the smoking cessation group, we compared baseline variables for those who did (n = 29) and did not attend (n = 46) at least one cessation group. Three variables met the p < .10 criteria:
- Participants attending the cessation group had been in treatment for more weeks on average than those not attending (8.9 weeks versus 5.7 weeks, p < .05)
- Participants attending the cessation group felt they had a higher mean chance of lung cancer than those not attending (66.2 percent versus 55.1 percent, p = .061)
- Those attending the cessation group attended more readiness groups on average (2.4 versus 1.8 groups, p < .05)
These three variables were entered into a regression controlling for age, race, education, and nesting within cohort, and including study condition (e.g., incentive versus control). The practice quit attempt was highly correlated with number of readiness group sessions attended (r = 0.47, p < .0001), because the practice quit attempt occurred after session two and success of the quit attempt was assessed in session three. This meant that participants who attended more readiness groups were much more likely to make a practice quit attempt. Because of this, practice quit attempt could not be entered into a single model together with number of readiness group sessions attended. To address this, we tested the association of readiness group attendance with the use of cessation services in one regression model, and then tested the association of practice quit attempt with use of cessation services in a second model.
In both of these regression analyses, having spent more weeks in the treatment program and having a higher perceived risk of lung cancer were modestly associated with attending the smoking cessation group. However, attending each additional readiness group session was associated with a doubling of the odds that participants would later attend the smoking cessation group (odds ratio [OR] = 2.23, 95 percent, confidence interval [CI] = 1.12 – 4.44). Making a successful practice quit attempt was also associated with higher odds of attending at least one smoking cessation group (OR = 6.78, CI 2.08 – 22.14).
Change in Smoking Behavior
Of seventy-five participants, sixty-one (81 percent) completed the thirty-day follow-up assessment. For these sixty-one participants, mean CPD decreased from before to after the readiness group (from 11.8 to 7.6 CPD, p < .0001), as did mean nicotine dependence as measured by the HSI (from 2.4 to 1.7, p < .0001). Of the sixty-one participants completing follow up, four reported having quit smoking at least seven days ago and registered expired CO < 4 ppm. Counting all others as smokers, this gives a 5.3 percent quit rate after the readiness group ended, but before the cessation group started.
The readiness intervention reported here represents the first combined use of the ES and practice quit attempt strategies among smokers enrolled in addiction treatment, and an early use of incentives to support attendance and participation rather than smoking cessation. Of seventy-five participants, twenty-nine (38.7 percent) initiated smoking cessation services. Interest in quitting smoking was not a requirement for participation. Half of the participants had made no quit attempt in the past year, at baseline, and one-fourth were not thinking of quitting smoking at all. In this context 38.7 percent attending smoking cessation groups appears substantial, but we acknowledge that over half of participants did not attend one smoking cessation group.
The hypothesis that incentives for participation in the readiness intervention would yield greater use of smoking cessation services was not supported. Incentives supporting readiness group participation were modest, and may have been too small to be effective. It is also possible that motivation as conceptualized by ES, or quitting rehearsal as conceptualized by the practice quit attempt, are stronger strategies to support use of smoking cessation services. This pilot study offers only one data point within a large literature on motivational incentives. However, based on this study, use of incentives to support participation in readiness groups or similar precessation activities may not be effective, while directly incentivizing smoking reduction or cessation, as in Robles et al. (2005), may hold more promise.
Each additional readiness group session attended was associated with a doubling of the odds that the participant would later use smoking cessation services. This suggests a dosage effect which, if replicated, would support a relationship between the readiness group intervention and use of cessation services. Similarly, those making a successful practice quit attempt were nearly seven times more likely to use smoking cessation services. This was within a wide confidence interval, however, suggesting the weakness of the estimate or the small sample size. At the end of the readiness group, in comparison with baseline, participants reported lower CPD and lower nicotine dependence.
Limitations of this study include the absence of a non-readiness-group control condition, which prohibits causal interpretation. A modest sample size restricts ability to observe associations that may exist between baseline variables and use of smoking cessation services, or to observe any differential impact of incentives added to the readiness intervention. The inclusion of women only limits generalizability by gender. The readiness group was designed to increase motivation to quit smoking, however the single measure of motivation (readiness to quit smoking) showed no change pre-post readiness group, possibly because it only assessed three stages rather than providing a continuous measure. Participation in the smoking cessation group offers another measure of motivation and, by this measure, 38.7 percent of participants were either motivated to quit at the start of the study or their motivation increased during the time of the readiness intervention.
Understanding these limitations, the readiness intervention offers a model for more effectively addressing smoking in residential drug abuse treatment. The readiness group was acceptable to participants, demonstrated by a high rate of attendance, and was associated with both initiation of smoking cessation services and with pre-post reductions in smoking behavior.
Acknowledgments: This work was supported by University of California Tobacco Related Disease Research Program (21XT-0088) and by the NIDA San Francisco Treatment Research Center (P50 DA009253). The authors thank leadership, staff, and patients of HealthRIGHT 360 who supported this work.
Alessi, S. M., Petry, N. M., & Urso, J. (2008). Contingency management promotes smoking reductions in residential substance abuse patients. Journal of Applied Behavior Analysis, 41(4), 617–22.
Baca, C. T., & Yahne, C. E. (2009). Smoking cessation during substance abuse treatment: What you need to know. Journal of Substance Abuse Treatment, 36(2), 205–19.
Bandiera, F. C., Anteneh, B., Le, T., Delucchi, K., & Guydish, J. (2015). Tobacco-related mortality among persons with mental health and substance abuse problems. PLoS One, 10(3), e0120581.
Borland, R., Yong, H. H., O’Connor, R. J., Hyland, A., & Thompson, M. E. (2010). The reliability and predictive validity of the Heaviness of Smoking Index and its two components: findings from the International Tobacco Control Four Country study. Nicotine and Tobacco Research, 12(Suppl.), S45–50.
Carpenter, M. J., Hughes, J. R., Gray, K. M., Wahlquist, A. E., Saladin, M. E., & Alberg, A. J. (2011). Nicotine therapy sampling to induce quit attempts among smokers unmotivated to quit: A randomized clinical trial. Archives of Internal Medicine, 171(21), 1901–7.
DiClemente, C. C., Prochaska, J. O., Fairhurst, S. K., Velicer, W. F., Velasquez, M. M., & Rossi, J. S. (1991). The process of smoking cessation: An analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology, 59(2), 295–304.
Drobes, D. J. (2002). Cue reactivity in alcohol and tobacco dependence. Alcoholism, Clinical and Experiential Research, 26(12), 1928–9.
Fiore, M. C., Jaén, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., Currie, S. J., . . . Wewers, M. E. (2008). Clinical practice guideline: Treating tobacco use and dependence: 2008 update. Retrieved from https://bphc.hrsa.gov/buckets/treatingtobacco.pdf
Guydish, J., Yu, J., Le, T., Pagano, A., & Delucchi, K. (2015). Predictors of tobacco use among New York State addiction treatment patients. American Journal of Public Health, 105(1), e57–64.
Hall, S. M., Humfleet, G. L., Reus, V. I., Muñoz, R. F., Hartz, D. T., & Maude-Griffin, R. (2002). Psychological intervention and antidepressant treatment in smoking cessation. Archives of General Psychiatry, 59(10), 930–6.
Hall, S. M., Tsoh, J. Y., Prochaska, J. J., Eisendrath, S., Rossi, J. S., Redding, C. A., . . . Gorecki, J. A. (2006). Treatment for cigarette smoking among depressed mental health outpatients: A randomized clinical trial. American Journal of Public Health, 96(10), 1808–14.
Halpern-Felsher, B. L., Biehl, M., Kropp, R. Y., & Rubinstein, M. L. (2004). Perceived risks and benefits of smoking: Differences among adolescents with different smoking experiences and intentions. Preventative Medicine, 39(3), 559–67.
Hughes, J. (2002). Do smokers with current or past alcoholism need different or more intensive treatment? Alcoholism, Clinical and Experiential Research, 26(12), 1934–5.
Joseph, A. M., Nichol, K. L., & Anderson, H. (1993). Effect of treatment for nicotine dependence on alcohol and drug treatment outcomes. Addictive Behaviors, 18(6), 635–44.
Kalman, D., Kim, S., DiGirolamo, G., Smelson, D., & Ziedonis, D. (2010). Addressing tobacco use disorder in smokers in early remission from alcohol dependence: The case for integrating smoking cessation services in substance use disorder treatment programs. Clinical Psychology Review, 30(1), 12–24.
Lasser, K., Boyd, J. W., Woolhandler, S., Himmelstein, D. U., McCormick, D., & Bor, D. H. (2000). Smoking and mental illness: A population-based prevalence study. JAMA, 284(20), 2606–10.
Martin, J. E., Calfas, K. J., Patten, C. A., Polarek, M., Hofstetter, C. R., Noto, J., & Beach, D. (1997). Prospective evaluation of three smoking interventions in 205 recovering alcoholics: One-year results of Project SCRAP-Tobacco. Journal of Consulting and Clinical Psychology, 65(1), 190–4.
Martinez, C., Guydish, J., Le, T., Tajima, B., & Passalacqua, E. (2015). Predictors of quit attempts among smokers enrolled in substance abuse treatment. Addictive Behaviors, 40, 1–6.
Orleans, C. T., & Hutchinson, D. (1993). Tailoring nicotine addiction treatments for chemical dependency patients. Journal of Substance Abuse Treatment, 10(2), 197–208.
Prochaska, J. J., Delucchi, K., & Hall, S. M. (2004). A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of Consulting and Clinical Psychology, 72(6), 1144–56.
Prochaska, J. O., Butterworth, S., Redding, C. A., Burden, V., Perrin, N., Leo, M., . . . Prochaska, J. M. (2008). Initial efficacy of MI, TTM tailoring, and HRIs with multiple behaviors for employee health promotion. Preventative Medicine, 46(3), 226–31.
Robles, E., Crone, C. C., Whiteside-Mansell, L., Conners, N. A., Bokony, P. A., Worley, L. L. M., & McMillan, D. E. (2005). Voucher-based incentives for cigarette smoking reduction in a women's residential treatment program. Nicotine and Tobacco Research, 7(1), 111–7.
Saxon, A. J., McGuffin, R., & Walker, R. D. (1997). An open trial of transdermal nicotine replacement therapy for smoking cessation among alcohol- and drug-dependent inpatients. Journal of Substance Abuse Treatment, 14(4), 333–7.
Sobell, M. B. (2002). Alcohol and tobacco: Clinical and treatment issues. Alcoholism, Clinical and Experiential Research, 26(12), 1954–5.
SRNT Subcommittee on Biochemical Verification. (2002). Biochemical verification of tobacco use and cessation. Nicotine and Tobacco Research, 4(2), 149–59.
Stuyt, E. B. (1997). Recovery rates after treatment for alcohol/drug dependence: Tobacco users versus nontobacco users. The American Journal on Addictions, 6(2), 159–67.
Tsoh, J. Y., Chi, F. W., Mertens, J. R., & Weisner, C. M. (2011). Stopping smoking during first year of substance use treatment predicted nine-year alcohol and drug treatment outcomes. Drug and Alcohol Dependence, 114(2–3), 110–8.
Velicer, W. F., & Prochaska, J. O. (1999). An expert system intervention for smoking cessation. Patient Education and Counseling, 36(2), 119–29.
Velicer, W. F., Prochaska, J. O., & Redding, C. A. (2006). Tailored communications for smoking cessation: Past successes and future directions. Drug and Alcohol Review, 25(1), 49–57.
Velicer, W. F., Redding, C. A., Sun, X., & Prochaska, J. O. (2007). Demographic variables, smoking variables, and outcome across five studies. Health Psychology, 26(3), 278–87.
Editor’s Note: This article was adapted from an article by the same authors previously published in the Journal of Substance Abuse Treatment (JSAT). This article has been adapted as part of Counselor’s memorandum of agreement with JSAT. The following citation provides the original source of the article:
Guydish, J., Gruber, V. A., Le, T., Tajima, B., Blakely Andrews, K., Leo, H., . . . Tsoh, J. Y. (2016). A pilot study of a readiness group to increase initiation of smoking cessation services among women in residential addiction treatment. Journal of Substance Abuse Treatment, 63, 39–45.