Thomas Liss

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.

GENDER DIFFERENCES IN ADOLESCENT MARIJUANA USE AND ASSOCIATED PSYCHOSOCIAL CHARACTERISTICS

Marijuana use in adolescents is associated with many adverse outcomes, including neurobiological and health consequences. Despite this, little is known about gender differences in the correlates of adolescent marijuana use. This study attempted to fill this gap by examining gender differences in the correlates of lifetime and past 30-day marijuana use. Data from a cross-sectional statewide survey of adolescent risk behavior participation in Connecticut were analyzed using &khgr;2 and hierarchical logistic regression methodologies to examine the demographic, psychosocial, and risk behavior correlates of adolescent marijuana use. Gender-by-trait interactions were tested with hierarchical logistic regression. Of the 4523 participants (51.8% females, 75.8% white), 40.4% endorsed lifetime marijuana use and 24.5% endorsed past 30-day marijuana use. Risk behavior participation, particularly other substance use, had the most robust associations with lifetime and past 30-day adolescent marijuana use; participation in extracurricular activities seemed protective. Gender interactions were observed for African American, Asian, or other race and participation in extracurricular activities; in these 3 cases, males had a greater likelihood of use. They were also observed for having a job (lifetime use only), with females having elevated odds, and past 30-day cigarette smoking (past 30-day use only), with males having elevated odds. Finally, there was preliminary evidence of a faster transition from initiation of marijuana use to regular use in females, when compared with males. These results indicate important gender differences in the correlates of marijuana use in adolescents, and these findings may facilitate the development of gender-informed prevention and early intervention programs for adolescent marijuana use.

IMPULSIVE SENSATION SEEKING, PARENTAL HISTORY OF ALCOHOL PROBLEMS, AND CURRENT ALCOHOL AND TOBACCO USE IN ADOLESCENTS

Objectives:This study attempted to evaluate whether impulsive sensation seeking mediated the relationship between parental alcohol problems and offspring alcohol and tobacco use. Methods:Participants were Connecticut high school students (n = 2733) completing a survey of high-risk behaviors. Variables of interest included past month alcohol use, past month binge alcohol use, frequency of past month alcohol use, past month tobacco use, having a biologic parent with an alcohol problem, and score on the Impulsive Sensation Seeking scale (ImpSS) from the Zuckerman–Kuhlman Personality Questionnaire—Form III. Results:ImpSS scores were elevated in past month users of alcohol, binge users of alcohol, users of both tobacco and alcohol, and they increased with increasing frequency of past month alcohol use. Also, parental history of alcohol use increased the likelihood of past month alcohol use, binge use, use of both tobacco and alcohol, and higher levels of past month alcohol use. Mediational analyses did not seem to support the hypothesis that impulsive sensation seeking mediates the relationship between parental history of alcohol problems and alcohol and tobacco use in offspring. Conclusions:Impulsive sensation seeking and parental history of alcohol problems seem to be independent factors that contribute to the co-occurrence of alcohol and tobacco use in adolescents. These findings can inform prevention and treatment efforts.

Combining Cognitive Behavioral Therapy with Contingency Management for Smoking Cessation in Adolescent Smokers: A Preliminary Comparison of Two Different CBT Formats

This pilot study evaluated the optimal format of cognitive behavioral therapy (CBT) to combine with contingency management (CM) in a four-week, high school-based smoking cessation program. Thirty-four adolescent smokers received a standard weekly version of CBT or a frequent brief behavioral intervention. Results indicate a trend toward a higher seven-day point prevalence end-of-treatment abstinence rate and percent days abstinent during treatment in the CBT condition. In addition, significantly more participants in the CBT group completed treatment. These preliminary results suggest that when combined with CM, the standard weekly format of CBT is more acceptable to adolescent smokers.

An exploratory randomized controlled trial of a novel high-school-based smoking cessation intervention for adolescent smokers using abstinence-contingent incentives and cognitive behavioral therapy

BACKGROUND There are few effective smoking cessation interventions for adolescent smokers. We developed a novel intervention to motivate tobacco use behavior change by (1) enhancing desire to quit through the use of abstinence-contingent incentives (CM), (2) increasing cessation skills through the use of cognitive behavioral therapy (CBT), and (3) removing cessation barriers through delivery within high schools. METHODS An exploratory four-week, randomized controlled trial was conducted in Connecticut high schools to dismantle the independent and combined effects of CM and CBT; smokers received CM alone, CBT alone, or CM+CBT. Participants included 82 adolescent smokers seeking smoking cessation treatment. The primary outcome was seven-day end-of-treatment (EOT) point prevalence (PP) abstinence, determined using self-reports confirmed using urine cotinine levels. Secondary outcomes included one-day EOT PP abstinence and cigarette use during treatment and follow up. RESULTS Among participants who initiated treatment (n=72), group differences in seven-day EOT-PP abstinence were observed (χ(2)=10.48, p<0.01) with higher abstinence in the CM+CBT (36.7%) and CM (36.3%) conditions when compared with CBT (0%). One-day EOT-PP abstinence evidenced similar effects (χ(2)=10.39, p<0.01; CM+CBT: 43%, CM: 43%, CBT: 4.3%). Survival analyses indicated differences in time to first cigarette during treatment (χ(2)=8.73, p=0.003; CBT: Day 3, CM: Day 9, CM+CBT: Day 20). At one- and three-month follow ups, while no differences were observed, the CM alone group had the slowest increase in cigarette use. CONCLUSIONS High-school, incentive-based smoking cessation interventions produce high rates of short-term abstinence among adolescent smokers; adding cognitive behavioral therapy does not appear to further enhance outcomes.

An exploratory pilot study of the relationship between neural correlates of cognitive control and reduction in cigarette use among treatment-seeking adolescent smokers.

Despite high rates of tobacco use during adolescence, few empirically validated smoking cessation strategies exist for adolescent smokers. Developing an understanding of the neural underpinnings of cognitive control processes in adolescent smokers, and their relationship to quit behaviors, may help advance the development of enhanced behavioral and pharmacological therapies. The current pilot study explored the relationship between brain responses during performance of the Stroop color-word interference task and reduction in tobacco use (as measured by changes in cotinine levels) in treatment-seeking adolescent smokers participating in a high school-based smoking-cessation program. Eleven adolescent daily smokers participated in a prequit session during which neural activity in response to congruent and incongruent events in a Stroop task was examined using functional MRI (fMRI). Changes in urine cotinine levels from prequit baseline to end of treatment were calculated and correlated with brain activity. Adolescents with greater activation in the inferior frontal gyrus, insula, thalamus, and anterior cingulate had greater reductions in cotinine levels. The preliminary observation of a relationship between treatment outcome and neural correlates of cognitive control prior to treatment onset provides insight into individual differences in adolescent brain function that might relate importantly to treatment outcome.

A preliminary experimental investigation of peer influence on risk-taking among adolescent smokers and non-smokers.

BACKGROUND Epidemiological evidence suggests that peer influence plays a significant role in a variety of adolescent risk-taking behaviors, including tobacco use. We attempted to establish this relationship in a controlled laboratory setting. METHOD We modified the Balloon Analog Risk Task (BART) task to include a peer component to investigate whether peer influences alter risk-taking behaviors. Thirty-nine adolescents (22 smokers, 17 non-smokers) completed one experimental session during which the standard and peer BART were presented in counterbalanced order, with the dependent measures being adjusted mean number of pumps and explosions. We also examined the relationship of changes in the BART (standard-peer) to personality measures of impulsivity (BIS-11) and resistance to peer influence (RPI). RESULTS A significant interaction of BART type and smoking status was present (p=.05); specifically smokers had a greater increase in the number of explosions by 2.27 (SD=3.12) compared to an increase of .29 (SD=2.87) by non-smokers. BIS-11 scores were related to peer-influenced BART changes: those who were more impulsive experienced greater changes in risk-taking, but no similar relationships were observed for the RPI. CONCLUSIONS These results suggest that peer influences enhance risk-taking among adolescents, and that smokers may be more susceptible to these influences.

Preliminary examination of tobacco withdrawal in adolescent smokers during smoking cessation treatment.

Tobacco withdrawal symptoms have been shown to play a significant role in mediating relapse to smoking in adult smokers; however, few prospective studies have examined the course of tobacco withdrawal symptoms over time and their connection to lapse in adolescent smokers. Withdrawal symptoms were assessed weekly for 4 weeks in a sample of adolescent smokers participating in a pilot cessation intervention. Adolescent smokers experienced an exacerbation in overall withdrawal symptoms, particularly of cravings and restlessness, although symptoms were generally mild. The course of symptoms was different for boys and girls: Girls generally experienced a peak and subsequent decline in symptoms early in the establishment of abstinence, whereas boys experienced a constant level of symptoms that did not decline over the 4 weeks. Finally, withdrawal symptoms experienced on quit day were not related to lapse to smoking during the course of treatment for either boys or girls. These results suggest that although withdrawal symptoms may be uncomfortable, they may not be the most salient to a lapse to smoking for adolescent smokers attempting to quit. These findings have direct implications for the design and implementation of treatment of nicotine dependence in adolescent smokers.

Contingency management for smoking cessation: Enhancing feasibility through use of immunoassay test strips measuring cotinine

Contingency management (CM) is a powerful behavioral intervention shown to reduce the use of a variety of substances including tobacco. Use of CM techniques for smoking cessation has been restricted by the use of multiple daily measurements of breath CO as the objective indicator to reinforce abstinence. Cotinine, with its longer half-life, may be a better marker. We evaluated the use of urinary cotinine (determined using once-daily semiquantitative immunoassay test strips and verified using quantitative GC/HPLC techniques) as an abstinence indicator in treatment-seeking adult and adolescent smokers participating in a CM-based intervention program. Both techniques of determining urinary cotinine were highly sensitive and moderately specific at detecting abstinence, and they were highly concordant. However, specificity was somewhat lower during the first few days of a quit attempt and improved over time. The results were similar in adults and adolescent smokers, and suggest that during the first few days of a quit attempt it would be advisable to continue to use daily multiple CO measurements to verify abstinence. However, once abstinence is achieved, once-daily immunoassay test strips could be used for continued monitoring of urinary cotinine levels. Immunoassay testing can identify individuals who relapse to smoking, though this study cannot evaluate whether the strips can identify resumption of abstinence. These results suggest that the use of cotinine as an abstinence indicator, by reducing the number of daily appointments, could significantly enhance the feasibility and utility of CM-based interventions for smoking cessation.

Nicotine dependence severity as a cross-sectional predictor of alcohol-related problems in a sample of adolescent smokers.

INTRODUCTION Given the prevalence of alcohol use among adolescents and its negative consequences, it is important to learn more about correlates of alcohol-related problems in this population. Cigarette smoking appears to be associated with alcohol-related problems in adolescents. The purpose of this study was to assess cigarettes smoked per day and nicotine dependence (ND) severity as predictors of alcohol-related problems in cross-sectional models, using data from a smoking cessation clinical trial for adolescents. METHOD Data obtained at intake were used to assess smoking-related variables as cross-sectional predictors of alcohol-related problems in models along with drinks per week and key demographics, using hierarchical multiple regression. RESULTS ND severity, as measured using the modified Fagerström Tolerance Questionnaire, significantly predicted alcohol-related problems, both when this score included and did not include an item concerning cigarettes smoked per day. A separate continuous item capturing cigarettes per day did not predict alcohol-related problems. DISCUSSION ND severity predicted alcohol-related problems in cross-sectional regression models, holding constant alcohol consumption and key demographics. This suggests that ND severity may be a clinical indicator of alcohol-related problems among adolescent smokers. To our knowledge, this is the first analysis of associations between smoking and alcohol involvement in a sample of adolescent smokers participating in a clinical trial.