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1.  Predictive value of readiness, importance, and confidence in ability to change drinking and smoking 
BMC Public Health  2012;12:708.
Visual analog scales (VAS) are sometimes used to assess change constructs that are often considered critical for change. Aims of Study: 1.) To determine the association of readiness to change, importance of changing and confidence in ability to change alcohol and tobacco use at baseline with the risk for drinking (more than 21 drinks per week/6 drinks or more on a single occasion more than once per month) and smoking (one or more cigarettes per day) six months later. 2.) To determine the association of readiness, importance and confidence with alcohol (number of drinks/week, number of binge drinking episodes/month) and tobacco (number of cigarettes/day) use at six months.
This is a secondary analysis of data from a multi-substance brief intervention randomized trial. A sample of 461 Swiss young men was analyzed as a prospective cohort. Participants were assessed at baseline and six months later on alcohol and tobacco use, and at baseline on readiness to change, importance of changing and confidence in ability to change constructs, using visual analog scales ranging from 1–10 for drinking and smoking behaviors. Regression models controlling for receipt of brief intervention were employed for each change construct. The lowest level (1–4) of each scale was the reference group that was compared to the medium (5–7) and high (8–10) levels.
Among the 377 subjects reporting unhealthy alcohol use at baseline, mean (SD) readiness, importance and confidence to change drinking scores were 3.9 (3.0), 2.7 (2.2) and 7.2 (3.0), respectively. At follow-up, 108 (29%) reported no unhealthy alcohol use. Readiness was not associated with being risk-free at follow-up, but high importance (OR 2.94; 1.15, 7.50) and high confidence (OR 2.88; 1.46, 5.68) were. Among the 255 smokers at baseline, mean readiness, importance and confidence to change smoking scores were 4.6 (2.6), 5.3 (2.6) and 5.9 (2.7), respectively. At follow-up, 13% (33) reported no longer smoking. Neither readiness nor importance was associated with being a non-smoker, whereas high confidence (OR 3.29; 1.12, 9.62) was.
High confidence in ability to change was associated with favorable outcomes for both drinking and smoking, whereas high importance was associated only with a favorable drinking outcome. This study points to the value of confidence as an important predictor of successful change for both drinking and smoking, and shows the value of importance in predicting successful changes in alcohol use.
Trial registration number
PMCID: PMC3490974  PMID: 22931392
Readiness to change; Importance of changing; Confidence in ability to change; Unhealthy alcohol use; Smoking
2.  Does Readiness To Change Predict Subsequent Alcohol Consumption In Medical Inpatients With Unhealthy Alcohol Use? 
Addictive behaviors  2009;34(8):636-640.
We studied whether readiness to change predicts alcohol consumption (drinks per day) 3 months later in 267 medical inpatients with unhealthy alcohol use. We used 3 readiness to change measures: a 1 to 10 visual analog scale (VAS) and two factors of the Stages of Change Readiness and Treatment Eagerness Scale: Perception of Problems (PP) and Taking Action (TA). Subjects with the highest level of VAS-measured readiness consumed significantly fewer drinks 3 months later [Incidence rate ratio (IRR) and 95% confidence interval (CI): 0.57 (0.36, 0.91) highest vs. lowest tertile]. Greater PP was associated with more drinking [IRR (95%CI): 1.94 (1.02, 3.68) third vs. lowest quartile]. Greater TA scores were associated with less drinking [IRR (95%CI): 0.42 (0.23, 0.78) highest vs. lowest quartile]. Perception of Problems' association with more drinking may reflect severity rather than an aspect of readiness associated with ability to change; high levels of Taking Action appear to predict less drinking. Although assessing readiness to change may have clinical utility, assessing the patient's planned actions may have more predictive value for future improvement in alcohol consumption.
PMCID: PMC2789443  PMID: 19428189
unhealthy alcohol use; readiness to change; medical inpatients; Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES)
3.  Improvements in readiness to change and drinking in primary care patients with unhealthy alcohol use: a prospective study 
BMC Public Health  2009;9:101.
The course of alcohol consumption and cognitive dimensions of behavior change (readiness to change, importance of changing and confidence in ability to change) in primary care patients are not well described. The objective of the study was to determine changes in readiness, importance and confidence after a primary care visit, and 6-month improvements in both drinking and cognitive dimensions of behavior change, in patients with unhealthy alcohol use.
Prospective cohort study of patients with unhealthy alcohol use visiting primary care physicians, with repeated assessments of readiness, importance, and confidence (visual analogue scale (VAS), score range 1–10 points). Improvements 6 months later were defined as no unhealthy alcohol use or any increase in readiness, importance, or confidence. Regression models accounted for clustering by physician and adjusted for demographics, alcohol consumption and related problems, and discussion with the physician about alcohol.
From before to immediately after the primary care physician visit, patients (n = 173) had increases in readiness (mean +1.0 point), importance (+0.2), and confidence (+0.5) (all p < 0.002). In adjusted models, discussion with the physician about alcohol was associated with increased readiness (+0.8, p = 0.04). At 6 months, many participants had improvements in drinking or readiness (62%), drinking or importance (58%), or drinking or confidence (56%).
Readiness, importance and confidence improve in many patients with unhealthy alcohol use immediately after a primary care visit. Six months after a visit, most patients have improvements in either drinking or these cognitive dimensions of behavior change.
PMCID: PMC2679737  PMID: 19358730
4.  Predicting Treatment Seekers Readiness to Change their Drinking Behavior in the COMBINE Study 
Initial motivation and readiness to change are complex constructs and have been important but inconsistent predictors of treatment attendance and drinking outcomes in studies of alcoholism treatment. Motivation can be described in multiple ways as simply the accumulation of consequences that push change, a shift in intentions, or engagement in various tasks that are part of a larger process of change.
Using baseline data from participants in the COMBINE Study, this study re-evaluated the psychometric properties of a 24-item, measure of motivation derived from the URICA that yielded four subscales representing attitudes and experiences related to tasks of stages of Precontemplation, Contemplation, Action, and Maintenance Striving as well as a second order factor score representing a multidimensional view of readiness to change drinking. A variety of hypothesized predictors of readiness and the stage subscales were examined using multiple regression analyses in order to better understand the nature of this measure of motivation.
Findings supported the basic subscale structure and the overall motivational readiness score derived from this measure. Readiness to change drinking behavior was predicted by baseline measures of perceived stress, drinking severity, psychiatric co-morbidity, self-efficacy, craving, and with positive treatment outcome expectancies. However, absolute values were small indicating that readiness for change is not explained simply by demographic, drinking severity, treatment, change process, or contextual variables.
This measure demonstrated good psychometric properties and results supported the independence as well as convergent and divergent validity of the measured constructs. Predictors of overall readiness and subscale scores indicate that a variety of personal and contextual factors contribute to treatment seekers motivation to change in an understandable but complex manner.
PMCID: PMC2954369  PMID: 19320633
Stages of Change; Alcohol Treatment; Motivation; Readiness
5.  A theory of organizational readiness for change 
Change management experts have emphasized the importance of establishing organizational readiness for change and recommended various strategies for creating it. Although the advice seems reasonable, the scientific basis for it is limited. Unlike individual readiness for change, organizational readiness for change has not been subject to extensive theoretical development or empirical study. In this article, I conceptually define organizational readiness for change and develop a theory of its determinants and outcomes. I focus on the organizational level of analysis because many promising approaches to improving healthcare delivery entail collective behavior change in the form of systems redesign--that is, multiple, simultaneous changes in staffing, work flow, decision making, communication, and reward systems.
Organizational readiness for change is a multi-level, multi-faceted construct. As an organization-level construct, readiness for change refers to organizational members' shared resolve to implement a change (change commitment) and shared belief in their collective capability to do so (change efficacy). Organizational readiness for change varies as a function of how much organizational members value the change and how favorably they appraise three key determinants of implementation capability: task demands, resource availability, and situational factors. When organizational readiness for change is high, organizational members are more likely to initiate change, exert greater effort, exhibit greater persistence, and display more cooperative behavior. The result is more effective implementation.
The theory described in this article treats organizational readiness as a shared psychological state in which organizational members feel committed to implementing an organizational change and confident in their collective abilities to do so. This way of thinking about organizational readiness is best suited for examining organizational changes where collective behavior change is necessary in order to effectively implement the change and, in some instances, for the change to produce anticipated benefits. Testing the theory would require further measurement development and careful sampling decisions. The theory offers a means of reconciling the structural and psychological views of organizational readiness found in the literature. Further, the theory suggests the possibility that the strategies that change management experts recommend are equifinal. That is, there is no 'one best way' to increase organizational readiness for change.
PMCID: PMC2770024  PMID: 19840381
6.  Motivation rulers for smoking cessation: a prospective observational examination of construct and predictive validity 
Although popular clinically, the psychometric properties of motivation rulers for tobacco cessation are unknown. This study examined the psychometric properties of rulers assessing importance, readiness, and confidence in tobacco cessation.
This observational study of current smokers was conducted at 10 US emergency departments (EDs). Subjects were assessed during their ED visit (baseline) and reassessed two weeks later. We examined intercorrelations between the rulers as well as their construct and predictive validity. Hierarchical multinomial logistic regressions were used to examine the rulers’ predictive ability after controlling for covariables.
We enrolled 375 subjects. The correlations between the three rulers ranged from 0.50 (between Important and Confidence) to 0.70 (between Readiness and Confidence); all were significant (p < 0.001). Individuals in the preparation stage displayed the highest motivation-ruler ratings (all rulers F 2, 363 ≥ 43; p < 0.001). After adjusting for covariables, each of the rulers significantly improved prediction of smoking behavior change. The strength of their predictive ability was on par with that of stage of change.
Our results provide preliminary support for the psychometric soundness of the importance, readiness, and confidence rulers.
PMCID: PMC3507634  PMID: 23186265
Tobacco; Tobacco cessation; Motivation; Stage of change; Reliability; Validity
7.  Smoking frequency among current college student smokers: distinguishing characteristics and factors related to readiness to quit smoking 
Health Education Research  2011;27(1):141-150.
Given the increased prevalence of non-daily smoking and changes in smoking patterns, particularly among young adults, we examined correlates of smoking level, specifically motives for smoking, and readiness to quit smoking among 2682 college undergraduates who completed an online survey. Overall, 64.7% (n = 1736) were non-smokers, 11.6% (n = 312) smoked 1–5 days, 10.5% (n = 281) smoked 6–29 days and 13.2% (n = 353) were daily smokers. Ordinal regression analyses modeling smoking level indicated that correlates of higher smoking level included having more friends who smoke (β = 0.63, 95% CI 0.57–0.69) and more frequent other tobacco use (β = 0.04, 95% CI 0.02–0.05), drinking (β = 0.04, 95% CI 0.02–0.07) and binge drinking (β = 0.09, 95% CI 0.06–0.13). Bivariate analyses indicated that daily smokers (versus the subgroups of non-daily smokers) were less likely to smoke for social reasons but more likely to smoke for self-confidence, boredom, and affect regulation. Controlling for sociodemographics, correlates of readiness to quit among current smokers included fewer friends who smoke (P = 0.002), less frequent binge drinking (P = 0.03), being a social smoker (P < 0.001), smoking less for self-confidence (P = 0.04), smoking more for boredom (P = 0.03) and less frequent smoking (P = 0.001). Specific motives for smoking and potential barriers to cessation particularly may be relevant to different groups of college student smokers.
PMCID: PMC3605919  PMID: 22156071
8.  Toward prevention of alcohol exposed pregnancies: characteristics that relate to ineffective contraception and risky drinking 
Journal of behavioral medicine  2009;32(5):443-452.
Alcohol-exposed pregnancy is a leading cause of preventable birth defects in the United States. This paper describes the motivational patterns that relate to risky drinking and ineffective contraception, two behaviors that can result in alcohol-exposed pregnancy. As part of an intervention study aimed at reducing alcohol-exposed pregnancy 124 women were recruited and reported demographic characteristics, readiness to change, stages of change, drinking, contraception, and sexual behavior history. Our results showed the following. Drinking: A significant positive correlation was found between the number of drinks consumed in 90 days and the Importance to reduce drinking (r = .23, p = .008). A significant negative correlation between number of drinks and confidence to reduce drinking (r = −.39, p = .000) was found as well. Significant differences were found in the total number of drinks consumed in 90 days between the five stages of change (F = (4,118), 3.12, p = .01). Women in Preparation reported drinking a significantly higher number of drinks than women in other stages of change. Contraception: There were significant negative correlations between ineffective contraception and Importance (r = −.38, p = .00), confidence (r = −.20, p = .02) and Readiness (r = −.43, p = .00) to use contraception effectively. Significant differences in contraception ineffectiveness were found for women in different stages of change (F = (4,115) 8.58, p = .000). Women in Precontemplation reported significantly higher levels of contraception ineffectiveness compared to women in other stages of change. Results show a clear relationship between higher alcohol consumption and higher levels of motivation to reduce drinking. In contrast, higher levels of ineffective contraception were related to lower levels of motivation to use contraception effectively. This suggests risky drinking may be better targeted with brief skills building interventions and ineffective contraception may require interventions that enhance problem awareness and motivation.
PMCID: PMC2868058  PMID: 19459039
Alcohol exposed pregnancy; Binge drinking; Contraception; Self-efficacy; Stages of change
9.  Readiness to change and post-intervention drinking among Hispanic college students living on the US/Mexico border 
Addictive behaviors  2010;36(3):183-189.
The purpose of the present study was to examine readiness to change as a predictor of post-intervention alcohol consumption among Hispanic college student drinkers taking part in a brief harm reduction intervention.
Participants of the intervention study were 109 Hispanic college students residing on the US/Mexico border who self-identified as regular drinkers. This manuscript reports findings from a subset of participants who had complete data at 3-month follow-up (N=84). Participants completed the Readiness to Change Questionnaire, the Rutgers Alcohol Problem Index, and the Form-90 Steady Pattern drinking assessment prior to receiving an intervention.
Hierarchical least-squares regression was used to predict baseline readiness to change scores from alcohol consumption and related consequences, and then to predict 3-month post-intervention drinking from baseline drinking and readiness to change. Alcohol consumption and consequences significantly predicted readiness to change at baseline, and follow-up drinking was significantly predicted from baseline drinking, readiness to change, and an interaction between the two variables. Findings indicated that readiness to change may function differently in people with varying levels of alcohol involvement.
Greater readiness to change predicted reduced alcohol consumption only among the heaviest drinkers; among lighter drinkers, greater readiness to change predicted increased alcohol consumption. Possible explanations for this finding are discussed.
PMCID: PMC4049223  PMID: 21109355
Alcohol; Hispanics; College students; Readiness to change
10.  Which came first: the readiness or the change? Longitudinal relationships between readiness to change and drinking among college drinkers 
Addiction (Abingdon, England)  2010;105(11):1899-1909.
Although readiness to change (RTC) is cited as a key mechanism underlying drinking behavior change, empirical evidence supporting RTC as a predictor of college drinking has been mixed. Considering methodological limitations of previous studies, the current aim was to conduct a more comprehensive test of longitudinal relationships between readiness to change and college drinking.
In this correlational, longitudinal study, we used a series of cross-lagged path analyses to test associations between RTC and college drinking outcomes over a 2-year period.
Data collection was conducted via online surveys on a university campus in the US Pacific Northwest.
Participants (n = 818; 58% women) were college students who reported at least one heavy-drinking episode in the past month and participated in a randomized controlled trial of personalized normative feedback interventions.
Drinking quantity–frequency items and the Rutgers Alcohol Problem Index assessed drinking outcomes. The Readiness to Change Questionnaire assessed RTC.
For drinking-related problems, the best-fitting model included cross-lagged paths between RTC and subsequent drinking-related problems. For drinking quantity–frequency, best-fitting models also included the cross-lagged paths between drinking quantity–frequency and subsequent RTC. Higher RTC almost uniformly predicted higher subsequent levels of drinking and greater experience of drinking-related problems, and drinking quantity–frequency variables were primarily positive predictors of subsequent RTC.
Contrary to previous assumptions, ‘the Readiness to Change Questionnaire’ does not appear to be predictive of lower levels of subsequent drinking.
PMCID: PMC3934960  PMID: 20854333
alcohol use; college drinking; motivation; path analysis; readiness to change
Addiction (Abingdon, England)  2013;108(4):712-722.
To assess age variation in correlates of drinking cessation.
Prospective study of a U.S. general population sample.
Face-to-face household interviews.
Past-year ≥monthly drinkers interviewed at baseline and 3-year follow-up (n=14,885).
Baseline values and selected changes over follow-up in alcohol consumption, alcohol use disorder (AUD), sociodemographic and health characteristics, other substance use and psychiatric comorbidity were used to predict drinking cessation in three age groups.
Correlates of drinking cessation varied over the life course, with pregnancy/presence of an infant, nicotine or drug use disorder, incident AUD, cluster A personality disorder, liver disease and incident retirement being important at younger ages and high-school graduation, family income ≥$70,000, volume of ethanol intake, Asian race/ethnicity, mood disorder and incident cardiovascular disease being significant at older ages. Age-invariant correlates included smoking cessation over follow-up, OR=2.82 (95% CI=1.62–4.92) to 3.45 (2.20–5.39); college education, OR=0.42 (0.27–0.65) to 0.54 (0.36–0.83); Black and Hispanic race/ethnicity, OR = 1.74 (1.18–2.29) to 1.88 (1.21–2.93) and 1.58 (1.11–1.25) to 1.73 (0.83–3.63), respectively, and months since last drink, OR=1.24 (1.13–1.36) to1.29 (1.19–1.39).
Factors associated with ceasing alcohol use in US adults appear to differ over the life course, reflecting age variation in both their prevalence and impact and supporting the importance of role transitions and health problems (the “sick quitter” effect). The most consistent correlates of drinking cessation included factors reflecting ability/inability to give up potentially addictive substances and factors associated with perceived acceptability of drinking and subgroup-specific drinking contexts that might facilitate/impede continued drinking.
PMCID: PMC3602325  PMID: 23216848
drinking cessation; former drinkers; sick quitters
12.  Concurrent Drinking and Smoking among College Students: An Event-Level Analysis 
Cigarette smoking and drinking commonly co-occur among college students, a population that is at high risk for developing alcohol and nicotine use disorders. Several studies have been conducted that have examined predictors of drinking or smoking to gain a better understanding of the antecedents of engaging in these behaviors. Yet, few studies have examined specific factors that influence concurrent smoking and drinking in this population. The current study used data from a 21-day electronic diary-based study of college students (n = 86) who engaged in concurrent drinking and smoking to examine event-level associations between alcohol use and cigarette smoking in the student’s natural environment. We specifically focused on within-person analyses of contexts in which students reported smoking and drinking simultaneously in comparison to contexts in which students reporting drinking without smoking. Situational contexts included environmental setting, whether s/he was alone or with others, and changes in stress and urges to smoke before initiating drinking. Results indicated that students drank more while smoking and smoked three times as many cigarettes, on average, during drinking episodes. Being with others at a party or a bar was associated with increased odds of smoking while drinking. Likewise, increased stress since the prior assessment predicted a greater likelihood of smoking while drinking. Based on the findings from the present study, it is important for future prevention and intervention efforts to consider social settings and heightened stress among students as potential risk factors for engaging in concurrent drinking and smoking.
PMCID: PMC3894655  PMID: 21895348
alcohol; drinking; smoking; college students; ecological momentary assessment
13.  Posttreatment Motivation and Alcohol Treatment Outcome 9 Months Later: Findings From Structural Equation Modeling 
Objective: To investigate the association between posttreatment motivation to change as measured by the Readiness to Change Questionnaire Treatment Version and drinking outcomes 9 months after the conclusion of treatment for alcohol problems. Method: Data from 392 participants in the United Kingdom Alcohol Treatment Trial were used to fit structural equation models investigating relationships between motivation to change pre- and posttreatment and 5 outcomes 9 months later. The models included pathways through changes in drinking behavior during treatment and adjustment for sociodemographic information. Results: Greater posttreatment motivation (being in action vs. preaction) was associated with 3 times higher odds of the most stringent definition of positive outcome (being abstinent or entirely a nonproblem drinker) 9 months later (odds ratio = 3.10, 95% confidence interval [1.83, 5.25]). A smaller indirect effect of pretreatment motivation on this outcome was seen from pathways through drinking behavior during treatment and posttreatment motivation (probit coefficient = 0.08, 95% confidence interval [0.03, 0.14]). A similar pattern of results was seen for other outcomes evaluated. Conclusion: Posttreatment motivation to change has hitherto been little studied and is identified here as a clearly important predictor of longer term treatment outcome.
This study found that those individuals who reported that they were ready to change their drinking at the end of a treatment program were much more likely to show positive outcomes 9 months subsequently than were persons not indicating such a readiness to change. This suggests that attempting to enhance motivation throughout the process may be an important component of successful alcohol treatment.
PMCID: PMC4352962  PMID: 25244390
alcohol problems; treatment; readiness to change; motivation; outcome predictors
14.  A Comparison of the Concurrent and Predictive Validity of Three Measures of Readiness to Change Alcohol Use in a Clinical Sample of Adolescents 
Psychological assessment  2011;23(4):983-994.
We compared three measures of readiness to change alcohol use commonly used in clinical research and practice with adolescents: the Readiness Ruler, the SOCRATES (subscales of Recognition and Taking Steps), and a Staging Algorithm. The analysis sample consisted of 161 male and female adolescents presenting for intensive outpatient alcohol who reported current alcohol use at the initial assessment. Evidence for concurrent validity was assessed by computing simple correlations of each readiness measure with the other three, and of each readiness measure with drinking behavior (percentage of days abstinent (PDA) and drinks per drinking day (DDD), respectively, in the last 30 days) at the start of treatment and at the 6-month follow-up assessment. Evidence for predictive validity was based on percentage of independent variance accounted for by each of the readiness measures in predicting drinking behavior at six months from the start of treatment, and then in predicting drinking behavior at 12 months from the readiness assessment at 6 months. The results showed that all but Recognition had good concurrent validity, the Readiness Ruler score showed consistent evidence for predictive validity, and the Staging Algorithm showed good predictive validity for DDD at 6 and 12 months. For the 82 participants with an alcohol use disorder diagnosis, the findings for the Ruler and Recognition were similar, but the Staging Algorithm had poorer prediction of DDD at 12 months, and Taking Steps was a better predictor of 6- and 12-month PDA and DDD. Research and clinical implications of the findings are discussed.
PMCID: PMC3433156  PMID: 21767028
Readiness to change; alcohol use; measurement validity; adolescents
15.  Readiness to change, drinking, and negative consequences among Polish SBIRT patients 
Addictive Behaviors  2011;37(3):287-292.
The aim of this study is to examine the longitudinal relationship of readiness to change, drinking pattern, amount of alcohol consumed, and alcohol-related negative consequences among at-risk and dependent drinkers enrolled in a Screening, Brief Intervention and Referral to Treatment (SBIRT) trial in an emergency department in southern Poland. The study examined 299 patients randomized to either an assessment or intervention condition and followed at 3 and 12 months after initial presentation. Patients indicating a readiness or were unsure of changing drinking behavior were significantly more likely to decrease the maximum number of drinks per occasion and the usual number of drinks in a sitting in the 3-months following study entry when compared to those that rated changing drinking behavior as unimportant. Readiness to change was not predictive of outcomes between the baseline and 12-month follow-up. Drinking outcomes and negative consequences by readiness and research condition were non-significant. This is the first Polish study utilizing SBIRT to enable patients to identify their hazardous drinking and reduce alcohol consumption. While some drinking outcomes improved with motivation, these improvements were not maintained at 12-months following SBIRT. Attention to additional constructs of readiness to change and drinking patterns may augment the effectiveness of SBIRT.
PMCID: PMC3258358  PMID: 22119521
16.  Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial 
Objective To evaluate the effectiveness of different brief intervention strategies at reducing hazardous or harmful drinking in primary care. The hypothesis was that more intensive intervention would result in a greater reduction in hazardous or harmful drinking.
Design Pragmatic cluster randomised controlled trial.
Setting Primary care practices in the north east and south east of England and in London.
Participants 3562 patients aged 18 or more routinely presenting in primary care, of whom 2991 (84.0%) were eligible to enter the trial: 900 (30.1%) screened positive for hazardous or harmful drinking and 756 (84.0%) received a brief intervention. The sample was predominantly male (62%) and white (92%), and 34% were current smokers.
Interventions Practices were randomised to three interventions, each of which built on the previous one: a patient information leaflet control group, five minutes of structured brief advice, and 20 minutes of brief lifestyle counselling. Delivery of the patient leaflet and brief advice occurred directly after screening and brief lifestyle counselling in a subsequent consultation.
Main outcome measures The primary outcome was patients’ self reported hazardous or harmful drinking status as measured by the alcohol use disorders identification test (AUDIT) at six months. A negative AUDIT result (score <8) indicated non-hazardous or non-harmful drinking. Secondary outcomes were a negative AUDIT result at 12 months, experience of alcohol related problems (alcohol problems questionnaire), health utility (EQ-5D), service utilisation, and patients’ motivation to change drinking behaviour (readiness to change) as measured by a modified readiness ruler.
Results Patient follow-up rates were 83% at six months (n=644) and 79% at 12 months (n=617). At both time points an intention to treat analysis found no significant differences in AUDIT negative status between the three interventions. Compared with the patient information leaflet group, the odds ratio of having a negative AUDIT result for brief advice was 0.85 (95% confidence interval 0.52 to 1.39) and for brief lifestyle counselling was 0.78 (0.48 to 1.25). A per protocol analysis confirmed these findings.
Conclusions All patients received simple feedback on their screening outcome. Beyond this input, however, evidence that brief advice or brief lifestyle counselling provided important additional benefit in reducing hazardous or harmful drinking compared with the patient information leaflet was lacking.
Trial registration Current Controlled Trials ISRCTN06145674.
PMCID: PMC3541471  PMID: 23303891
17.  Stage 1 of the meaningful use incentive program for electronic health records: a study of readiness for change in ambulatory practice settings in one integrated delivery system 
Meaningful Use (MU) provides financial incentives for electronic health record (EHR) implementation. EHR implementation holds promise for improving healthcare delivery, but also requires substantial changes for providers and staff. Establishing readiness for these changes may be important for realizing potential EHR benefits. Our study assesses whether provider/staff perceptions about the appropriateness of MU and their departments’ ability to support MU-related changes are associated with their reported readiness for MU-related changes.
We surveyed providers and staff representing 47 ambulatory practices within an integrated delivery system. We assessed whether respondent’s role and practice-setting type (primary versus specialty care) were associated with reported readiness for MU (i.e., willingness to change practice behavior and ability to document actions for MU) and hypothesized predictors of readiness (i.e., perceived appropriateness of MU and department support for MU). We then assessed associations between reported readiness and the hypothesized predictors of readiness.
In total, 400 providers/staff responded (response rate approximately 25%). Individuals working in specialty settings were more likely to report that MU will divert attention from other patient-care priorities (12.6% vs. 4.4%, p = 0.019), as compared to those in primary-care settings. As compared to advanced-practice providers and nursing staff, physicians were less likely to have strong confidence in their department’s ability to solve MU implementation problems (28.4% vs. 47.1% vs. 42.6%, p = 0.023) and to report strong willingness to change their work practices for MU (57.9% vs. 83.3% vs. 82.0%, p < 0.001). Finally, provider/staff perceptions about whether MU aligns with departmental goals (OR = 3.99, 95% confidence interval (CI) = 2.13 to 7.48); MU will divert attention from other patient-care priorities (OR = 2.26, 95% CI = 1.26 to 4.06); their department will support MU-related change efforts (OR = 3.99, 95% CI = 2.13 to 7.48); and their department will be able to solve MU implementation problems (OR = 2.26, 95% CI = 1.26 to 4.06) were associated with their willingness to change practice behavior for MU.
Organizational leaders should gauge provider/staff perceptions about appropriateness and management support of MU-related change, as these perceptions might be related to subsequent implementation.
PMCID: PMC4272806  PMID: 25495926
18.  Brief Assessment of Readiness to Change Tobacco Use in Treated Youth 
This study examined the concurrent and predictive validity of four brief measures of readiness to change tobacco use for use with adolescents in clinical practice: Readiness Ruler, Thoughts About Abstinence (TAA), motivation to abstain, and confidence to abstain; and a single-item measure of difficulty to abstain. Participants were 154 adolescent smokers recruited from outpatient addictions treatment, who completed assessments shortly after admission, and at 6- and 12-month follow-up. Concurrent validity analyses indicated that the four readiness measures were moderately correlated at each time point. Predictive validity analyses indicated that Ruler and motivation to abstain ratings predicted number of cigarettes smoked at 6- and 12-months. Perceived difficulty to abstain predicted cigarette use over and above the readiness to change measures. Results support the clinical utility of the Ruler and motivation to abstain as brief measures of readiness to change, and perceived difficulty to abstain, as tools to aid adolescent tobacco cessation.
PMCID: PMC3137741  PMID: 21489740
readiness to change; tobacco; adolescent; substance abuse treatment
19.  Alcohol Craving in Patients Diagnosed with a Severe Mental Illness and Alcohol Use Disorder: Bi-Directional Relationships between Approach and Avoidance Inclinations and Drinking 
The current study was undertaken to better understand the craving-drinking relationship among individuals dually diagnosed with a severe mental illness (SMI) and an alcohol use disorder (AUD). Using an ambivalence conceptualization of craving (Breiner et al., 1999), we investigated the bi-directional relationships between desires and behavioral intentions to use (approach inclinations) and not use (avoidance inclinations) alcohol and drinking outcomes in patients diagnosed with a SMI-AUD.
Patients (N = 278) seeking outpatient dual diagnosis treatment from a community mental health center were followed longitudinally over the course of 6 months. Assessments at baseline, 2-month, 4-month, and 6-month intervals included approach and avoidance inclinations, alcohol urges, readiness to change, and drinking outcomes.
Time-lagged multilevel growth curve modeling found that avoidance inclinations moderated the effect of approach inclinations on subsequent drinking outcomes differentially over time. Specifically, avoidance inclinations attenuated the effect of approach on subsequent heavier drinking levels, and high avoidance/low approach demonstrated significant decreases on levels of drinking over time. Results also indicated that number of drinks consumed and heavy drinking days predicted subsequent approach inclinations differentially over time, such that lower levels of drinking predicted decreases in approach inclinations. Decreases in drinking also predicted higher subsequent avoidance inclinations, which were maintained over time.
These findings highlight the complexity of subjective craving responses and the importance of measuring both approach and avoidance inclinations. Among those diagnosed with SMI-AUDs, treatment strategies that increase avoidance inclinations may increase abstinence rates in this difficult-to-treat population.
PMCID: PMC3938894  PMID: 23895085
20.  Social anxiety and drinking refusal self-efficacy moderate the relationship between drinking game participation and alcohol-related consequences 
Participation in drinking games is associated with excessive drinking and alcohol risks. Despite the growing literature documenting the ubiquity and consequences of drinking games, limited research has examined the influence of psychosocial factors on the experience of negative consequences as the result of drinking game participation.
The current event-level study examined the relationships among drinking game participation, social anxiety, drinking refusal self-efficacy (DRSE) and alcohol-related consequences in a sample of college students.
Participants (n =976) reported on their most recent drinking occasion in the past month in which they did not preparty.
After controlling for sex, age, and typical drinking, higher levels of social anxiety, lower levels of DRSE, and playing drinking games predicted greater alcohol-related consequences. Moreover, two-way interactions (Social Anxiety × Drinking Games, DRSE × Drinking Games) demonstrated that social anxiety and DRSE each moderated the relationship between drinking game participation and alcohol-related consequences. Participation in drinking games resulted in more alcohol problems for students with high social anxiety, but not low social anxiety. Students with low DRSE experienced high levels of consequences regardless of whether they participated in drinking games; however, drinking game participation was associated with more consequences for students confident in their ability to resist drinking.
Findings highlight the important role that social anxiety and DRSE play in drinking game-related risk, and hence provide valuable implications for screening at-risk students and designing targeted harm reduction interventions that address social anxiety and drink refusal in the context of drinking games.
PMCID: PMC4331114  PMID: 25192207
College alcohol use; drinking games; self-efficacy; social anxiety
21.  Characteristics and predictors of readiness to quit among emergency medical patients presenting with respiratory symptoms 
To examine behavioral factors that lead patients to consider quitting smoking and features associated with readiness to quit among adults who are seeking treatment in the emergency department (ED) for respiratory symptoms.
A toal of 665 adult smokers seeking treatment in an ED for respiratory symptoms and respiratory illness answered survey questions during the ED visit.
Patients self-reported "readiness to quit" was broadly distributed among this patient population. Patients with COPD, pneumonia or asthma perceived higher risks from smoking than other patients with respiratory complaints. Over half of all participants had scores indicative of depression. Regression analysis showed that prior efforts to quit, confidence, perceived importance of quitting and decisional balance were each significantly predictive of readiness to quit, accounting for 40% of the variance.
While many of these patients appear unaware of the connection between their symptoms and their smoking, patients with diagnosed chronic respiratory illness perceived higher risks from their smoking. In patients who do not perceive these risks, physician intervention may increase perceived risk from smoking and perceived importance of quitting. Interventions designed for the ED setting targeting this patient population should consider screening for depressive symptoms and, when appropriate, making referrals for further evaluation and/or treatment. Medications that can help alleviate depression and withdrawal symptoms while quitting smoking, such as bupropion, may be particularly useful for this subset of patients, as depression is a substantial barrier to quitting.
PMCID: PMC3120652  PMID: 21645378
22.  Prospective Analysis of Early Lapse to Drinking and Smoking Among Individuals in Concurrent Alcohol and Tobacco Treatment 
The aims of the current study were to examine, prospectively, 1) dynamic changes in affective state, self-efficacy, and urge in the hours before initial smoking and drinking lapses among individuals in concurrent alcohol and smoking treatment, and 2) the extent to which self-efficacy, urge to use, and/or the use of one substance predicted lapse to the other substance. Ninety-six men and women recruited for a clinical trial of concurrent alcohol and tobacco treatment were eligible for inclusion. Only data from those who experienced an initial lapse to drinking (n=29), or smoking (n=32) were included. Two outpatient substance abuse clinics provided concurrent alcohol and smoking treatment on a weekly basis for three months. Ecological Momentary Assessment (EMA) methods were employed over a 28-day monitoring period to assess antecedents to first drink and a 14-day monitoring period was examined for initial smoking lapses. Baseline and EMA measures of positive and negative affect, alcohol/smoking urge, alcohol/smoking abstinence self-efficacy, nicotine withdrawal, and quantity/frequency of alcohol and tobacco use were examined as lapse predictors. Analyses of EMA ratings controlled for the corresponding baseline measure. Smoking lapse among individuals in concurrent alcohol and tobacco treatment was foreshadowed by higher urges to smoke, lower positive mood, and lower confidence to resist smoking. Drinking lapse was preceded by lower confidence to resist smoking, but only among individuals who reported recent smoking. Concurrent alcohol and smoking treatment should focus on the enhancement of abstinence self-efficacy, positive mood, and the curbing of urges in order to offset lapse risk.
PMCID: PMC3336035  PMID: 22023022
alcoholism treatment; smoking cessation; ecological momentary assessment; smoking relapse; drinking relapse
23.  Readiness for Smoke-free Policy and Overall Strength of Tobacco Control in Rural Tobacco-growing Communities 
Health promotion practice  2012;14(2):238-246.
Rural, tobacco-growing areas are disproportionately affected by tobacco use, secondhand smoke, and weak policies. The study determined whether overall strength of Resources, Capacity and Efforts in tobacco control predicts readiness for smoke-free policy in rural communities, controlling for county population size and pounds of tobacco produced. This was a correlational, cross-sectional analysis of data from key informants (n = 148) and elected officials (n = 83) from 30 rural counties who participated in telephone interviews examining smoke-free policy. Six dimensions of community readiness (knowledge, leadership, resources, community climate, existing smoke-free policies, and political climate) were identified and summed to assess overall readiness for smoke-free policy. General strength of overall Resources, Capacity and Efforts in tobacco control at the county level was measured. Readiness for smoke-free policy was lower in communities with higher smoking rates, higher tobacco production, and smaller population. Efforts related to general tobacco control (i.e., media advocacy, training and technical assistance) predicted readiness for local smoke-free policy development (standardized β=.35, p=.05), controlling for county population size and pounds of tobacco produced. Given that small, rural tobacco-growing communities are least ready for smoke-free policy change, tailoring and testing culturally sensitive approaches that account for this tobacco-growing heritage are warranted.
PMCID: PMC3584198  PMID: 22773621
public policy; environmental tobacco smoke; advocacy; community readiness
24.  Injuries, negative consequences, and risk behaviors among both injured and uninjured emergency department patients who report using alcohol and marijuana 
Brief intervention (BI) to reduce hazardous drinking and negative consequences such as injury has been effective when given in the emergency department (ED). The effectiveness and effect of BI has varied between injured and uninjured ED patients. This study compares injured and uninjured ED patients who admit to alcohol and marijuana use to determine their need and their readiness for BI.
Patients and Methods:
Participants volunteered to enter a randomized controlled trial of BI to reduce hazardous alcohol and marijuana use. Adult ED patients who had had alcohol in the last month and smoked marijuana in the last year were recruited. Those patients who were admitted to hospital, were under police custody, or were seeking treatment for substance use or psychiatric disorder were excluded. Research assistants interviewed participants using a validated questionnaire. Data were analyzed using SAS (version 9.1). Binominal tests of proportions, t-test analyses, and transformations were conducted as appropriate.
Injured (n = 249) and uninjured (n = 266) study participants reported very high, statistically equivalent (P > 0.05), rates of binge drinking (4–5 days/month), marijuana use (13 days/month), driving under the influence of marijuana or alcohol (>49% in the last 3 months), injury (>83% in the last year), and other negative consequences (>64% in the last 3 months) prior to their ED visit. These behaviors and the consequences demonstrate a need for change. Both injured and uninjured subjects were ready to change (>56%) and confident they could change (>91%) alcohol and marijuana use.
ED patients who admit to alcohol and marijuana use also use other hazardous substances and participate in high-risk behaviors. In both injured and uninjured patients who admit using alcohol and marijuana, the ED visit is an opportunity to deliver BI to reduce alcohol and marijuana use and associated risk behaviors and the subsequent injury and negative consequences. Given their risk behaviors and experience of negative consequences, members of both injured and uninjured groups have an equal need for BI. Fortunately, in both groups, a high number of members express motivation to change.
PMCID: PMC2700582  PMID: 19561952
Alcohol; brief intervention; injury prevention; marijuana
Drug and alcohol dependence  2011;118(1):78-82.
It is known that daily smoking is associated with the development of alcohol use disorders. However, non-daily smoking is prevalent in young adults and is associated with increased rates of problematic alcohol use in cross-sectional data. It is unknown whether non-daily smoking is predictive of hazardous drinking and alcohol use disorders using longitudinal data. The primary aim of the present investigation was to explore the temporal relationship between non-daily smoking and drinking in young adults, and secondarily, whether college status modified this relationship.
Using Waves 1 (2001–2002) and 2 (2004–2005) of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), we examined the predictive relationship of smoking status at Wave 1 and change in college status between Waves on alcohol drinking, hazardous drinking, and alcohol abuse and dependence disorders at Wave 2. The sample was restricted to individuals aged 18–25 years at Wave 1.
Daily and non-daily smokers at Wave 1, compared to nonsmokers, were at a greater risk for hazardous drinking and alcohol use disorders at Wave 2, after controlling for Wave 1 drinking. College status did not modify smoking and drinking interactions.
The findings indicate non-daily smoking is predictive of increased, problematic alcohol use among young adults longitudinally and they support increasing evidence that non-daily smokers represent an important population. Future research should be conducted to continue developing targeted interventions. Early treatments for smoking behavior might have a beneficial effect on reducing the development of problematic patterns of alcohol use and alcohol use disorders.
PMCID: PMC3134579  PMID: 21441000
young adults; smoking; alcohol; NESARC; hazardous drinking

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