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1.  Financial Incentives for Smoking Cessation Among Depression-Prone Pregnant and Newly Postpartum Women: Effects on Smoking Abstinence and Depression Ratings 
Nicotine & Tobacco Research  2015;17(4):455-462.
We examined whether pregnant and newly postpartum smokers at risk for postpartum depression respond to an incentive-based smoking-cessation treatment and how the intervention impacts depression ratings.
This study is a secondary data analysis. Participants (N = 289; data collected 2001–2013) were smokers at the start of prenatal care who participated in 4 controlled clinical trials on the efficacy of financial incentives for smoking cessation. Women were assigned either to an intervention wherein they earned vouchers exchangeable for retail items contingent on abstaining from smoking or to a control condition wherein they received vouchers of comparable value independent of smoking status. Treatments were provided antepartum through 12-weeks postpartum. Depression ratings (Beck Depression Inventory [BDI]-1A) were examined across 7 antepartum/postpartum assessments. Women who reported a history of prior depression or who had BDI scores ≥ 17 at the start of prenatal care were categorized as depression-prone (Dep+), while those meeting neither criterion were categorized as depression-negative (Dep−).
The intervention increased smoking abstinence independent of depression status (p < .001), and it decreased mean postpartum BDI ratings as well as the proportion of women scoring in the clinical range (≥17 and >21) compared with the control treatment (ps ≤ .05). Treatment effects on depression ratings were attributable to changes in Dep+ women.
These results demonstrate that depression-prone pregnant and newly postpartum women respond well to this incentive-based smoking-cessation intervention in terms of achieving abstinence, and the intervention also reduces the severity of postpartum depression ratings in this at-risk population.
PMCID: PMC4402351  PMID: 25762756
2.  Some Observations from Behavioral Economics for Consideration in Promoting Money Management among Those with Substance Use Disorders 
Behavioral economics research has revealed systematic biases in decision making that merit consideration in efforts to promote money management skills among those with substance use disorders (SUDs).
The objective of this article was to briefly review the literature on five of those biases (i.e., hyperbolic delay discounting, defaults and preference for the status quo, loss aversion, mental accounting, and failure to account for opportunity cost) that may have particular relevance to the topic of money management.
Selected studies are reviewed to illustrate these biases and how they may relate to efforts to promote money management skills among those with substance use disorders. Studies were identified by searching PubMed using the terms “behavioral economics” and “substance use disorders”, reviewing bibliographies of published articles, and discussions with colleagues.
Only one of these biases (i.e., hyperbolic delay discounting) has been investigated extensively among those with SUDs. Indeed, it has been found to be sufficiently prevalent among those with SUDs to be considered as a potential risk factor for those disorders and certainly merits careful consideration in efforts to improve money management skills in that population. There has been relatively little empirical research reported regarding the other biases among those with SUDs, although they appear to be sufficiently fundamental to human behavior and relevant to the topic of money management (e.g., loss aversion) to also merit consideration. There is precedent of effective leveraging of behavioral economics principles in treatment development for SUDs (e.g., contingency management), including at least one intervention that explicitly focuses on money management (i.e., advisor–teller money management therapy).
Conclusions and Scientific Significance
The consideration of the systematic biases in human decision making that have been revealed in behavioral economics research has the potential to enhance efforts to devise effective strategies for improving money management skills among those with SUDs.
PMCID: PMC4789152  PMID: 22211484
behavioral economics; substance use disorders; money management; delay discounting; self-control
3.  Editorial: 2nd Special Issue on behavior change, health, and health disparities 
Preventive medicine  2015;80:1-4.
This Special Issue of Preventive Medicine (PM) is the 2nd that we have organized on behavior change, health, and health disparities. This is a topic of fundamental importance to improving population health in the U.S. and other industrialized countries that are trying to more effectively manage chronic health conditions. There is broad scientific consensus that personal behavior patterns such as cigarette smoking, other substance abuse, and physical inactivity/obesity are among the most important modifiable causes of chronic disease and its adverse impacts on population health. As such behavior change needs to be a key component of improving population health. There is also broad agreement that while these problems extend across socioeconomic strata, they are overrepresented among more economically disadvantaged populations and contribute directly to the growing problem of health disparities. Hence, behavior change represents an essential step in curtailing that unsettling problem as well. In this 2nd Special Issue, we devote considerable space to the current U.S. prescription opioid addiction epidemic, a crisis that was not addressed in the prior Special Issue. We also continue to devote attention to the two largest contributors to preventable disease and premature death, cigarette smoking and physical inactivity/obesity as well as risks of co-occurrence of these unhealthy behavior patterns. Across each of these topics we included contributions from highly accomplished policymakers and scientists to acquaint readers with recent accomplishments as well as remaining knowledge gaps and challenges to effectively managing these important chronic health problems.
PMCID: PMC4778247  PMID: 26257372
Behavior change; Chronic health conditions; Cigarette smoking; Tobacco use; Health disparities; Obesity; Prescription opioid abuse; Lifestyle; Behavioral economics
4.  Yaws 
International Journal of STD & AIDS  2014;26(10):696-703.
Yaws is a non-venereal endemic treponemal infection caused by Treponema pallidum sub-species pertenue, a spirochaete bacterium closely related to Treponema pallidum ssp. pallidum, the agent of venereal syphilis. Yaws is a chronic, relapsing disease predominantly affecting children living in certain tropical regions. It spreads by skin-to-skin contact and, like syphilis, occurs in distinct clinical stages. It causes lesions of the skin, mucous membranes and bones which, without treatment, can become chronic and destructive. Treponema pallidum ssp. pertenue, like its sexually-transmitted counterpart, is exquisitely sensitive to penicillin. Infection with yaws or syphilis results in reactive treponemal serology and there is no widely available test to distinguish between these infections. Thus, migration of people from yaws-endemic areas to developed countries may present clinicians with diagnostic dilemmas. We review the epidemiology, clinical presentation and treatment of yaws.
PMCID: PMC4655361  PMID: 25193248
Syphilis; Yaws; Treponema pallidum pertenue; non-venereal endemic syphilis; neglected tropical diseases
5.  Racial Differences in Breast Cancer, Cardiovascular Disease, and All-Cause Mortality Among Women with Ductal Carcinoma In Situ of the Breast 
Ductal carcinoma in situ (DCIS) of the breast represents 15-20% of new breast cancer diagnoses in the U.S. annually. However, long-term competing risks of mortality, as well as racial differences in outcomes among US women with DCIS are unknown.
Case data from the years 1978-2010 was obtained using SEER*Stat software available through the National Cancer Institute from the 2010 SEER registries. Included were all women aged 40 and over with newly diagnosed DCIS. There were 67,514 women in the analysis, including 54,518 white women and 6,113 black women.
A total of 12,173 deaths were observed over 607,287 person-years of follow-up. The 20-year cumulative incidence of all-cause death among women with DCIS was 39.6% (CI: 38.9-40.3). The corresponding 20-year rates for breast cancer death and CVD death were 3.2% (CI: 3.0-3.4) and 13.2% (CI: 12.8-13.7), respectively. Black women with DCIS had a higher risk of death compared to white women, with these hazard ratios elevated throughout the entire study period. For example, between 1990 and 2010, black women had a higher risk of all-cause death (HR 3.06, CI: 2.39-3.91), breast cancer death (HR 5.78, CI: 3.16-10.57), and CVD death (HR 6.43, CI: 3.61-11.45) compared to white women diagnosed between 50-59 years of age.
The risk of all-cause and CVD death was greater than breast cancer death among women diagnosed with DCIS over 20 years. Black women had higher risks of dying from all-causes compared to white women. These differences persisted into the modern treatment era.
PMCID: PMC4372117  PMID: 25326349
epidemiology; racial differences; ductal carcinoma in situ; cardiovascular mortality; breast cancer mortality
6.  Examining Two Different Schedules of Financial Incentives for Smoking Cessation Among Pregnant Women 
Preventive medicine  2014;0:51-57.
To examine whether an efficacious voucher-based incentives intervention for decreasing smoking during pregnancy and increasing fetal growth could be improved without increasing costs. The strategy was to redistribute the usual incentives so that higher values were available early in the quit attempt.
118 pregnant smokers in greater Burlington, VT (studied 2006–2011) were randomly assigned to the revised (RCV) or usual (CV) schedule of abstinence-contingent vouchers, or to a non-contingent vouchers (NCV) control condition wherein vouchers were provided independent of smoking status. Smoking status was biochemically verified; serial sonographic estimates of fetal growth were obtained at gestational weeks 30–34.
RCV and CV conditions increased point-prevalence abstinence above NCV levels at early (RCV: 40%, CV: 46%, NCV: 13%, p = .007) and late-pregnancy (RCV: 45%; CV: 36%; NCV, 18%; p = .04) assessments, but abstinence levels did not differ between the RCV and CV conditions. The RCV intervention did not increase fetal growth above control levels while the CV condition did so (p < .05).
This trial further supports the efficacy of CV for increasing antepartum abstinence and fetal growth, but other strategies (e.g., increasing overall incentive values) will be necessary to improve outcomes further.
PMCID: PMC4183736  PMID: 24704135
financial incentives; vouchers; contingency management; tobacco; pregnancy; smoking cessation; fetal growth; birth outcomes
7.  Examining the Timing of Changes in Cigarette Smoking Upon Learning of Pregnancy 
Preventive medicine  2014;0:58-61.
Objective and Method
Timeline Follow-back interviews were conducted with 107 pregnant women enrolling in smoking cessation and relapse prevention clinical trials in the Burlington, VT area between 2006–2009 to examine the time course of changes in smoking between learning of pregnancy and the first prenatal care visit. We know of no systematic studies of this topic.
Women reported learning of pregnancy at 5.1 ± 2.2 weeks gestation and attending a first prenatal care visit at 10.1 ± 3.6 weeks gestation. In the intervening five weeks, 22% of women became abstainers, 62% reduced their smoking, and 16% maintained or increased their smoking. Women who made changes typically reported doing so within the first 2 days after learning of pregnancy, with few changes occurring beyond the first week after learning of pregnancy.
In this first effort to systematically characterize the time course of changes in smoking upon learning of pregnancy, the majority of pregnant smokers who quit or made reductions reported doing so soon after receiving the news. Further research is needed to assess the reliability of these results and to examine whether devising strategies to provide early interventions for women who continue smoking after learning of pregnancy are warranted.
PMCID: PMC4252916  PMID: 25016042
8.  Borrowing from tobacco control to curtail the overweight and obesity epidemic: Leveraging the U.S. Surgeon General's Report 
Preventive medicine  2015;80:47-49.
There is broad agreement that more needs to be done to curtail the U.S. overweight and obesity epidemic. Fifty years of regular Surgeon General's Reports on the health consequences of smoking appear to have been a highly effective contributor to the notable successes that have been made in reducing smoking prevalence. Comparing the rate of Surgeon General's Reports on smoking and obesity reveals striking differences, with more than a five-fold lower rate of reporting on the latter. Developing practices that more effectively leverage the power of the U.S. Surgeon General's Office in efforts to reduce obesity is a relatively straightforward but potentially powerful additional step that warrants consideration.
PMCID: PMC4490146  PMID: 25562755
Cigarette smoking; Tobacco control; Obesity; U.S. Surgeon General's Report
9.  The Basic Helix-Loop-Helix/Leucine Zipper Transcription Factor USF2 Integrates Serum-Induced PAI-1 Expression and Keratinocyte Growth 
Journal of cellular biochemistry  2014;115(10):1840-1847.
Plasminogen activator inhibitor type-1 (PAI-1), a major regulator of the plasmin-dependent pericellular proteolytic cascade, is prominently expressed during the tissue response to injury although the factors that impact PAI-1 induction and their role in the repair process are unclear. Kinetic modeling using established biomarkers of cell cycle transit (c-MYC; cyclin D1; cyclin A) in synchronized human (HaCaT) keratinocytes, and previous cytometric assessments, indicated that PAI-1 transcription occurred early after serum-stimulation of quiescent (G0) cells and prior to G1 entry. It was established previously that differential residence of USF family members (USF1→USF2 switch) at the PE2 region E box (CACGTG) characterized the G0→G1 transition period and the transcriptional status of the PAI-1 gene. A consensus PE2 E box motif (5′-CACGTG-3′) at nucleotides -566 to -561 was required for USF/E box interactions and serum-dependent PAI-1 transcription. Site-directed CG→AT substitution at the two central nucleotides inhibited formation of USF/probe complexes and PAI-1 promoter-driven reporter expression. A dominant-negative USF (A-USF) construct or double-stranded PE2 “decoy” attenuated serum- and TGF-β1-stimulated PAI-1 synthesis. Tet-Off induction of an A-USF insert reduced both PAI-1 and PAI-2 transcripts while increasing the fraction of Ki-67+ cells. Conversely, overexpression of USF2 or adenoviral-delivery of a PAI-1 vector inhibited HaCaT colony expansion indicating that the USF1→USF2 transition and subsequent PAI-1 transcription are critical events in the epithelial go-or-grow response. Collectively, these data suggest that USF2, and its target gene PAI-1, regulate serum-stimulated keratinocyte growth, and likely the cadence of cell cycle progression in replicatively-competent cells as part of the injury repair program.
PMCID: PMC4134751  PMID: 24905330
PAI-1; USF; transcription; keratinocytes; gene regulation; expression profiling; SERPINE1
10.  Spontaneous Reductions in Smoking during Double-blind Buprenorphine Detoxification 
Addictive behaviors  2014;39(9):1353-1356.
Evidence suggests a positive association between administration of psychoactive drugs and rates of cigarette smoking. Prevalence of smoking among opioid-dependent individuals, for example, is four times greater than the general population. We recently completed a randomized double-blind trial evaluating outpatient buprenorphine taper for prescription opioid (PO) abusers, which provided an unique opportunity to examine naturalistic changes in smoking among participants who detoxified without resumption of illicit opioid use. Participants received no smoking-cessation services and were not encouraged to alter their smoking in any way. A subset of 10 opioid-dependent smokers, who were randomized to receive the same 4-week buprenorphine taper and successfully completed detoxification, were included in the present study. They provided staff-observed urine specimens thrice-weekly throughout the 12-week trial. Specimens were analyzed onsite via enzyme-multiplied immunoassay for urinary cotinine, a metabolite of nicotine that provides a sensitive biochemical measure of smoking status. Mean cotinine levels were significantly different across study phases, with significantly lower cotinine levels during taper (1317.5 ng/ml) and post-taper (1015.8 ng/ml) vs. intake (1648.5 ng/ml) phases (p’s<.05). Overall, mean cotinine levels decreased by 38% between intake and end-of-study, reflecting a reduction of approximately eight cigarettes per day. These data provide additional evidence that opioids influence smoking and extend prior findings to include primary PO abusers, rigorous double-blind opioid dosing conditions and urinary cotinine. These results also suggest that, while likely insufficient for complete cessation, patients who successfully taper from opioids may also experience concurrent reductions in smoking and thus may be ideal candidates for smoking cessation services.
PMCID: PMC4083850  PMID: 24845165
smoking; cigarettes; buprenorphine; opioid; detoxification
11.  Examining Vulnerability to Smokeless Tobacco Use Among Adolescents and Adults Meeting Diagnostic Criteria for Major Depressive Disorder 
Smoking prevalence is unevenly distributed in the U.S. population, with those with mental illness, other substance use disorders, and lower socioeconomic status being especially vulnerable. Less research has been conducted on the association between these same vulnerabilities and smokeless tobacco (ST) use. The present study examined cigarette and ST use among adolescents and adults who met diagnostic criteria for major depressive disorder in the National Survey on Drug Use and Health (NSDUH).
Utilizing the most recent (2011) NSDUH, we compared odds for current cigarette smoking and ST use among adolescents and adults meeting criteria for past-year major depressive disorder to the general population, after adjusting for potential confounding influences of sociodemographic and other substance use characteristics. Analyses were conducted to examine sex as a moderator of the relation between major depressive disorder and tobacco use.
Odds for current cigarette smoking among those classified with major depressive disorder were increased among adolescents (OR with 95% CI = 1.33 [1.05, 1.69], p = 0.021) and adults (OR = 1.70 [1.47, 1.97], p < .0005), while odds for current ST use did not differ among adolescents (OR = 0.90 [0.54, 1.49], p = 0.678) and were lower among adults (OR = 0.68 [0.51, 0.91], p = 0.010). Sex was not a significant moderator in adolescents or adults.
Major depressive disorder is associated with increased risk for smoking but not ST use among adolescents and adults further demonstrating heterogeneity in predictors of vulnerability to use of different tobacco products.
PMCID: PMC4124457  PMID: 24978349
smokeless tobacco; cigarette smoking; epidemiology; major depression; NSDUH
12.  State-by-State Variations in Cardiac Rehabilitation Participation Are Associated With Educational Attainment, Income, and Program Availability 
Wide geographic variations in cardiac rehabilitation (CR) participation in the United States have been demonstrated but are not well understood. Socioeconomic factors such as educational attainment are robust predictors of many health-related behaviors, including smoking, obesity, physical activity, substance abuse, and cardiovascular disease. We investigated potential associations between state-level differences in educational attainment, other socioeconomic factors, CR program availability, and variations in CR participation.
A retrospective database analysis was conducted using data from the US Census Bureau, the Centers for Disease Control and Prevention, and the 1997 Medicare database. The outcome of interest was CR participation rates by state, and predictors included state-level high school (HS) graduation rates (in 2001 and 1970), median household income, smoking rates, density of CR program (programs per square mile and per state population), sex and race ratios, and median age.
The relationship between HS graduation rates and CR participation by state was significant for both 2001 and 1970 (r = 0.64 and 0.44, respectively, P < .01). Adding the density of CR programs (per population) and income contributed significantly with a cumulative r value of 0.74 and 0.71 for the models using 2001 and 1970, respectively (Ps < .01). The amount of variance accounted for by each of the 3 variables differed between the 2000 and 1970 graduation rates, but both models were unaltered by including additional variables.
State-level HS graduation rates, CR programs expressed as programs per population, and median income were strongly associated with geographic variations in CR participation rates.
PMCID: PMC4098712  PMID: 24820451
education; income; program availability; state cardiac rehabilitation participation
14.  Maternal Body Mass Index Moderates the Influence of Smoking Cessation on Breast Feeding 
Nicotine & Tobacco Research  2013;16(5):527-535.
Smoking cessation is associated with greater breast feeding in newly postpartum women, while being overweight or obese is associated with lower rates of breast feeding. The purpose of this study is to examine whether the increases in breast feeding associated with smoking cessation are moderated by maternal body mass index (BMI). To our knowledge, the interaction of maternal smoking status and overweight/obesity on breast feeding has not been previously reported.
Participants (N = 370) were current or recent smokers at the start of prenatal care who participated in controlled trials on smoking cessation or relapse prevention during/after pregnancy. Study participants were followed from the start of prenatal care through 24 weeks postpartum. Smoking status was biochemically verified, and maternal reports of breast feeding were collected at 2-, 4-, 8-, 12-, and 24-week postpartum assessments.
Women who reported postpartum smoking abstinence or had a normal/underweight prepregnancy BMI (<25) were more likely to be breast feeding at the time that smoking status was ascertained (odds ratio [OR] = 3.02, confidence interval [CI] = 2.09–4.36, and OR = 2.07, CI = 1.37–3.12, respectively). However, smoking status and BMI interacted such that (a) normal/underweight women showed a stronger association between smoking abstinence and breast feeding (OR = 4.58, CI = 2.73–7.66) than overweight/obese women (OR = 1.89, CI = 1.11–3.23), and (b) abstainers showed an association between normal/underweight BMI and breast feeding (OR = 3.53, CI = 1.96–6.37), but smokers did not (OR = 1.46, CI = 0.88–2.44).
Overweight/obesity attenuates the positive relationship between smoking abstinence and greater breast feeding among newly postpartum women.
PMCID: PMC3977482  PMID: 24203932
Addiction (Abingdon, England)  2015;110(4):690-692.
PMCID: PMC4412735  PMID: 25771694
Contingency management; financial incentives; pregnancy; smoking cessation; vouchers
16.  Does Impulsiveness Moderate Response to Financial Incentives for Smoking Cessation Among Pregnant and Newly Postpartum Women? 
We examined whether impulsiveness moderates response to financial incentives for cessation among pregnant smokers. All participants were randomized to either a condition wherein financial incentives were delivered contingent on smoking abstinence or to a control condition wherein incentives were delivered independent of smoking status. The study was conducted in two steps: First, we examined associations between baseline impulsiveness scores and abstinence at late pregnancy and 24-weeks postpartum as part of a planned prospective study of this topic using data from a recently completed, randomized controlled clinical trial (N = 118). Next, to increase statistical power, we conducted a second analysis collapsing results across that recent trial and two prior trials involving the same contingent incentive and control conditions (N = 236). Impulsivity was assessed using a delay discounting (DD) of hypothetical monetary rewards task in all three trials and Barratt Impulsiveness Scale (BIS) in the most recent trial. Neither DD nor BIS predicted antepartum or postpartum smoking status in the single or combined trials. Receiving abstinence-contingent incentives, lower baseline smoking rate (cigs/day), and a history of quit attempts pre-pregnancy predicted greater odds of antepartum abstinence across the single and combined trials. No variable predicted postpartum abstinence across the single and combined trials, although a history of antepartum quit attempts and receiving abstinence-contingent incentives predicted in the single and combined trials, respectively. Overall, this study provides no evidence that impulsiveness as assessed by DD or BIS moderates response to this treatment approach while underscoring a substantial association of smoking rate and prior quit attempts with abstinence across the contingent incentives and control treatment conditions.
PMCID: PMC4388785  PMID: 25730417
Pregnant smokers; Contingency management; Financial Incentives; Impulsivity; Impulsiveness; Smoking Cessation
17.  Behavior change, health, and health disparities: An introduction 
Preventive medicine  2014;68:1-4.
This Special Issue of Preventive Medicine (PM) focuses on behavior change, health, and health disparities, topics of fundamental importance to improving population health in the U.S. and other industrialized countries. While the U.S. health care system and those of other industrialized countries were developed to manage infectious disease and acute illnesses, it is chronic health conditions that most need to be understood and managed in the 21st century. The evidence is clear that personal behavior patterns like cigarette smoking and physical inactivity/obesity are critically important proximal causes of chronic disease (cardiovascular disease, site-specific cancers, type-2 diabetes) and as such behavior change will need to be a key component of their management. As the outstanding contributions to this Special Issue illustrate, substantial headway is being made in advancing knowledge including developing effective prevention and treatment strategies, with cigarette smoking being an excellent example that change is possible. That said, cigarette smoking continues to be responsible for approximately 480,000 premature deaths annually in the U.S. alone and 5 million globally. So more needs to be done, especially in economically disadvantaged populations. The same certainly applies to the challenges of the obesity epidemic, which of course is a more recent problem and understandably efforts to curtail it are in earlier stages of development.
PMCID: PMC4338024  PMID: 25456804
18.  Characterizing and Improving HIV and Hepatitis Knowledge Among Primary Prescription Opioid Abusers 
Drug and alcohol dependence  2013;133(2):10.1016/j.drugalcdep.2013.08.007.
The high rates of HIV and Hepatitis C (HCV) infection among opioid abusers is a serious public health problem, and efforts to enhance knowledge regarding risks for HIV/hepatitis infection in this population are important. Abuse of prescription opioids (PO), in particular, has increased substantially in the past decade and is associated with increasing rates of injection drug use and HCV infection.
This study describes the effects of a brief HIV/HCV educational intervention delivered in the context of a larger randomized, double-blind clinical trial evaluating the relative efficacy of 1-, 2-, and 4-week outpatient buprenorphine tapers and subsequent oral naltrexone maintenance for treating PO dependence. HIV- and HCV-related knowledge and risk behaviors were characterized pre- and post-intervention in 54 primary PO abusers.
The educational intervention was associated with significant improvements in HIV (p<.001) and HCV (p<.001) knowledge. Significant improvements (p<.001) were observed on all three domains of the HIV questionnaire (i.e., general knowledge, sexual risk behaviors, drug risk behaviors) and on 21 and 11 individual items on the HIV and HCV questionnaires, respectively. Self-reported likelihood of using a condom also increased significantly (p<.05) from pre- to post-intervention. No additional changes in self-reported risk behaviors were observed.
These results suggest that a brief, easy-to-administer intervention is associated with substantial gains in HIV and HCV knowledge among PO abusers and represents the necessary first step towards the dissemination of a structured prevention HIV and HCV intervention for PO abusers.
PMCID: PMC3824383  PMID: 24051063
HIV; hepatitis C; noninjection; injection; education; intervention; opioids; prescription opioids; treatment; buprenorphine
19.  Examining Educational Attainment, Pre-Pregnancy Smoking Rate, and Delay Discounting as Predictors of Spontaneous Quitting Among Pregnant Smokers 
We investigated three potential predictors (educational attainment, pre-pregnancy smoking rate, and delay discounting [DD]) of spontaneous quitting among pregnant smokers. These predictors were examined alone and in combination with other potential predictors using study-intake assessments from controlled clinical trials examining the efficacy of financial incentives for smoking cessation and relapse prevention. Data from 349 pregnant women (231 continuing smokers and 118 spontaneous quitters) recruited from the greater Burlington, Vermont area contributed to this secondary analysis, including psychiatric/sociodemographic characteristics, smoking characteristics, and performance on a computerized DD task. Educational attainment, smoking rate, and DD values were each significant predictors of spontaneous quitting in univariate analyses. A model examining those three predictors together retained educational attainment as a main effect and revealed a significant interaction of DD and smoking rate (i.e., DD was a significant predictor at lower but not higher smoking rates). A final model considering all potential predictors included education, the interaction of DD and smoking rate, and five additional predictors (i.e., stress ratings, the belief that smoking during pregnancy will “greatly harm my baby,” age of smoking initiation, marital status, and prior quit attempts during pregnancy. The present study contributes new knowledge on predictors of spontaneous quitting among pregnant smokers with substantive practical implications for reducing smoking during pregnancy.
PMCID: PMC4180793  PMID: 25069014
delay discounting; pregnancy; cigarette smoking; health disparities; spontaneous quitting
20.  A Randomized, Double-blind Evaluation of Buprenorphine Taper Duration in Primary Prescription Opioid Abusers 
JAMA psychiatry  2013;70(12):1347-1354.
Although abuse of prescription opioids (POs) is a significant public health problem, few experimental studies have investigated the treatment needs of this growing population.
To evaluate, following brief stabilization with a combination of buprenorphine hydrochloride and naloxone hydrochloride dihydrate, the relative efficacy of 1-, 2-, and 4-week buprenorphine tapering regimens and subsequent naltrexone hydrochloride therapy in PO-dependent outpatients.
A double-blind, 12-week randomized clinical trial was conducted in an outpatient research clinic. Following a brief period of buprenorphine stabilization, 70 PO-dependent adults were randomized to receive 1-, 2-, or 4-week tapers followed by naltrexone therapy.
During phase 1 (weeks 1–5 after randomization), participants visited the clinic daily; during phase 2 (weeks 6–12), visits were reduced to thrice weekly. Participants received behavioral therapy and urine toxicology testing throughout the trial.
The percentage of participants negative for illicit opioid use, retention, naltrexone ingestion, and favorable treatment response (ie, retained in treatment, opioid abstinent, and receiving naltrexone at the end of the study).
Opioid abstinence at the end of phase 1 was greater in the 4-week compared with the 2- and 1-week taper conditions (P = .02), with 63% (n = 14), 29% (n = 7), and 29% (n = 7) of participants abstinent in the 4-, 2-, and 1-week conditions, respectively. Abstinence at the end of phase 2 was also greater in the 4-week compared with the 2- and 1-week conditions (P = .03), with 50% (n = 11), 16% (n = 4), and 20% (n = 5) of participants abstinent in the 4-, 2-, and 1-week conditions, respectively. There were more treatment responders in the 4-week condition (P = .03), with 50% (n = 11), 17% (n = 4), and 21% (n = 5) of participants in the 4-, 2-, and 1-week groups considered responders at the end of treatment, respectively. Retention and naltrexone ingestion also were superior in the 4-week vs briefer tapers (both P = .04). Experimental condition (ie, taper duration) was the strongest predictor of treatment response, followed by buprenorphine stabilization dose.
This study represents a rigorous experimental evaluation of outpatient buprenorphine stabilization, brief taper, and naltrexone maintenance for treatment of PO dependence. Results suggest that a meaningful subset of PO-dependent outpatients may respond positively to a 4-week taper plus naltrexone maintenance intervention.
PMCID: PMC4131728  PMID: 24153411
21.  Examining the effects of initial smoking abstinence on response to smoking-related stimuli and response inhibition in a human laboratory model 
Psychopharmacology  2013;231(10):2145-2158.
Research is needed on initial smoking abstinence and relapse risk.
This study aims to investigate the effects of different durations of initial abstinence on sensitivity to smoking-related stimuli and response inhibition in the context of a larger battery of outcome measures.
Smokers were randomly assigned to receive payment contingent on smoking abstinence across all 15 study days (15C) or just the final 2 days (2C). Smoking status and subject ratings were assessed daily. Participants completed fMRI sessions at baseline and day 14 during which they completed craving ratings after exposure to smoking-related and neutral stimuli and performed a response inhibition task. On day 15, participants completed a smoking preference session involving 20 exclusive choices between smoking and money.
The payment contingencies were effective in producing greater smoking abstinence in the 15C vs. 2C conditions. Ratings of withdrawal decreased, while ratings of ease and confidence in abstaining increased in the 15C vs. 2C conditions across the 15-day study. 15C participants were less likely to choose the smoking option in the preference session. 15C participants reported greater reductions in craving compared to the 2C participants in the presence of smoking-related and neutral stimuli (i.e., decreases in generalized craving), but no differences were noted in cue reactivity per se or in response inhibition.
Results systematically replicate prior observations that a period 2 weeks of initial abstinence decreases the relative reinforcing effects of smoking and improves other outcomes associated with relapse risk compared to the initial day or two of a cessation effort, and extends them by underscoring the importance of generalized rather than cue-induced craving in relation to relapse risk during the initial weeks of smoking cessation.
PMCID: PMC4123458  PMID: 24337077
Cigarette smoking; Abstinence; Reinforcement; Nicotine withdrawal; Craving; Contingency management; Financial incentives; Cue reactivity; Response inhibition
22.  Incentives and health: An introduction 
Preventive medicine  2012;55(0):S2-S6.
PMCID: PMC4107351  PMID: 22554884
23.  Improving Medicaid Health Incentives Programs: Lessons from Substance Abuse Treatment Research 
Preventive medicine  2014;63:87-89.
This commentary addresses the efforts of Medicaid programs in several US states to employ financial incentives to increase healthy behavior among their beneficiaries. While these Medicaid incentives programs have been successful at boosting rates of less effortful behaviors, like semiannual dental visits, they have fallen short in promoting more complex behaviors, like smoking cessation, drug abstinence, and weight management. Incentives have been extensively studied as a treatment for substance use disorders for over 20 years, with good success. We identify two variables shown by meta-analysis to moderate the efficacy of incentives interventions in substance abuse treatment, the immediacy of incentive delivery and size (or magnitude) of the incentive, that are lacking in current Medicaid incentives program. We also offer some guidance on how these moderating variables could be addressed within Medicaid programs. This is a critical time for such analysis, as more than 10 states are employing incentives in their Medicaid programs, and some are currently reevaluating their incentives strategies.
PMCID: PMC4043298  PMID: 24613792
24.  Characterizing and Improving HIV/AIDS Knowledge Among Cocaine-Dependent Outpatients Using Modified Materials* 
Drug and alcohol dependence  2012;127(0):220-225.
Only 56% of outpatient substance abuse treatment programs in the U.S. provide HIV/AIDS education, likely due to the time required to complete existing educational interventions. This report describes results of a third study in a series to develop a brief educational intervention to increase HIV/AIDS knowledge among cocaine-dependent outpatients.
Participants (N=90) were randomized to experimental or control conditions and completed two HIV/AIDS knowledge pre-tests with response formats modified to “true-false-don’t know.” Pre-test results were later compared to historical controls that completed pre-tests in their original “true-false” format. Next, participants in the experimental condition completed an HIV/AIDS educational intervention while participants in the control condition completed a sham intervention. Participants in both conditions then completed knowledge tests a second time. Participants in both conditions were subsequently crossed over, and then completed knowledge tests a third time. Post-intervention analyses were conducted using test data from all participants who completed the educational intervention (N=56). A subset of these participants (N=40) completed follow-up tests approximately 9 weeks after completing the educational intervention.
Scores on both pre-tests were lower than those observed in historical controls (p < .001). Scores on knowledge tests increased from baseline after participants completed the educational intervention (p < .001), but not after the sham intervention (p >.05). Scores at follow-up remained higher than baseline scores (p < .001).
Modifying response formats to include a “don’t know” option likely increases identification of baseline knowledge deficits. This brief intervention is effective at increasing HIV/AIDS knowledge among cocaine-dependent outpatients.
PMCID: PMC4026286  PMID: 22889696
HIV/AIDS education; HIV/AIDS drug users; HIV/AIDS knowledge
25.  Illicit Drug Use Among Pregnant Women Enrolled in Treatment for Cigarette Smoking Cessation 
Nicotine & Tobacco Research  2012;15(5):987-991.
Smoking during pregnancy is the leading preventable cause of poor pregnancy outcomes in the United States. In population studies and nationwide surveys, pregnant smokers report more illicit drug use than pregnant nonsmokers. The purpose of this study was to examine the prevalence of illicit drug use among pregnant women enrolled in clinical trials for smoking cessation.
Urine specimens from 115 pregnant women were tested for illicit drug use during a study intake visit (~10th week of pregnancy) and during the final antepartum (FAP) smoking-status assessment (~28th week of pregnancy). Participants smoked about 18 cigarettes/day prepregnancy, were generally young (<25 years), Caucasian, with a high school education and without private insurance.
About 34% of specimens from the intake visit and 25% of those from the FAP assessment tested positive for an illicit drug. The most common drug detected was marijuana (90% of positive specimens), followed by opioids (18%), cocaine (5%), benzodiazepines (3%), and methadone (3%). None tested positive for amphetamines. The majority of women (53%) who tested positive for an illicit substance at intake also tested positive at the FAP assessment.
Approximately a quarter to a third of pregnant women enrolled in these smoking-cessation trials were determined to be using illicit drugs, with marijuana use being the most prevalent. Those providing smoking-cessation services to pregnant women may want to be prepared to assist with obtaining services for other drug use as well.
PMCID: PMC3621582  PMID: 23072871

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