Web-Based Contingency Management for Adolescent Tobacco Smokers: A Clinical Trial.

INTRODUCTION: Adolescence is a critical time when the majority of tobacco users initiate smoking. Contingency management for adolescent smoking cessation has shown promise in previous studies, but efficacy following removal of contingencies is not well understood. This study examined a remote form of contingency management among non-treatment-seeking adolescent smokers. METHODS: Participants (N = 127) submitted breath carbon monoxide (CO) three times daily throughout a 42-day program. For this randomized trial, participants in the active condition (n = 63) were reinforced for providing CO measurements on schedule and below a set criterion, whereas those in the control condition (n = 64) were reinforced for providing CO measurements on schedule. Self-reported smoking and urinary cotinine levels were collected at several timepoints. RESULTS: Active condition showed greater within-group reductions in CO levels relative to control condition, but not at 3- or 6-month follow-up. Active condition reported significantly less smoking during treatment compared to control condition, but not at follow-up. There were no significant differences for urinary cotinine. Overall treatment adherence was low, with only 37% and 51% of possible CO samples being submitted among active and control, respectively. Poor treatment adherence may explain the disparity between CO and cotinine results, and poor follow-up treatment efficacy. CONCLUSIONS: This study replicates feasibility of a remote form of contingency management for adolescent smoking. CO results suggest active condition reduced smoking within group, but treatment adherence and posttreatment efficacy was poor. Future research should focus on increasing adherence for this type of program among adolescent smokers. IMPLICATIONS: This study demonstrates feasibility of a remote form of contingency management therapy for smoking cessation among adolescents, while providing posttreatment efficacy data. Within-group efficacy of this form of treatment is suggested, but treatment adherence and follow-up efficacy were poor. This study underscores the need for further development of contingency management therapy for adolescent smoking cessation, which emphasizes better treatment adherence and posttreatment efficacy.

Delay discounting and self-reported impulsivity in adolescent smokers and nonsmokers living in rural Appalachia.

Background and Objectives This study evaluated whether impulsivity (delay discounting and BIS-11-A) is associated with adolescent smoking status in a region with strong environmental risk factors for smoking. Methods Forty-two adolescent smokers and nonsmokers from rural Appalachia completed discounting and self-reported impulsivity assessments. Results The BIS-11-A, but not the measure of discounting, was associated with smoking status; however, neither assessment predicted smoking status once parent/best-friend smoking variables were statistically accounted for. Discussion and Conclusions In regions with strong environmental risk factors for smoking, delay discounting may play a more limited role in risk of initiation. Scientific Significance Helps to better define impulsivity as risk factors for smoking in relation to familial and broader cultural variables.

Self-reported impulsivity, but not behavioral choice or response impulsivity, partially mediates the effect of stress on drinking behavior.

Stress and impulsivity contribute to alcohol use, and stress may also act via impulsivity to increase drinking behavior. Impulsivity represents a multi-faceted construct and self-report and behavioral assessments may effectively capture distinct clinically relevant factors. The present research investigated whether aspects of impulsivity mediate the effect of stress on alcohol use. A community-based sample of 192 men and women was assessed on measures of cumulative stress, alcohol use, self-reported impulsivity, and behavioral choice and response impulsivity. Data were analyzed using regression and bootstrapping techniques to estimate indirect effects of stress on drinking via impulsivity. Cumulative adversity exhibited both direct effects and indirect effects (via self-reported impulsivity) on drinking behavior. Additional models examining specific types of stress indicated direct and indirect effects of trauma and recent life events, and indirect effects of major life events and chronic stressors on drinking behavior. Overall, cumulative stress was associated with increased drinking behavior, and this effect was partially mediated by self-reported impulsivity. Self-reported impulsivity also mediated the effects of different types of stress on drinking behavior. These findings highlight the value of mediation models to examine the pathways through which different types of stress increase drinking behavior. Treatment and prevention strategies should focus on enhancing stress management and self-control.

Relationship between weight status and delay discounting in a sample of adolescent cigarette smokers.

Obesity and cigarette smoking are often cited separately as the top two preventable causes of death in the United States; however, little research has explored the factors associated with being both obese and a smoker. Delay discounting is a behavioral characteristic that may underlie both of these conditions/behaviors. Delay discounting describes the extent to which an individual discounts the value of an outcome because of a delay in its occurrence. Higher rates of discounting are often considered as an index of impulsivity and have been linked with obesity and cigarette smoking. No research to date has explored delay discounting in a sample of obese smokers. For this study, adolescent smokers classified as obese (body mass index >95th percentile) and healthy weight (body mass index between the 5th and 85th percentiles) were compared on a laboratory assessment of delay discounting. Obese smokers discounted significantly more by delay than healthy weight smokers. This difference remained statistically significant even after controlling for demographic variables that differed across groups. These findings suggest that the relationships between delay discounting and obesity and cigarette smoking may be additive, such that extreme discounting might proportionally increase the risk of becoming an obese smoker. However, future prospective study is needed to fully determine the veracity of this hypothesis.

Discrete Roles for Impulsivity and Compulsivity in Gambling Disorder.

Background and Objective: Complex associations between gambling disorder (GD) and impulsivity have been identified. However, little is known regarding how compulsivity associates with different impulsivity domains in GD. In this study, we examined associations between self-reported and behavioral measures of impulsivity-assessed through the Barratt Impulsiveness Scale (BIS-11) and the Experiential Discounting Task (EDT), respectively- and compulsivity-measured using the Padua Inventory and the Wisconsin Card Sorting Test (WCST), respectively-, in an adult sample with GD (N = 132, 94 men and 38 women, ages ranging from 18 to 69 years). GD severity was assessed using the South Oaks Gambling Screen. Methods: Structural Equation Modeling was used to examine relationships between impulsivity and compulsivity measures, age, and GD severity. Results: BIS-11 non-planning and BIS-11 total scores positively correlated with GD severity. The standardized coefficients for the SEM showed direct positive contributions of BIS-11 non-planning, Padua and EDT scores to GD severity. Only participants' ages directly contributed to WCST perseverative errors, and no direct or indirect effects were found with respect to GD severity. Conclusion: The findings suggest that specific aspects of impulsivity and compulsivity contribute to GD severity. Interventions specifically targeting domains that are most relevant to GD severity may improve treatment outcomes.

Neurocognitive vulnerability to youth suicidal behavior.

Neurocognitive deficits have been associated with suicidal behavior in adults with major depressive disorder (MDD), but it is unclear if similar impairments are linked to youth suicidal behavior. This study compared neurocognitive functioning in suicidal and non-suicidal youth with a lifetime history of MDD and explored whether neurocognitive functioning predicted future suicide attempts. Neurocognition was examined using the Cambridge Neuropsychological Test Automated Battery (CANTAB) and Iowa Gambling Task (IGT) in 309 youths ages 12-15 (117 suicide attempters; 132 suicidal ideators; 60 never-suicidal). Prospective analyses included 284 youths (41 youth with a future attempt; 243 without a future attempt). Multivariate analysis of variance (MANOVA) yielded a significant group-by-sex interaction effect [Wilks' Λ = 0.901, F (16, 560) = 1.87, p = .021] for the primary neurocognitive outcomes, guiding the decision to stratify the sample by sex. Female suicide attempters and ideators were slower to respond correctly to both positive and negative emotion words than never-suicidal controls on tests of affective bias. Male suicide attempters and ideators made significantly more total and between errors than never-suicidal subjects. Exploratory analyses found that total commission errors on the Affective Go/No-Go (AGN) test significantly predicted future suicide attempts in females, and that higher strategy scores on Spatial Working Memory (SWM) tests predicted future male attempts. Study findings identified sex-specific neurocognitive deficits that differentiate suicidal and non-suicidal youth with histories of MDD. Extended longitudinal studies are needed to elucidate the temporal association between neurocognitive impairments and suicidal behavior and frame targets for early preventive interventions.

Delay discounting as a mediator of the relationship between perceived stress and cigarette smoking status in adolescents.

There has been a wealth of research providing evidence for the relationship between stress and cigarette smoking during adolescence. Despite this knowledge, little is known about possible behavioral mechanisms by which stress exerts its influence on the decision to smoke. This study sought to examine one such behavioral characteristic, delay discounting, that may mediate the relationship between stress and cigarette smoking. Delay discounting generally refers to the discounting of value for outcomes because they are delayed; and high rates of delay discounting have been linked to impulsive behavior. For the current research, adolescent smokers (n = 50) and nonsmokers (n = 50) were compared using a self-report measure of perceived stress and a laboratory assessment of delay discounting. Smokers tended to report higher levels of stress and to discount more by delay, and there was a significant association between reported stress and delay discounting. In addition, delay discounting mediated the relationship between stress and cigarette smoking status. These results suggest that discounting by delay may be a behavior through which stress exerts influence on an adolescent's decision to smoke.

Characteristics of psychopathy in adolescent nonsmokers and smokers: Relations to delay discounting and self reported impulsivity.

This research compared impulsive behavior in adolescent nonsmokers with low ratings of psychopathy (n = 25) and daily smokers with low (n = 25) and high (n = 25) ratings of psychopathy. Assessments of impulsive behavior included question-based and real-time measures of delay discounting and a self report assessment of impulsivity (Barratt Impulsiveness Scale-Adolescent). Smokers with low psychopathy ratings discounted more by delay (i.e., more impulsively) than nonsmokers on both assessments of discounting; however, smokers with high psychopathy ratings did not differ from nonsmokers on either measure. Inversely, from the self report assessment of impulsivity, smokers with low psychopathy ratings did not differ from nonsmokers, but smokers with high psychopathy ratings were more impulsive than nonsmokers. These findings indicate that delay discounting and self reported impulsivity relate differently to characteristics of psychopathy in adolescent nonsmokers and smokers. Also, these findings demonstrate that there are definable subgroups of smokers for whom the frequently observed relationship between cigarette smoking and delay discounting does not apply.

Dimensions of impulsive behavior: Predicting contingency management treatment outcomes for adolescent smokers.

BACKGROUND: Behavioral measures of impulsive behavior include the dimensions of behavioral disinhibition, decision-making, and lapses of attention. These behaviors are associated with a range of risky activities during adolescence, including cigarette smoking; however, few studies have evaluated their associations with tobacco treatment outcomes. The current study examined the relationship between impulsive behavior and contingency management treatment outcomes for adolescent smokers. METHODS: Data from two contingency management smoking cessation trials were combined (N = 189 adolescents). Participants provided breath carbon monoxide (CO) samples with incentives delivered contingent (i.e., active treatment [AT] condition) or non-contingent (i.e., control treatment [CT] condition) on CO level. Dimensions of impulsive behavior were assessed pre- and post-treatment using the Go/Stop Task, a measure of delay discounting, a continuous performance task, while self-reported impulsivity was assessed with the Barratt Impulsiveness Scale-Adolescent. Relationships between impulsive behavior and treatment outcomes (efficacy and adherence) were assessed using linear mixed effects models. RESULTS: Participants in the AT condition had significantly lower program CO levels at each treatment phase. Delay discounting in the AT condition predicted CO levels, with those discounting the most lowering their breath CO levels the least. Delay discounting also predicted program adherence across both conditions. CONCLUSIONS: Delay discounting may be the most relevant dimension of impulsive behavior to predict outcomes for adolescent smokers completing CM programs, both in terms of successful reductions in smoking and program adherence. Suggestions are made to reduce the effects of delay discounting for adolescent smokers using this treatment approach.

Dimensions of impulsive behavior in adolescents: laboratory behavioral assessments.

Impulsivity is a multifaceted construct that defines a range of maladaptive behavioral styles. The present research aimed to identify different dimensions of impulsive behavior in adolescents from a battery of laboratory behavioral assessments. In one analysis, correlations were examined between two self report and seven laboratory behavioral measures of impulsivity. The correlation between the two self report measures was high compared to correlations between the self report and laboratory behavioral measures. In a second analysis, a principal components analysis was performed with just the laboratory behavioral measures. Three behavioral dimensions were identified -- "impulsive decision-making", "impulsive inattention", and "impulsive disinhibition". These dimensions were further evaluated using the same sample with a confirmatory factor analysis, which did support the hypothesis that these are significant and independent dimensions of impulsivity. This research indicates there are at least three separate subtypes of impulsive behavior when using laboratory behavioral assessments with adolescent participants.

A web-based contingency management program with adolescent smokers.

The present study evaluated a new 30-day Web-based contingency management program for smoking abstinence with 4 daily-smoking adolescents. Participants made 3 daily video recordings of themselves giving breath carbon monoxide (CO) samples at home that were sent electronically to study personnel. Using a reversal design, participants could earn money for continued abstinence during the treatment phases (CO < or =5 ppm). All participants were compliant with the treatment (submitting 97.2% of samples), and all achieved prolonged abstinence from smoking.

Adolescent smokers rate delayed rewards as less certain than adolescent nonsmokers.

This research compared adolescent smokers (n=45) and nonsmokers (n=35) on ratings of certainty about receiving delayed rewards during a delay discounting procedure. Consistent with a previous finding [Patak, M., Reynolds, B., 2007. Question-based assessments of delay discounting: do respondents spontaneously incorporate uncertainty into their valuations for delayed rewards? Addict. Behav. 32, 351-357] participants generally rated the delayed rewards as increasingly uncertain with longer delays, and ratings of certainty were correlated with delay discounting (r=.37). Also, the adolescent smokers rated the delayed rewards as significantly less certain than the nonsmokers. These findings indicate that adolescents who smoke cigarettes evaluate delayed outcomes as less certain than adolescents who do not smoke cigarettes.

Behavioral impulsivity predicts treatment outcome in a smoking cessation program for adolescent smokers.

OBJECTIVE: To examine the relationship between impulsivity and smoking cessation treatment response among adolescents. METHODS: Thirty adolescent smokers participated in a high school based smoking cessation program combining contingency management and cognitive behavioral therapy. Self-report (Barratt impulsiveness scale (BIS-II); Kirby delay discounting measure (DDM)) and behavioral (experiential discounting task (EDT); continuous performance task (CPT)) measures of impulsivity were assessed at treatment onset. RESULTS: Sixteen participants (53%) were abstinent from smoking at completion of the four-week study. Compared to abstinent adolescents, those not achieving abstinence discounted monetary rewards more on the EDT and committed more commission errors on the CPT. Group differences were not observed on the BIS-II or DDM. CONCLUSIONS: These preliminary results suggest that specific behavioral measures of impulsivity may be associated with the ability to initiate and/or maintain abstinence from smoking among adolescent smokers.

Laboratory and self-report assessments of impulsive behavior in adolescent daily smokers and nonsmokers.

This research compared adolescent daily smokers (n=25) and nonsmokers (n=26) on different measures of impulsivity. Assessments included question-based measures of delay (DDQ) and probability (PDQ) discounting, a measure of behavioral disinhibition (go-stop task), and a self-report measure of impulsivity (Barratt Impulsiveness Scale-Adolescent). Adolescent smokers were more impulsive on the DDQ and Barratt Impulsiveness Scale--Adolescent but not on the PDQ or the go-stop task. However, there was a significant interaction between smoking status and gender on the go-stop task, with male smokers performing less impulsively on this measure than male nonsmokers--an effect not observed with the female adolescents. These findings indicate that adolescents who smoke cigarettes are more impulsive with respect to some, but not all, types of impulsivity than are adolescents who do not smoke.

Question-based assessments of delay discounting: do respondents spontaneously incorporate uncertainty into their valuations for delayed rewards?

This research was designed to determine if, and to what extent, participants incorporate uncertainty into their valuations for delayed rewards when completing measures of delay discounting, even though uncertainty is not specified in the delay-discounting questions. Twenty-four adolescent participants completed a question-based measure of delay discounting and immediately following answered questions about perceived certainties of receiving the delayed rewards. Results showed that respondents rated the delayed rewards as increasingly uncertain with longer delays. Also, ratings of uncertainty were correlated with rate of delay discounting (r=0.55). These findings suggest participants automatically evaluate delayed rewards as uncertain when using this assessment procedure. The current finding may hold important implications for future addiction research in interpreting why addicted persons often discount more by delay than non-addicted controls, i.e., delay to reward or uncertainty about delayed rewards?

Temporal and probabilistic discounting of rewards in children and adolescents: effects of age and ADHD symptoms.

This study investigated whether age and ADHD symptoms affected choice preferences in children and adolescents when they chose between (1) small immediate rewards and larger delayed rewards and (2) small certain rewards and larger probabilistic uncertain rewards. A temporal discounting (TD) task and a probabilistic discounting (PD) task were used to measure the degree to which the subjective value of a large reward decreased as one had to wait longer for it (TD), and as the probability of obtaining it decreased (PD). Rewards used were small amounts of money. In the TD task, the large reward (10 cents) was delayed by between 0 and 30s, and the immediate reward varied in magnitude (0-10 cents). In the PD task, receipt of the large reward (10 cents) varied in likelihood, with probabilities of 0, 0.25, 0.5, 0.75, and 1.0 used, and the certain reward varied in magnitude (0-10 cents). Age and diagnostic group did not affect the degree of PD of rewards: All participants made choices so that total gains were maximized. As predicted, young children, aged 6-11 years (n = 25) demonstrated steeper TD of rewards than adolescents, aged 12-17 years (n = 21). This effect remained significant even when choosing the immediate reward did not shorten overall task duration. This, together with the lack of interaction between TD task version and age, suggests that steeper discounting in young children is driven by reward immediacy and not by delay aversion. Contrary to our predictions, participants with ADHD (n = 22) did not demonstrate steeper TD of rewards than controls (n = 24). These results raise the possibility that strong preferences for small immediate rewards in ADHD, as found in previous research, depend on factors such as total maximum gain and the use of fixed versus varied delay durations. The decrease in TD as observed in adolescents compared to children may be related to developmental changes in the (dorsolateral) prefrontal cortex. Future research needs to investigate these possibilities.

Acute-alcohol effects on the Experiential Discounting Task (EDT) and a question-based measure of delay discounting.

Alcohol is widely believed to increase impulsive behavior. However, this has been difficult to demonstrate for impulsive choice using existing measures of delay discounting. We hypothesized a new real-time discounting task would be more sensitive to acute effects of alcohol. Measures included were a (a) question-based measure of delay discounting, the (b) Experiential Discounting Task (EDT), the (c) Balloon Analogue Risk Task (BART), the (d) Stop Task, and the (e) Go/No-Go Task. A three-session, double-blind, placebo-controlled, within-subjects design was used. Placebo, 0.4, or 0.8 g/kg alcohol doses were administered in a counterbalanced order over the three testing sessions. Twenty four (13 females) healthy social drinkers between the ages of 21 and 35 participated. Alcohol increased impulsive responding only on the EDT and the Stop Task. On the EDT, participants performed more impulsively after the 0.8 g/kg dose compared to placebo, whereas on the Stop Task, both the 0.4 and 0.8 g/kg doses increased impulsive responding. Alcohol had no significant effects on the other measures. The EDT was more sensitive to the acute effects of alcohol than previously used discounting tasks. Procedural differences between the EDT and question-based measures are discussed in the context of these divergent findings.

Diazepam impairs behavioral inhibition but not delay discounting or risk taking in healthy adults.

There are reports that diazepam can increase, decrease, or have no effect on measures of impulsive behavior, which may be related, in part, to differences among the tasks used to measure impulsivity. This study examined the effects of a relatively high dose of diazepam (20 mg) on 5 measures of impulsive behavior in healthy adult men and women. Volunteers (N = 18) participated in a 2-session double-blind randomized design in which they received 20 mg diazepam or placebo. One hour after ingesting the capsule, participants completed mood questionnaires and several impulsivity tasks to measure subtypes of impulsive behavior, including behavioral inhibition, delay and probability discounting, and risk taking. Diazepam impaired behavioral inhibition but had no effect on measures of discounting or risk taking. These results are discussed in the context of other recent findings suggesting that different behavioral indices of impulsivity are dissociable and governed by separate underlying mechanisms.

A pilot study of home-based smoking cessation programs for rural, appalachian, pregnant smokers.

OBJECTIVE: To evaluate a web-based contingency management program (CM) and a phone-delivered cessation counseling program (Smoking Cessation for Healthy Births [SCHB]) with pregnant smokers in rural Appalachia who were ≤12 weeks gestation at enrollment. DESIGN: Two group randomized design. SETTING: Home-based cessation programs in rural Appalachia Ohio and Kentucky. PARTICIPANTS: A community sample of pregnant smokers (N = 17). METHODS: Participants completed demographic and smoking-related questionnaires and were assigned to CM (n = 7) or SCHB (n = 10) conditions. Smoking status was assessed monthly using breath carbon monoxide and urinary cotinine. RESULTS: For CM, two of seven (28.57%) of the participants achieved abstinence, and three of 10 (30%) of those enrolled in SCHB were abstinent by late in pregnancy. Participants in CM attained abstinence more rapidly than those in SCHB. However, those in SCHB experienced less relapse to smoking, and a greater percentage of these participants reduced their smoking by at least 50%. CONCLUSION: Based on this initial evaluation, the web-based CM and SCHB programs appeared to be feasible for use with rural pregnant smokers with acceptable program adherence for both approaches. Future researchers could explore combining these programs to capitalize on the strengths of each, for example, rapid smoking cessation based on CM incentives and better sustained cessation or reductions in smoking facilitated by the counseling support of SCHB.

Sex differences in drug abuse: Etiology, prevention, and treatment.

This special issue exemplifies one of the major goals of the current editor of Experimental and Clinical Psychopharmacology (Dr. Suzette Evans): to increase the number of manuscripts that emphasize females and address sex differences. Taken together, these articles represent a broad range of drug classes and approaches spanning preclinical research to treatment to better understand the role of sex differences in drug abuse. While not all studies found sex differences, we want to emphasize that finding no sex difference is just as important as confirming one, and should be reported in peer-reviewed journals. It is our intention and hope that this special issue will further advance scientific awareness about the importance of accounting for sex differences in the study of substance abuse. Participant sex is an essential variable to consider in developing a more comprehensive understanding of substance abuse. Rather than viewing investigating sex differences as burdensome, investigators should seize this opportune area ripe for innovative research that is long overdue.