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EMA of Treatment Mediators and Proximal Predictors of Smoking During a Quit Attempt

EMA of Treatment Mediators and Proximal Predictors of Smoking During a Quit Attempt. Danielle E. McCarthy, Ph.D. demccart@rci.rutgers.edu March 13, 2012. Learning Objectives. Learn about discoveries regarding treatment mediators and proximal predictors of smoking made using EMA

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EMA of Treatment Mediators and Proximal Predictors of Smoking During a Quit Attempt

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  1. EMA of Treatment Mediators and Proximal Predictors of Smoking During a Quit Attempt Danielle E. McCarthy, Ph.D. demccart@rci.rutgers.edu March 13, 2012

  2. Learning Objectives • Learn about discoveries regarding treatment mediators and proximal predictors of smoking made using EMA • Learn about ways to use existing software to develop tailored self-report and cognitive and behavioral EMA • Learn about the validity of real-time, field measures of impulsivity

  3. Mediators of treatment effects • Bupropion SR (McCarthy et al., 2008, Addiction) • Positive affect on quit day • Craving decline 1st week • Motivation to quit 1st week • Self-efficacy 1st week • Brief counseling (McCarthy et al., 2010, Addiction) • Self-efficacy 1st month post-quit • Decline in perceived difficulty quitting over 1st month post-quit

  4. Predictors of Point-Prevalence Abstinence • 3 months post-quit (N=70; McCarthy et al., 2006, J Abnormal) • Pre-quit negative affect increases • Craving increases at outset of attempt • 2 months post-quit (N=372; McCarthy et al., 2010, Addiction) • Social support received • Access to cigarettes • Increasing attempts to prevent urges • Motivation to quit • Withdrawal distress • Post-lapse demoralization • Stressful events

  5. Relations among coping, affect, and smoking over 48 hours (Minami et al., 2011, Addiction) Negative Affect Positive Affect + Stress Coping Smoking Urge Coping Gender Pre-Quit Coping Experience

  6. Relations among affect, cognition, and smoking over 24 hours (Minami et al., in preparation) Confidence Negative Affect Smoking Positive Affect Motivation Time b/n reports Trigger exposure

  7. Current Study Questions • Can impulsivity be measured in real time in subjects’ natural environments? • Can real-time assessment tell us more about smoking cessation success than baseline assessment? • What variables influence impulsivity within subjects?

  8. How is impulsivity related to smoking? • Smokers more impulsive than nonsmokers or ex-smokers (see Mitchell, 2004 for review) • Impulsivity may be a marker for risk of cessation failure or relapse • Among recent quitters, delay discounting and risk aversion predictive of relapse latency (Goto et al., 2009) • Impulsivity may be dynamic • Discounting greater in drive states (Lowenstein, 2005; Giordano et al., 2002)

  9. Study Design • Prospective longitudinal study • Smokers attempting to quit • Followed 1 week pre- and 3 weeks post-quit • 4 EMA reports per day for 28 days • All smokers received treatment • 4 15-minute individual counseling sessions • 12-week supply of 2- or 4-mg nicotine lozenges

  10. Participants • Inclusion criteria: • At least 18 years of age • At least 10 cigarettes per day for at least 6 months • CO at least 8 ppm • Able to read and write English • Willing to complete 5 office visits and 4 EMA reports daily for 4 weeks • Motivated to quit smoking (at least 6 on a 10-point scale)

  11. Participants • Exclusion criteria • Use of other tobacco, marijuana, or other drugs in the past month • Concurrent use of other stop smoking treatments • Serious psychopathology (bipolar disorder, schizophrenia, other psychotic disorder) • Contraindications to lozenge use • Unwillingness to prevent pregnancy

  12. Participants • 99 adult smokers retained through quit date • 41% Female • 6% Hispanic • 70% White, 20% African American, 6% Asian American, 4% Other • Age M=45.2, SD=11.7, Range=20-74 • Cigarettes/day M=18.9, SD=6.9, Range=10-40 • Fagerström Test of Nicotine DependenceM=5.3, SD=2.0, Range=1-9 • 27% CO-confirmed abstinence 3 weeks post-quit

  13. Study Procedures • Telephone screening • Orientation session • CO testing • Questionnaires • ED training • ED recording • Carry ED at all times, 4 3-5-minute reports per day • Office visits • Five weekly visits over 5 weeks • Follow-up • Phone call 12 weeks post-quit • Possible 5-minute office visit at 12 weeks

  14. Baseline Measures • Delay discounting • e.g., “Would you prefer $42 today or $100 in 1 week?” • Delayed rewards of $20-$2500 • Delays of 1 day-2 years • 26 series of items, up to 50 questions per series • Used Johnson & Bickel, 2002 delay discounting algorithm to identify indifference points • 1 choice up to $100 randomly selected to treat as real

  15. Baseline Measures • Behavioral disinhibition • Continuous Performance Task-II (Conners & MHS Staff, 2000) • Press space bar for every letter but “X” • “X” appears on 10% of trials • 6 blocks of 60 trials • Modified so trials with 1, 2, and 4 s inter-trial intervals interspersed randomly within blocks • $0.02 for every correct response • Feedback regarding errors and money earned between blocks

  16. EMA Impulsiveness Measures • Delay discounting • 8 items per report • Rewards of $25-$100 at delays of 1-42 days • One report treated as real • Starting value of sooner reward (Vp=Vd /(1+kbaseD)) tailored to baseline discounting rate (kbase=1/D(Vd/Vp-1)) • Next sooner reward based on previous responses (midpoint between min and max indifference points) • Final k based on estimated indifference point at 8th question (kEMA=1/D(Vd/Vp-1))

  17. Sample Alarm ScreenAlarm screen 2210 Alert Friday, 7/13/2010 12:45 pm-1:00 pm Private Appointment 83202138 GO Go To Snooze Clear

  18. EMA Discounting Instructions Welcome Remember... Daily k.01 At least 1 of these choices will be REAL during the study! (Press Next to continue) Please indicate which option, A or B, you prefer by tapping the letter. (Press Next to continue) 83202138 GO Previous Next Previous Next

  19. Sample EMA Discounting Items Would you prefer? Would you prefer? 1A. $ 24.27 today 1B. $ 25.00 in 2 weeks Your choice: 2A. $ 15.67 today 2B. $ 25.00 in 2 weeks Your choice: Previous Previous Next Next

  20. Additional Items PAST 15 MINUTES… PAST 15 MINUTES... Please answer the next questions based on how you have FELT IN GENERAL in the PAST 15 MINUTES. (Press Next to continue) I have felt EXCITED Disagree Agree Previous Previous Next Next

  21. Sample ED Items PAST 24 HOURS… PAST 15 MINUTES... I have felt EXCITED How WILLING are you to WORK HARD AT QUITTING SMOKING? Disagree Agree Agree Disagree Missing Response I have felt EXCITED Extremely Not At All Next Previous OK

  22. Final Sample Item and Ending a Report PAST 15 MINUTES… JUST BEFORE PROMPT: WHERE were you? Have you been with SOMEONE WHO WAS SMOKING? Next Next Previous Previous

  23. More Sample Items PAST 2 HOURS… PAST 2 HOURS… 0 1 2 3 4 5 6 7 8 9 How many CIGARETTES have you smoked IN THE PAST 2 HOURS? How many CIGARETTES Select one… Next Next Previous Previous

  24. EMA Measure of Behavioral Disinhibition • 2-minute, 60-trial CPT-II • DV=Commission error rate • MiniCog software (Shephard, Kho, Chen, & Kosslyn, 2006; Cambridge, MA) • Custom programming of items through Adobe Dreamweaver (San Jose, CA) • Some limits (no multi-screen trials) • Reaction time temporal resolution ~10 ms • Requires extra log-in step • Randomization of items

  25. Sample Questions 2210 MiniCog MiniCog Keyboard Login ID l______ Notes ____________ __________ __________ ______________________ Next 83202138 GO Done

  26. Instructions • 2-minute, 60-trial CPT-II • DV=Commission error rate The rate at which the letters appear may vary– so pay close attention. You will earn 2¢ for every correct response. Please press the GO key to continue. You will see a series of letters appear on the screen one at a time. Each time you see a letter, press the center GO key, except when the letter is an X. If the letter is an X, do nothing. Please press the GO key to continue. 2210 GO GO

  27. EMA CPT-II Task F H X GO GO GO

  28. Delay Discounting 7,204 records from 99 subjects

  29. Delay Discounting

  30. Delay Discounting *Jump

  31. Delay Discounting *Jump *Slope

  32. Delay Discounting *Jump Steeper in those high in cognitive instability *Slope Steeper in those high in cognitive instability

  33. Delay Discounting Unrelated to initial cessation failure or abstinence 3 weeks post-quit

  34. Behavioral Disinhibition6,719 records from 91 subjects *Slope

  35. Behavioral Disinhibition Baseline error rate related to 3-week abstinence; EMA rates not predictive

  36. Discussion • EMA measures significantly related to validated baseline behavioral measures • Self-reported cognitive instability related to EMA discounting level and growth • EMA measures did not predict abstinence above and beyond baseline measures

  37. Limitations • Interim analysis with limited power • Imperfect adherence to EMA assessment schedule • Smoking not controlled for in models • Skew in discounting and disinhibition distributions

  38. Future Directions • Identify internal (e.g., craving) and contextual factors (e.g., exposure to smoking cues) associated with momentary fluctuations in impulsivity • Interim analyses suggest that positive affect, but not negative affect, predicts change in k • Examine short-term relations between changes in impulsivity and subsequent smoking

  39. Collaborators • U. Wisconsin • Timothy Baker • Michael Fiore • Doug Jorenby • Daniel Lawrence • Megan Piper • Stevens Smith • U. Missouri-Columbia • Thomas Piasecki • Rutgers • Gretchen Chapman • Haruka Minami • Krysten Williams • Vivian Yeh • Haewon Yoon • U. Pittsburgh • Saul Shiffman

  40. Questions?Comments?

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