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Hitsman B, Papandonatos GD, Gollan JK, Huffman MD, Niaura R, Mohr DC, Veluz-Wilkins AK, Lubitz SF, Hole A, Leone FT, Khan SS, Fox EN, Bauer AM, Wileyto EP, Bastian J, Schnoll RA. Efficacy and safety of combination behavioral activation for smoking cessation and varenicline for treating tobacco dependence among individuals with current or past major depressive disorder: A 2 × 2 factorial, randomized, placebo-controlled trial. Addiction 2023; 118:1710-1725. [PMID: 37069490 DOI: 10.1111/add.16209] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 03/28/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND AND AIMS Treatment of depression-related psychological factors related to smoking behavior may improve rates of cessation among adults with major depressive disorder (MDD). This study measured the efficacy and safety of 12 weeks of behavioral activation for smoking cessation (BASC), varenicline and their combination. DESIGN, SETTING, PARTICIPANTS This study used a randomized, placebo-controlled, 2 × 2 factorial design comparing BASC versus standard behavioral treatment (ST) and varenicline versus placebo, taking place in research clinics at two urban universities in the United States. Participants comprised 300 hundred adult smokers with current or past MDD. INTERVENTIONS BASC integrated behavioral activation therapy and ST to increase engagement in rewarding activities by reducing avoidance, withdrawal and inactivity associated with depression. ST was based on the 2008 PHS Clinical Practice Guideline. Both treatments consisted of eight 45-min sessions delivered between weeks 1 and 12. Varenicline and placebo were administered for 12 weeks between weeks 2 and 14. MEASUREMENTS Primary outcomes were bioverified intent-to-treat (ITT) 7-day point-prevalence abstinence at 27 weeks and adverse events (AEs). FINDINGS No significant interaction was detected between behavioral treatment and pharmacotherapy at 27 weeks (χ2 (1) = 0.19, P = 0.67). BASC and ST did not differ (χ2 (1) = 0.43, P = 0.51). Significant differences in ITT abstinence rates (χ2 (1) = 4.84, P = 0.03) emerged among pharmacotherapy arms (16.2% for varenicline, 7.5% for placebo), with results favoring varenicline over placebo (rate ratio = 2.16, 95% confidence interval = 1.08, 4.30). All significant differences in AE rates after start of medication were higher for placebo than varenicline. CONCLUSION A randomized trial in smokers with major depressive disorder found that varenicline improved smoking abstinence versus placebo at 27 weeks without elevating rates of adverse events. Behavioral activation for smoking cessation did not outperform standard behavioral treatment, with or without adjunctive varenicline therapy.
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Affiliation(s)
- Brian Hitsman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, United States
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, United States
| | - George D Papandonatos
- Department of Biostatistics and Center for Statistical Sciences, Brown University School of Public Health, Providence, Rhode Island, United States
| | - Jacqueline K Gollan
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, United States
- Asher Center for the Study and Treatment of Depressive Disorders, Chicago, Illinois, United States
| | - Mark D Huffman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
- John T. Milliken Department of Medicine, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, United States
- Cardiovascular Program, The George Institute for Global Health, University of South Wales, Newtown, New South Wales, Australia
| | - Raymond Niaura
- Department of Epidemiology, School of Global Public Health, New York University, New York, New York, United States
| | - David C Mohr
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, United States
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, United States
| | - Anna K Veluz-Wilkins
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Su Fen Lubitz
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Anita Hole
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Frank T Leone
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania, United States
| | - Sadiya S Khan
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Erica N Fox
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Anna-Marika Bauer
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - E Paul Wileyto
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Joseph Bastian
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Robert A Schnoll
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
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Quinn MH, Olonoff M, Bauer AM, Fox E, Jao N, Lubitz SF, Leone F, Gollan JK, Schnoll R, Hitsman B. History and Correlates of Smoking Cessation Behaviors Among Individuals With Current or Past Major Depressive Disorder Enrolled in a Smoking Cessation Trial. Nicotine Tob Res 2022; 24:37-43. [PMID: 34259871 PMCID: PMC8666119 DOI: 10.1093/ntr/ntab147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Smoking among adults with major depressive disorder (MDD) is at least double that of the general US population. More effective smoking cessation interventions for depressed smokers may be facilitated through a better understanding of the smoking and depression-related characteristics of this population. METHODS We used baseline data from 300 participants enrolled in randomized clinical trial for smokers with current or past MDD. We described history of smoking cessation behaviors (ie, quit attempts, quit motivation, and cessation treatment utilization) and used multivariate regression to identify demographic and depression-related correlates of these behaviors. RESULTS Sixty-eight percent of participants reported at least one quit attempt in the past year, nearly 51% reported motivation to quit in the subsequent 30 days, and 83% reported prior use of a nicotine replacement therapy. A greater readiness to quit smoking was associated with increased age (p = .04) and lower cigarettes per day (p = .01). Greater use of smoking cessation medication was associated with greater education and nicotine dependence, minority race, and greater use of complementary reinforcers (eg, activities associated with increased reinforcing value of smoking; p's < .05). CONCLUSIONS These data indicate that smokers with current or past MDD are highly motivated to quit smoking and have a history of engaging in efforts to quit. Interventions to promote smoking cessation behaviors should address younger and lighter smokers, who may perceive less risk from tobacco use, and efforts to promote smoking cessation medications and counseling should address minority smokers who are engaging in complementary reinforcers. IMPLICATIONS These data are inconsistent with the assumption that smokers with serious mental illness are not willing to quit smoking and suggest the need for studies that test behavioral interventions that address complementary reinforcers to treat tobacco use in this community.
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Affiliation(s)
- Mackenzie Hosie Quinn
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew Olonoff
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Anna-Marika Bauer
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Erica Fox
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Nancy Jao
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Su Fen Lubitz
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Frank Leone
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Jacqueline K Gollan
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Robert Schnoll
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian Hitsman
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Halpern SD, Chowdhury M, Bayes B, Cooney E, Hitsman BL, Schnoll RA, Lubitz SF, Reyes C, Patel MS, Greysen SR, Mercede A, Reale C, Barg FK, Volpp KG, Karlawish J, Stephens-Shields AJ. Effectiveness and Ethics of Incentives for Research Participation: 2 Randomized Clinical Trials. JAMA Intern Med 2021; 181:1479-1488. [PMID: 34542553 PMCID: PMC8453363 DOI: 10.1001/jamainternmed.2021.5450] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Incentivizing research participation is controversial and variably regulated because of uncertainty regarding whether financial incentives serve as undue inducements by diminishing peoples' sensitivity to research risks or unjust inducements by preferentially increasing enrollment among underserved individuals. OBJECTIVE To determine whether incentives improve enrollment in real randomized clinical trials (RCTs) or serve as undue or unjust inducements. DESIGN, SETTING, AND PARTICIPANTS Two RCTs of incentives that were embedded in 2 parent RCTs, 1 comparing smoking cessation interventions (conducted at smoking cessation clinics in 2 health systems) and 1 evaluating an ambulation intervention (conducted across wards of the Hospital of the University of Pennsylvania) included all persons eligible for the parent trials who did not have prior knowledge of the incentives trials. Recruitment occurred from September 2017 to August 2019 for the smoking trial and January 2018 through May 2019 for the ambulation trial; data were analyzed from January 2020 to July 2020. INTERVENTIONS Patients were randomly assigned to incentives of $0, $200, or $500 for participating in the smoking cessation trial and $0, $100, or $300 for the ambulation trial. MAIN OUTCOMES AND MEASURES The primary outcome of each incentive trial was the proportion of people assigned to each recruitment strategy that consented to participate. Each trial was powered to test the hypotheses that incentives served neither as undue inducements (based on the interaction between incentive size and perceived research risk, as measured using a 10-point scale, on the primary outcome), nor unjust inducements (based on the interaction between incentive size and participants' self-reported income). Noninferiority methods were used to test whether the data were compatible with these 2 effects of incentives and superiority methods to compare the primary and other secondary outcomes. RESULTS There were a total of 654 participants (327 women [50.0%]; mean [SD] age, 50.6 [12.1] years; 394 Black/African American [60.2%], 214 White [32.7%], and 24 multiracial individuals [3.7%]) in the smoking trial, and 642 participants (364 women [56.7%]; mean [SD] age, 46.7 [15.6] years; 224 Black/African American [34.9%], 335 White [52.2%], and 5 multiracial individuals [0.8%]) in the ambulation trial. Incentives significantly increased consent rates among those in the smoking trial in 47 of 216 (21.8%), 78 of 217 (35.9%), and 104 of 221 (47.1%) in the $0, $200, and $500 groups, respectively (adjusted odds ratio [aOR] for each increase in incentive, 1.70; 95% CI, 1.34-2.17; P < .001). Incentives did not increase consent among those in the ambulation trial: 98 of 216 (45.4%), 102 of 212 (48.1%), and 92 of 214 (43.0%) in the $0, $100, and $300 groups, respectively (aOR, 0.88; 95% CI, 0.64-1.22; P = .45). In neither trial was there evidence of undue or unjust inducement (upper confidence limits of ORs for undue inducement, 1.15 and 0.99; P < .001 showing noninferiority; upper confidence limits of ORs for unjust inducement, 1.21 and 1.26; P = .01 and P < .001, respectively). There were no significant effects of incentive size on the secondary outcomes in either trial, including time spent reviewing the risk sections of consent forms, perceived research risks, trial understanding, perceived coercion, or therapeutic misconceptions. CONCLUSIONS AND RELEVANCE In these 2 randomized clinical trials, financial incentives increased trial enrollment in 1 of 2 trials and did not produce undue or unjust inducement or other unintended consequences in either trial. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02697799.
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Affiliation(s)
- Scott D Halpern
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Marzana Chowdhury
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian Bayes
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Elizabeth Cooney
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian L Hitsman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Robert A Schnoll
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Su Fen Lubitz
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Celine Reyes
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mitesh S Patel
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - S Ryan Greysen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ashley Mercede
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Catherine Reale
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Frances K Barg
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Anthropology, University of Pennsylvania School of Arts and Sciences, Philadelphia
| | - Kevin G Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Jason Karlawish
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Penn Memory Center at the Penn Neuroscience Center, Philadelphia, Pennsylvania
| | - Alisa J Stephens-Shields
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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4
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Kilaru AS, Lubitz SF, Davis J, Eriksen W, Siegel S, Kelley D, Perrone J, Meisel ZF. A State Financial Incentive Policy to Improve Emergency Department Treatment for Opioid Use Disorder: A Qualitative Study. Psychiatr Serv 2021; 72:1048-1056. [PMID: 33593105 DOI: 10.1176/appi.ps.202000501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In 2019, Pennsylvania established a voluntary financial incentive program designed to increase the engagement in addiction treatment for Medicaid patients with opioid use disorder after emergency department (ED) encounters. In this qualitative study involving hospital leaders, the authors examined decisions leading to participation in this program as well as barriers and facilitators that influenced its implementation. METHODS Twenty semistructured interviews were conducted with leaders from a diverse sample of hospitals and health systems across Pennsylvania. Interviews were planned and analyzed following the Consolidated Framework for Implementation Research. An iterative approach was used to analyze the interviews and determine key themes and patterns regarding implementation of this policy initiative in hospitals. RESULTS The authors identified six key themes that reflected barriers and facilitators to hospital participation in the program. Participation in the program was facilitated by community partners capable of arranging outpatient treatment for opioid use disorder, incentive payments focusing hospital leadership on opioid treatment pathways, multidisciplinary planning, and flexibility in adapting pathways for local needs. Barriers to program participation concerned the implementation of buprenorphine prescribing and the measurement of treatment outcomes. CONCLUSIONS A financial incentive policy encouraged hospitals to enact rapid system and practice changes to support treatment for opioid use disorder, although challenges remained in implementing evidence-based treatment-specifically, initiation of buprenorphine-for patients visiting the ED. Analysis of treatment outcomes is needed to further evaluate this policy initiative, but new delivery and payment models may improve systems to treat patients who have an opioid use disorder.
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Affiliation(s)
- Austin S Kilaru
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - Su Fen Lubitz
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - Jessica Davis
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - Whitney Eriksen
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - Sari Siegel
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - David Kelley
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - Jeanmarie Perrone
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - Zachary F Meisel
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
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Lubitz SF, Flitter A, Wileyto EP, Ziedonis D, Stevens N, Leone F, Mandell D, Kimberly J, Beidas R, Schnoll RA. History and Correlates of Smoking Cessation Behaviors Among Smokers With Serious Mental Illness. Nicotine Tob Res 2021; 22:1492-1499. [PMID: 31816049 DOI: 10.1093/ntr/ntz229] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 12/06/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Individuals with serious mental illness (SMI) smoke at rates two to three times greater than the general population but are less likely to receive treatment. Increasing our understanding of correlates of smoking cessation behaviors in this group can guide intervention development. AIMS AND METHODS Baseline data from an ongoing trial involving smokers with SMI (N = 482) were used to describe smoking cessation behaviors (ie, quit attempts, quit motivation, and smoking cessation treatment) and correlates of these behaviors (ie, demographics, attitudinal and systems-related variables). RESULTS Forty-three percent of the sample did not report making a quit attempt in the last year, but 44% reported making one to six quit attempts; 43% and 20%, respectively, reported wanting to quit within the next 6 months or the next 30 days. Sixty-one percent used a smoking cessation medication during their quit attempt, while 13% utilized counseling. More quit attempts were associated with lower nicotine dependence and carbon monoxide and greater beliefs about the harms of smoking. Greater quit motivation was associated with lower carbon monoxide, minority race, benefits of cessation counseling, and importance of counseling within the clinic. A greater likelihood of using smoking cessation medications was associated with being female, smoking more cigarettes, and receiving smoking cessation advice. A greater likelihood of using smoking cessation counseling was associated with being male, greater academic achievement, and receiving smoking cessation advice. CONCLUSIONS Many smokers with SMI are engaged in efforts to quit smoking. Measures of smoking cessation behavior are associated with tobacco use indicators, beliefs about smoking, race and gender, and receiving cessation advice. IMPLICATIONS Consideration of factors related to cessation behaviors among smokers with SMI continues to be warranted, due to their high smoking rates compared to the general population. Increasing our understanding of these predictive characteristics can help promote higher engagement in evidence-based smoking cessation treatments among this subpopulation.
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Affiliation(s)
- Su Fen Lubitz
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alex Flitter
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - E Paul Wileyto
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Douglas Ziedonis
- Department of Psychiatry, University of California, San Diego, CA
| | - Nathaniel Stevens
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Frank Leone
- Department of Medicine, Pulmonary, Allergy, & Critical Care Division, University of Pennsylvania, Philadelphia, PA
| | - David Mandell
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John Kimberly
- Department of Management, The Wharton School of Business, University of Pennsylvania, Philadelphia, PA
| | - Rinad Beidas
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, PA
| | - Robert A Schnoll
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Bauer AM, Hosie Quinn M, Lubitz SF, Flitter A, Ashare RL, Leone FT, Gross R, Hitsman B, Schnoll R. Medication adherence and rate of nicotine metabolism are associated with response to treatment with varenicline among smokers with HIV. Addict Behav 2021; 112:106638. [PMID: 32911350 DOI: 10.1016/j.addbeh.2020.106638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/27/2020] [Accepted: 08/28/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION PLWHA who smoke have shown lower cessation rates within placebo-controlled randomized trials of varenicline. Adherence and rate of nicotine metabolism may be associated with quit rates in such clinical trials. METHODS This secondary analysis of a randomized placebo-controlled trial of varenicline for smoking among PLWHA (N = 179) examined the relationship between varenicline adherence (pill count, ≥80% of pills), nicotine metabolism (based on the nicotine metabolite ratio; NMR) and end-of-treatment smoking cessation (self-reported 7-day point prevalence abstinence, confirmed with carbon monoxide of ≤ 8 ppm, at the end of treatment; EOT). RESULTS Combining varenicline and placebo arms, greater adherence (OR = 1.011, 95% CI:1.00-1.02, p = 0.051) and faster nicotine metabolism (OR = 3.08, 95% CI:1.01-9.37, p = 0.047) were related to higher quit rates. In separate models, adherence (OR = 1.009, 95% CI:1.004-1.01, p < 0.001) and nicotine metabolism rate (OR = 2.04, 95% CI:1.19-3.49, p = 0.009) interacted with treatment arm to effect quit rates. The quit rate for varenicline vs. placebo was higher for both non-adherent (19% vs. 5%; χ2[1] = 2.80, p = 0.09) and adherent (35% vs. 15%; χ2[1] = 6.51, p = 0.01) participants, but the difference between treatment arms was statistically significant only for adherent participants. Likewise, among slow metabolizers (NMR < 0.31), the varenicline quit rate was not significantly higher vs. placebo (14% vs. 5%; χ2[1] = 1.17, p = 0.28) but, among fast metabolizers (NMR ≥ 0.31), the quit rate for varenicline was significantly higher vs. placebo (33% vs. 14%; χ2[1] = 4.43, p = 0.04). CONCLUSIONS Increasing varenicline adherence and ensuring that fast nicotine metabolizers receive varenicline may increase quit rates for PLWHA.
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Affiliation(s)
| | | | - Su Fen Lubitz
- Department of Psychiatry, University of Pennsylvania, United States
| | - Alex Flitter
- Department of Psychiatry, University of Pennsylvania, United States
| | - Rebecca L Ashare
- Department of Psychiatry, University of Pennsylvania, United States
| | - Frank T Leone
- Department of Medicine/Division of Pulmonary, Allergy, & Critical Care, University of Pennsylvania, United States
| | - Robert Gross
- Department of Medicine/Division of Infectious Diseases, University of Pennsylvania, United States; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, United States
| | - Brian Hitsman
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, United States
| | - Robert Schnoll
- Department of Psychiatry and Abramson Cancer Center, University of Pennsylvania, United States.
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Ashare RL, Wileyto EP, Logue-Chamberlain E, Gross R, Tyndale RF, Lerman C, Hawk LW, Cinciripini P, George TP, Lubitz SF, Schnoll R. Patterns of lapses and recoveries during a quit attempt using varenicline and behavioral counseling among smokers with and without HIV. Psychol Addict Behav 2020; 35:788-796. [PMID: 32686950 DOI: 10.1037/adb0000619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Addressing tobacco use among HIV+ smokers is a priority. Lack of knowledge about how HIV+ smokers respond to tobacco use treatments limits our ability to effectively treat this population of smokers. Using data from 2 clinical trials that provided 12 weeks of varenicline and behavioral counseling, 1 with smokers with HIV (n = 89) and 1 with smokers without HIV (n = 179), we used mixed logistic regression modeling to compare point-prevalence abstinence rates and adherence to the initial target quit date (TQD) and Cox regression for repeated outcomes to evaluate lapse and recovery dynamics between the groups. Sixty percent of HIV- smokers refrained from smoking at the TQD while only 33% of HIV+ smokers did (odds ratio [OR] = 0.32, 95% CI [0.18, 0.56], p < .001). The point-prevalence abstinence rates at Week 12 were 31% (HIV-) and 28% (HIV+; OR = 0.7, 95% CI [0.42, 1.16], p = .16) and the point prevalence abstinence rates at Week 24 were 22% (HIV-) and 15% (HIV+; OR = 0.87, 95% CI [0.49, 1.57], p = .65). Although there was no interaction between HIV status and lapse risk, χ2(3) < 1, there was a significant interaction for the recovery model, (χ2(3) = 20.4, p < 0.001): as the number of events increased, the time to the next recovery became longer among smokers with HIV, compared to smokers without HIV. Although HIV+ smokers were treated effectively with varenicline, compared to HIV- smokers, they showed significantly lower initial cessation at the TQD and took increasingly longer to recover following lapses. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
| | | | | | - Robert Gross
- Center for Clinical Epidemiology and Biostatistics and Division of Infectious Diseases
| | - Rachel F Tyndale
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health and Department of Pharmacology and Toxicology, and Division of Brain and Therapeutics
| | | | | | | | - Tony P George
- Addictions Division, Centre for Addiction and Mental Health and Division of Brain and Therapeutics
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Schnoll R, Wileyto EP, Gross R, Hitsman B, Hawk LW, Cinciripini P, George TP, Benowitz NL, Lubitz SF, Ashare R, Tyndale RF, Lerman C. Evaluation of nicotine patch adherence measurement using self-report and saliva cotinine among abstainers in a smoking cessation trial. Drug Alcohol Depend 2020; 210:107967. [PMID: 32224420 PMCID: PMC7190433 DOI: 10.1016/j.drugalcdep.2020.107967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 02/11/2020] [Accepted: 03/13/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Adherence to nicotine patches relates to cessation. This is the first study to examine the validity of self-reported nicotine patch adherence relative to saliva cotinine. METHODS We used data from 198 clinical trial participants who received 11 weeks of nicotine patches, self-reported patch use, had saliva cotinine 1-week after the start of treatment assessed, and were not smoking when saliva was collected (CO < 6). Self-reported patch adherence was defined as: 3-day (before saliva collection), 7-day (before saliva collection), 3-week use (7 days before, and 14 days after, saliva collection), and 11-week use (7 days before, and 10 weeks after, saliva collection). Analyses, including receiver operating characteristic curves, considered differences in nicotine metabolism. Sensitivity, specificity and positive (PPV) and negative predictive value (NPV) assessed optimal cotinine cut-point for adherence. RESULTS Self-reported 7-day (r = 0.13) and 3-week (r = 0.13) patch use marginally correlated with week 1 cotinine (p's = 0.08) but not 3-day or 11-week. Significant area under the curve (AUC) values of 0.67 (95 %CI: 0.55-0.79) and 0.72 (95 %CI: 0.57-0.88) were found using 7-day self-report for the overall sample and for slow metabolizers (p's<0.01), but not for normal metabolizers. Optimal 1-week cotinine cut-points using 7-day self-report were 170 ng/mL (overall) and 184 ng/mL (slow), with sensitivity = 0.56-0.62, specificity = 0.69-0.78, PPV = 0.96-0.97, and NPV = 0.13-0.14. CONCLUSIONS Among CO-confirmed abstainers, self-reported patch use and saliva cotinine assessed 1-week into treatment, were modestly correlated and optimal cotinine cut-point differed by rate of nicotine metabolism. Seven-day patch use may be a more valid self-report measure of patch adherence based on cotinine than 3-day, 3-week, or 11-week. Rate of nicotine metabolism may affect this relationship.
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Affiliation(s)
- Robert Schnoll
- Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Suite 4100, Philadelphia, PA 19104, USA.
| | - E. Paul Wileyto
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, USA
| | - Robert Gross
- Division of Infectious Diseases and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, 3610 Hamilton Walk, Philadelphia, PA 19104, USA
| | - Brian Hitsman
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, 680 N Lake Shore Drive, Chicago, IL 60611, USA
| | - Larry W. Hawk
- Department of Psychology, State University of New York at Buffalo; 230 Park Hall, The State University of New York, Buffalo, NY 14260, USA
| | - Paul Cinciripini
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center; 1155 Pressler St, Houston, TX 77030, USA
| | - Tony P. George
- Centre for Addiction and Mental Health and Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto; 100 Stokes S., BGB 3288, Toronto, ON M6J 1H4, Canada
| | - Neal L. Benowitz
- Departments of Medicine, and Bioengineering & Therapeutic Sciences, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Su Fen Lubitz
- Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Suite 4100, Philadelphia, PA 19104, USA
| | - Rebecca Ashare
- Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Suite 4100, Philadelphia, PA 19104, USA
| | - Rachel F. Tyndale
- Department of Pharmacology & Toxicology, University of Toronto; 1 King’s College Circle, Toronto, ON M5S 1A8, Canada
| | - Caryn Lerman
- Department of Psychiatry and Norris Cancer Center, 1441 Eastlake Avenue, Health Sciences Campus, University of Southern California, Los Angeles, CA, 90033, USA
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9
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Quinn MH, Bauer AM, Flitter A, Lubitz SF, Ashare RL, Thompson M, Leone F, Gross R, Schnoll R. Correlates of varenicline adherence among smokers with HIV and its association with smoking cessation. Addict Behav 2020; 102:106151. [PMID: 31783245 DOI: 10.1016/j.addbeh.2019.106151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/30/2019] [Accepted: 09/30/2019] [Indexed: 12/15/2022]
Abstract
INTRODUCTION With medical advances, the life expectancy of people living with HIV/AIDS (PLWHA) has improved; however, tobacco use remains a prominent risk for mortality. Although studies have examined the efficacy of varenicline for treating smoking among PLWHA, the relationship between varenicline adherence and cessation and correlates of varenicline adherence remain under-studied. METHODS We conducted secondary analyses from a randomized placebo-controlled trial of varenicline for smoking among PLWHA, using data from participants who received varenicline (N = 89). The relationship between varenicline adherence (based on pill count) and end-of-treatment smoking cessation was assessed, as were correlates of varenicline adherence. RESULTS Those who were abstinent took an average of 137.1 pills (SD = 39.3), or 83% of pills prescribed, vs. 105.3 pills (SD = 64.1), or 64%, for those who were smoking (OR = 1.01, 95% CI: 1.001-1.021, p = 0.03); 52/89 (58%) participants were adherent based on taking ≥80% of pills. The quit rate for adherent participants was 35% (18/52) vs. 19% (7/37) for non-adherent participants. Adherent participants were older, smoked fewer cigarettes each day, started smoking at an older age, and had lower baseline creatinine vs. non-adherent participants (p < 0.05). There was a significant time-by-group interaction effect for anxiety (F[1,72] = 6.24, p = 0.02), depression (F[1,72] = 4.2, p = 0.04), and insomnia (F[1,72] = 7.73, p = 0.007), indicating that adherent participants had less depression, anxiety, and insomnia during the initial weeks of treatment, vs. non-adherent participants. CONCLUSIONS Our findings underscore the importance of varenicline adherence for determining cessation and highlight the role of early changes in anxiety, depression, and insomnia determining varenicline adherence.
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Affiliation(s)
| | - Anna-Marika Bauer
- Department of Psychiatry, University of Pennsylvania, PA, United States
| | - Alex Flitter
- Department of Psychiatry, University of Pennsylvania, PA, United States
| | - Su Fen Lubitz
- Department of Psychiatry, University of Pennsylvania, PA, United States
| | - Rebecca L Ashare
- Department of Psychiatry, University of Pennsylvania, PA, United States
| | - Morgan Thompson
- Department of Psychiatry, University of Pennsylvania, PA, United States
| | - Frank Leone
- Pulmonary, Allergy, & Critical Care Division, University of Pennsylvania, PA, United States
| | - Robert Gross
- Department of Medicine/Division of Infectious Diseases, University of Pennsylvania, PA, United States; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, PA, United States
| | - Robert Schnoll
- Department of Psychiatry, University of Pennsylvania, PA, United States.
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Kilaru AS, Perrone J, Kelley D, Siegel S, Lubitz SF, Mitra N, Meisel ZF. Participation in a Hospital Incentive Program for Follow-up Treatment for Opioid Use Disorder. JAMA Netw Open 2020; 3:e1918511. [PMID: 31899526 PMCID: PMC6991234 DOI: 10.1001/jamanetworkopen.2019.18511] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/29/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Austin S. Kilaru
- National Clinician Scholars Program, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Injury Science Center, University of Pennsylvania, Philadelphia
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David Kelley
- Office of Medical Assistance Programs, Department of Human Services, Commonwealth of Pennsylvania, Harrisburg
| | - Sari Siegel
- The Hospital and Healthsystem Association of Pennsylvania, Harrisburg
| | - Su Fen Lubitz
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nandita Mitra
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Zachary F. Meisel
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Injury Science Center, University of Pennsylvania, Philadelphia
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Abstract
Quitting smoking among people living with HIV/AIDS (PLWHA) is a priority. However, PLWHA and clinicians working with PLWHA are reluctant to use tobacco use treatments out of concern that smoking cessation can diminish anti-retroviral therapy (ART) adherence and quality of life (QoL) and increase psychiatric symptoms. This secondary analysis from a placebo-controlled varenicline trial for tobacco dependence among PLWHA (N = 179) examined if smoking cessation at the end of treatment (EOT) was associated with changes in ART adherence, QoL, anxiety and depression symptoms, and varenicline side effects. ART adherence was not affected by smoking cessation (p > 0.05), remaining ≥98% for all participants. Across 8 QoL subscales, 7 remained unchanged over time across smokers and abstainers; side effects were not associated with cessation. Controlling for baseline smoking rate, adherence to varenicline/placebo and counseling, and treatment arm, participants who had quit smoking at EOT reported a significant reduction in depression (β = -1.657, 95% CI: -2.893, -0.422, p = .009) and anxiety (β = -1.434, 95% CI: -2.812, -0.56, p = .041) and increased life satisfaction (β = 0.88, 95% CI: 0.21, 3.275, p = .027). When PLWHA quit smoking they may not experience adverse clinical outcomes including ART non-adherence and may experience beneficial psychological effects, supporting the use of FDA-approved smoking cessation treatments among PLWHA.
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Affiliation(s)
- Su Fen Lubitz
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Alex Flitter
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Rebecca L Ashare
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Morgan Thompson
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Frank Leone
- Pulmonary, Allergy, & Critical Care Division, University of Pennsylvania Presbyterian Medical Center, Philadelphia, PA, USA
| | - Robert Gross
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Schnoll
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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12
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Flitter AS, Lubitz SF, Ziedonis D, Stevens N, Leone FT, Mandell D, Kimberly J, Lopez O, Beidas RS, Schnoll RA. A Cluster-Randomized Clinical Trial Testing the Effectiveness of the Addressing Tobacco Through Organizational Change Model for Improving the Treatment of Tobacco Use in Community Mental Health Care: Preliminary Study Feasibility and Baseline Findings. Nicotine Tob Res 2019; 21:559-567. [PMID: 30388273 PMCID: PMC6468132 DOI: 10.1093/ntr/nty239] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/31/2018] [Indexed: 01/07/2023]
Abstract
INTRODUCTION People with mental illness are more likely to smoke and less likely to receive tobacco treatment than the general population. The Addressing Tobacco Through Organizational Change (ATTOC) approach supports organizational change to increase tobacco treatment in this population. We describe preliminary study feasibility and baseline behaviors and attitudes among clients and staff regarding tobacco treatment, and assesse correlates of treatment of smoking. METHODS Preliminary accrual, engagement, and baseline data are reported from a cluster-randomized trial comparing ATTOC to usual care. Feasibility, thus far, was the rate of site and participant accrual and engagement (eg, participants remaining in the trial). Correlates of assessing smoking, advising cessation, and providing treatment were assessed. RESULTS Site and participant accrual is 80% (8/10) and 86% (456/533), and engagement is 100% and 82%. "Staff asking about smoking" was reported by 63% of clients and 38% of staff; "staff advising cessation" was reported by 57% of clients and 46% of staff; staff report "assisting clients with any medication" at most 22% of the time, whereas at most 18% of clients report receiving a cessation medication; 59% of clients want tobacco treatment, but 36% of staff think that it is part of their job. "Staff assisting with medications" is related to more training, believing treating smoking is part of their job, and believing patients are concerned about smoking (ps < .05). CONCLUSIONS This trial of training in tobacco treatment within mental health care is feasible thus far; self-reported rates of tobacco treatment are low and associated with clinician attitudes and barriers. IMPLICATIONS Evaluation of ways to help address tobacco use treatment in community mental health care is feasible and needed, including the use of technical assistance and training guided by an organizational change approach.
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Affiliation(s)
- Alex S Flitter
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | - Su Fen Lubitz
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | - Douglas Ziedonis
- Department of Psychiatry, University of California, San Diego, CA
| | - Nathaniel Stevens
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | - Frank T Leone
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - David Mandell
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | - John Kimberly
- Wharton School of Business, University of Pennsylvania, Philadelphia, PA
| | - Oscar Lopez
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | - Rinad S Beidas
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA
| | - Robert A Schnoll
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
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13
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Schnoll R, Leone F, Veluz-Wilkins A, Miele A, Hole A, Jao NC, Paul Wileyto E, Carroll AJ, Kalhan R, Patel J, Langer C, Lubitz SF, Hitsman B. A randomized controlled trial of 24 weeks of varenicline for tobacco use among cancer patients: Efficacy, safety, and adherence. Psychooncology 2019; 28:561-569. [PMID: 30680852 DOI: 10.1002/pon.4978] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 12/23/2018] [Accepted: 12/31/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Continuing to smoke after a cancer diagnosis undermines prognosis. Yet few trials have tested Food and Drug Administration (FDA)-approved tobacco use medications in this population. Extended use varenicline may represent an effective treatment for cancer patients who smoke given barriers to cessation including a prolonged time line for relapse. METHODS A placebo-controlled randomized trial tested 12 weeks of varenicline plus 12 weeks of placebo (standard [ST]) vs 24 weeks of varenicline (extended [ET]) with seven counseling sessions for treatment-seeking cancer patients who smoke (N = 207). Primary outcomes were 7-day biochemically confirmed abstinence at weeks 24 and 52. Treatment adherence and side effects, adverse and serious adverse events, and blood pressure were assessed. RESULTS Point prevalence and continuous abstinence quit rates at weeks 24 and 52 were not significantly different across treatment arms (P's > 0.05). Adherence (43% of sample) significantly interacted with treatment arm for week 24 point prevalence (odds ratio [OR] = 2.31; 95% confidence interval [CI], 1.15-4.63; P = 0.02) and continuous (OR = 5.82; 95% CI, 2.66-12.71; P < 0.001) abstinence. For both outcomes, adherent participants who received ET reported higher abstinence (60.5% and 44.2%) vs ST (44.7% and 27.7%), but differences in quit rates between arms were not significant for nonadherent participants (ET: 9.7% and 4.8%; ST: 12.7% and 10.9%). There were no significant differences between treatment arms on side effects, adverse and serious adverse events, and rates of high blood pressure (P's > 0.05). CONCLUSIONS Compared with ST, ET varenicline does not increase patient risk and increases smoking cessation rates among patients who adhere to treatment. Studies are needed to identify effective methods to increase medication adherence to treat patient tobacco use effectively.
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Affiliation(s)
- Robert Schnoll
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frank Leone
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anna Veluz-Wilkins
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Andrew Miele
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anita Hole
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nancy C Jao
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - E Paul Wileyto
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Allison J Carroll
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Ravi Kalhan
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois.,Department of Medicine, Northwestern University, Chicago, Illinois
| | - Jyoti Patel
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Corey Langer
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Su Fen Lubitz
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian Hitsman
- Department of Preventive Medicine, Feinberg School of Medicine, and Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois
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14
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Krutsinger DC, McMahon J, Stephens-Shields AJ, Bayes B, Brooks S, Hitsman BL, Lubitz SF, Reyes C, Schnoll RA, Ryan Greysen S, Mercede A, Patel MS, Reale C, Barg F, Karlawish J, Polsky D, Volpp KG, Halpern SD. Randomized evaluation of trial acceptability by INcentive (RETAIN): Study protocol for two embedded randomized controlled trials. Contemp Clin Trials 2019; 76:1-8. [PMID: 30414865 PMCID: PMC6354250 DOI: 10.1016/j.cct.2018.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/02/2018] [Accepted: 11/06/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The most common and conceptually sound ethical concerns with financial incentives for research participation are that they may (1) represent undue inducements by blunting peoples' perceptions of research risks, thereby preventing fully informed consent; or (2) represent unjust inducements by encouraging enrollment preferentially among the poor. Neither of these concerns has been shown to manifest in studies testing the effects of incentives on decisions to participate in hypothetical randomized clinical trials (RCTs), but neither has been assessed in real RCTs. METHODS AND ANALYSES We are conducting randomized trials of real incentives embedded within two parent RCTs. In each of two trials conducted in parallel, we are randomizing 576 participants to one of three incentive groups. Following preliminary determination of patients' eligibility in the parent RCT, we assess patients' research attitudes, demographic characteristics, perceived research risks, time spent reviewing consent documents, ability to distinguish research from patient care, and comprehension of key trial features. These quantitative assessments will be supplemented by semi-structured interviews for a selected group of participants that more deeply explore patients' motivations for trial participation. The trials are each designed to have adequate power to rule out undue and unjust inducement. We are also exploring potential benefits of incentives, including possible increased attention to research risks and cost-effectiveness.
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Affiliation(s)
- Dustin C Krutsinger
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Jacqueline McMahon
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alisa J Stephens-Shields
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian Bayes
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven Brooks
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian L Hitsman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Su Fen Lubitz
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Celine Reyes
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robert A Schnoll
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - S Ryan Greysen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ashley Mercede
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mitesh S Patel
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Catherine Reale
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fran Barg
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA; Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Anthropology, University of Pennsylvania School of Arts and Sciences, Philadelphia, PA, United States
| | - Jason Karlawish
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Penn Memory Center at the Penn Neuroscience Center, Philadelphia, PA, USA; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Polsky
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Kevin G Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Scott D Halpern
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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