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EMA of Treatment Mediators and Proximal Predictors of Smoking
During a Quit Attempt
Danielle E. McCarthy, [email protected]
March 13, 2012
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
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
2
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
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-quit3
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
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 4
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
5
Stress Coping Smoking
Pre-Quit Coping Experience
Relations among coping, affect, and smoking over 48 hours (Minami et al., 2011, Addiction)
+
Negative Affect
Positive Affect
Urge Coping
Gender
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
6
Positive Affect
Smoking
Trigger exposure
Relations among affect, cognition, and smoking over 24 hours (Minami et al., in preparation)
Confidence
Motivation
Negative Affect
Time b/n reports
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
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?
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
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)
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
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
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
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)
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
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
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
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 Dependence M=5.3, SD=2.0, Range=1-9
– 27% CO-confirmed abstinence 3 weeks post-quit
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
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
13
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
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
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
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
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
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))
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
Sample Alarm ScreenAlarm screen
17
Alert
Friday, 7/13/201012:45 pm-1:00 pm
Private Appointment
Snooze Go ToClear
2210
83202138GO
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
EMA Discounting Instructions
83202138GO
Remember...
At least 1 of these choices will be REAL during the study!(Press Next to continue)
Previous Next
Welcome
Please indicate which option, A or B, you prefer by tapping the letter.(Press Next to continue)
Previous Next
Daily k .01
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
Sample EMA Discounting Items
Would you prefer?
1A. $ 24.27 today
1B. $ 25.00 in 2 weeks
Your choice:
Previous Next
A B
Would you prefer?
2A. $ 15.67 today
2B. $ 25.00 in 2 weeks
Your choice:
Previous Next
A B
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
Additional Items
20
PAST 15 MINUTES...
1 2 3 4 5
Disagree Agree
I have felt EXCITED
Previous Next
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)
Previous Next
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
Sample ED Items
21
PAST 15 MINUTES...
1 2 3 4 5Disagree Agree
I have felt EXCITED
OK
PAST 24 HOURS…
Not At All Extremely
How WILLING are you to WORK HARD AT QUITTING SMOKING?
Previous Next
I have felt EXCITED
Missing Response
Disagree Agree
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
Final Sample Item and Ending a Report
22
JUST BEFORE PROMPT:
Home
Work/School
Vehicle
Restaurant/Bar
Public Place
Others’ Home
Outside
Other
WHERE were you?
Previous Next
PAST 15 MINUTES…
Have you been with SOMEONE WHO WAS SMOKING?
Previous Next
Yes No
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
More Sample Items
23
PAST 2 HOURS…
How many CIGARETTES have you smoked IN THE PAST 2 HOURS?
Previous Next
PAST 2 HOURS…
Previous Next
Select one…
How many CIGARETTES
0123456789
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
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 items24
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
MiniCog
Next
Login ID l______
Notes ____________
__________
__________
Sample Questions
25
MiniCog
______________________Keyboard
1 2 3
4 5 6
7 8 9
( 0 )abc 123 Int’l
Done
2210
83202138GO
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
Instructions
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.
2210The 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.
GO
• 2-minute, 60-trial CPT-II• DV=Commission error rate
GO
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
EMA CPT-II Task
F X H
GO GO GO
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
Delay Discounting 7,204 records from 99 subjects
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
Delay Discounting
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
Delay Discounting
*Jump
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
Delay Discounting
*Jump
*Slope
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
Delay Discounting*JumpSteeper in those high in cognitive instability
*SlopeSteeper in those high in cognitive instability
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
Delay DiscountingUnrelated to initial cessation failure or abstinence 3 weeks post-quit
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
Behavioral Disinhibition6,719 records from 91 subjects
*Slope
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
Behavioral DisinhibitionBaseline error rate related to
3-week abstinence; EMA rates not predictive
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
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
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
Limitations
• Interim analysis with limited power
• Imperfect adherence to EMA assessment schedule
• Smoking not controlled for in models
• Skew in discounting and disinhibition distributions
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
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
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
Collaborators
• Rutgers– Gretchen Chapman– Haruka Minami– Krysten Williams– Vivian Yeh– Haewon Yoon
• U. Pittsburgh– Saul Shiffman
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• U. Wisconsin– Timothy Baker– Michael Fiore– Doug Jorenby– Daniel Lawrence– Megan Piper– Stevens Smith
• U. Missouri-Columbia– Thomas Piasecki
Smoking Cessation Laboratory
Tracking Impulsive Choice and Behavior
Questions?
Comments?
40