Jonathan B. Bricker, PhD Fred Hutchinson Cancer Research Center University of Washington

1. Jonathan B. Bricker, PhD Fred Hutchinson Cancer Research Center University of Washington Telephone-Delivered ACT for Adult Smoking Cessation: A Feasibility Study

2. Smoking is a Deadly Worldwide Behavior • 21% of US adults smoke (CDC, 2006). • 1.2 billion smokers worldwide (Mackay, 2006). • Kills 5 million per year now and 10 million per year by 2025 worldwide (Hatsumaki et al., 2008).

3. Smoking Leads to Loss of Valued Living • Medical illnesses: multiple cancers, heart disease, stroke, COPD (CDC, 2006). • Work: absenteeism and discrimination (Bunn et al., 2006). • Stigma & Shame (Stuber et al., 2008).

4. Quitlines Address This Problem 1-800-QUIT-NOW

5. Quitlines: Addressing Barriers to Reach Accessible: In US, 95% have a telephone, 85% have cell phones. (Pew Internet & American Life Project, 2009) Available: All 50 States have a quitline as do most of Europe and Latin America Cost-effective: Covered by insurance, Medicaid, or the state. Costs (about $350) less than face-to-face and with only 17% lower fraction of effectiveness. Relatively brief: about 90 minutes total (3 to 9 sessions) Many demographics make use: Men, minorities, poor

6. Problem:Quitlines have limited effectiveness 12-14% quit rates at 12 month post randomization (Stead et al., 2006). We are not helping 86-88% of smokers to quit!

7. Why don’t they work well? A lack of attention to basic processes that lead people to smoke and to relapse!

8. Basic Processes: Avoidance & Lack of Commitment • AvoidanceCoping at age 18 predicted a 2.75 times higher odds (p <.001) of smoking two years later (99% data retention; N = 3305; Schiff, Bricker, et al., in review) • Lack of Commitment to Quitting predicted a 2.32 times higher odds (p <.01) of relapse 26 weeks after quit date (92% data retention; N = 157; Kahler et al., 2006)

9. Acceptance & Commitment Therapy Directly Targets These Basic Processes

10. Acceptance of your “baggage” Committed Action in valued direction

11. Promise of ACT for Smoking Cessation ACT vs. NRT: N= 76; 21% vs. 9% biochemically verified 24-hour abstinence at 12-month follow-up (n.s. in ITT; Gifford et al., 2004) ACT + FAP vs. Zyban: N = 302; 35% vs. 20% 30-day abstinence at 12-month follow-up (p <.05 in ITT; Gifford, Kohlenberg et al., in review)

12. Promise of ACT for Smoking Cessation 3. En Español: ACT vs. CBT: N = 81; 30% vs. 13% 30-day abstinence at 12-month follow-up (p <.05 in ITT; Hernandez-Lopez, Luciano, Bricker et al., 2009; Psychology of Addictive Behaviors)

13. Telephone Study Aims Determine adherence to ACT telephone protocol. Determine participant receptivity to ACT intervention. Examine change in ACT processes of (a) acceptance and (b) commitment. Determine post treatment and 12-months post treatment abstinence rates.

14. Sample (N = 14) Female: 40% Minority: 53% (primarily African American) Median age: 49 Low income: 64% Depressed (MDE screen): 40% Over half a pack per day: 64%

15. Procedure Developed ACT telephone protocol (5-session; 90 minute total). Recruited primarily from high-minority population of Dallas TX metro area. Primary Eligibility: Adult daily smoker wishing to quit within the next 30 days.

16. Fidelity Ratings Intra- and inter-rater reliabilities: all Kappas = 1 (perfect agreement). Overall Adherence & Overall Competence: 4.61 (SD: .63) & 4.81 (SD: .39) mean ratings (out of 1 to 5 rating). Acceptance & Committed Action: 4.87 (SD: .35) & 4.83 (SD: .50) mean ratings. Percent of calls meeting or exceeding benchmark rating of “4” or more ranged from 93% to 100%. Schimmel-Bristow, Bricker et al. (2010; Society of Behavioral Medicine)

17. First evidence that ACT Can Be Briefly Delivered Via Telephone Mean length of contact time: 82 minutes Mean number of counseling calls: 3.5 (33% had all five calls)

18. Participants Were Highly Receptive Felt respect by counselor: 100% Intervention was a good fit: 86% Intervention helped them quit: 86%

19. ACT Processes Changed Acceptance of physical cravings (p = .001), emotions (p = .048), and thoughts (p = .085) that cue smoking increased from baseline to end of treatment. Commitment to quitting increased from baseline to end of treatment (p = . 01).

20. Telephone-Based ACT: Cessation Results at 20 Days Post Treatment (93% retention) 24-hour point prevalence: 43% 7-day point prevalence: 29% Harm reduction, from daily to less than daily smoking: 62%

21. Cessation Results at 12-months Post Treatment (93% retention) 12-month prolonged quit: 29% (ITT) & 31% (with complete data) No relapsing among any study participants Bricker et al. (2010); Nicotine & Tobacco Research, 12, 454-458.

22. The Promise of Cessation/Process Results Over double the 12% quit rate of adult quitline counseling (Stead et al., 2006) Similar to all prior face-to-face ACT quit studies (30%-35%)

23. Future Plans Obtain funding to test effectiveness of telephone-delivered ACT vs. CBT for smoking cessation. Adapt & test protocol for other outcomes: alcohol & substance use, weight loss/stigma. Once effectiveness data are available, disseminate telephone protocol, provide training to all interested clinicians, and implement in quitlines.

25. Fidelity Methods Adapted Hayes & Gifford ACT fidelity measure for the telephone protocol. 100% of the 54 counseling sessions coded by trained rater. 20% random sample re-rated for intra-rater reliability. 20% random sample rated by a second independent rater for inter-rater reliability.

26. Contact Info • Jonathan Bricker, PhD • Email: jbricker@uw.edu