1. Addictive behaviors research group. University of Oviedo, Spain.
The efficacy of Behavioral Activation and voucher-based Contingency Management for cigarette smokers with depression: a Randomized Controlled Trial
Alba González-Roz, Sara Weidberg, Ángel García-Pérez, Víctor Martínez-Loredo & Roberto Secades-Villa
Addictive behaviors research group. University of Oviedo, Spain.
Alba González De La Roz
GRUPO DE CONDUCTAS ADICTIVAS
Universidad de Oviedo

2. Acknowledgements and Disclosure of Interest
This work was supported by the Ministry of Economy and Competitiveness (MINECO) Ref. PSI P and by a predoctoral grant from the Spanish Government Ref. BES
Conflict of interest: none to declare
PI: Roberto Secades-Villa.

3. Background
Current stimates indicate that 23.95% of Spanish people are current smokers (National Institute of Statistics, ).
Smokers with depression show
High levels of nicotine dependence (Goodchild, Nargis, & Tursan d´Espaignet, 2017)
More difficulty in quitting smoking (Cinciripini et al., 2003; Zyeldonis et al., 2008)
Higher relapse rates (Brodbeck, 2014; Zvolensky, 2015)
Some studies reported promising results when adding mood management interventions (e.g.., Behavioral Activation) to standard smoking cessation treatments, but the scarce evidence precludes from yielding conclusions on the effectiveness of Mood Management interventions.
Contingency Management (CM) has extensively demonstated its efficacy in reducing tobacco use among special populations including adults with severe psychiatric disorders such as schizophrenia (Gallagher et al., 2007; Tidey et al., 2002; 2011).
CM interventions for smoking have not been implemented in smokers with major depression (Tidey, 2012).

4. Aims of the study
To analyze whether adding a CM component to a Cognitive Behavioral Treatment (CBT) + BA intervention would significantly increase rates of: adherence to treatment, smoking cessation and depressive symptoms among treatment-seeking smokers with elevated depressive symptoms.

5. Participants EXCLUSION INCLUSION CRITERIA CRITERIA
Randomized (n = 74)
INCLUSION
CRITERIA
EXCLUSION
CRITERIA
Allocation
CBT + BA (n= 41)
¨ Received allocated intervention (n= 41)
CBT + BA + CM (n= 33)
¨ Received allocated intervention (n= 33)
Severe psychiatric disorder
SUDs
Suicide risk
Receiving other cessation treatment
≥18 years old
≥10 cig/day
MDD (SCID I-CV: DSM-IV-TR)
≥14 on BDI-II
Discontinued intervention (i.e., not willing to quit) (n = 3)
Completed End of Treatment Assessment
(n= 38)
Lost to follow-up intervention (i.e., not willing to quit) (n = 2)
Completed End of Treatment Assessment
(n= 31)
Analysis
Analysed Intention-to-treat (n= 41)
Analysed Intention-to-treat (n= 33)

6. Treatment protocols CBT + BA TREATMENTS SCHEDULE BA Component
Duration: 8 weeks
One session per week of 1.5 hours
Group-based format: 4 patients
CO samples and urine cotinine collected twice a week
CBT + BA
BA Component
Behavioral Activation Treatment for Depression (BATD)
Assessment of the function of depressed behavior
Strategies for reduncing reinforcement of depressed behavior
Information gathering
Establishment of patient rapport
Monitoring daily activities
Scheduling activities
CBT Component
Nicotine fading (30%/week)
Information about tobacco
Self-monitoring of smoking
Feedback consumption (CO & cotinine)
Behavioral contract
Stimulus control
Training in alternative behaviors
Strategies for controlling nicotine withdrawal symptoms
Relapse prevention strategies

7. CBT + BA + CM Abstinence criteria Cotinine < 80ng/ml CO < 4 ppm
CM Component
SESSION
1 A
2 A
3 A
4 A
5 A
6 A
7 A 8
SESSION
1 B
2 B
3 B
4 B
5 B
6 B
7 B
Abstinence criteria
Cotinine < 80ng/ml
CO < 4 ppm
The maximum amount that patients could earn was 175€ (US$ 190) R+ R+ R+ R+ R+ R+ R+ 10 15 20 25 30 35 40

8. COMBINATION OF TWO STRATEGIES:
(1) Number of cigarettes per day
ex.: 20 – 18 – 12 – 8 – 0 – 0 – 0 - 0
(2) Change to other cigarette brands with lower nicotine level
ex. 0.8mg – S1: 0.6mg – S2: 0.4mg – s3: 0.2 mg – s4: 0.1 mg – 0.2mg – 0 – 0 – 0 – 0
Nicotine Fading
WEEK 1
70% nicotine intake
WEEK 2
40% nicotine intake
WEEK 3
10% nicotine intake
WEEK 4
WEEK 5 0%
Abstinence
WEEK 6
WEEK 7
0% Abstinence
WEEK 8

9. Individualized cotinine reductions in urine samples

10. Sample Characteristics
CBT + BA
(n = 41)
CBT + BA + CM
(n = 33)
p value
Age (years)a
51.58 ± 9.55
52.71 ± 8.54
.596
Gender (% women) 75
82.4
.630
CO (ppm)a
27.08 ± 16.58
20.79 ± 8.01
.038
Cotinine (ng/ml) ± ±
.407
Cigarettes per daya
23.75 ± 8.46
21.24 ± 8.36
.204
Years of smokinga
32.80 ± 10.53
32.71 ± 8.87
.967
Fagerström Testa
6.07 ± 1.77
6.03 ± 2.22
.063
BDI-IIa
26.72 ± 9.65
30.42 ± 8.50
.091
Current diagnosis 22 26
.080
Single episode
31.8
15.4 -
Recurrent episode
63.6
57.7
Chronic disorder
4.5
26.9
BADSa
23.63 ± 6.007
21.97 ±7.88
.31
EROSa
33.17±19.80
26.36±18.68
.14
Note. CBT= Cognitive-Behavioral Treatment; BA= Behavioral Activation; CM= Contingency Management; CO (ppm) = carbon monoxide (parts per million); BDI-II = Beck Depression Inventory; BADS-SF = Behavioral Activation for Depression scale-short form ; EROS = The Environmental Reward Contingency Scale; a = Mean ± SD

11. Attendance to all treatment sessions
CBT+BA+CM
93.5%
SESSIONS
CBT+BA
71.1%
p = 0.039, Cramer’s V = .29

12. In-treatment Abstinence
CBT+BA
CBT+BA+MC
p =.55
DAYS OF ABSTINENCE

13. Depressive Symptomatology
CBT + BA
CBT + BA + CM p
Intake
26.72 ± 9.65
30.42 ± 8.50
.091
EOT
11.87 ± 8.61
11.10 ± 6.86
.68

14. Relapse curve

15. Conclusions
It is noteworthy that a 68% of the total sample achieved abstinence at the end of treatment, which is substantially higher than reported by previous studies using either BA protocols or pharmacotherapy.
A greater percentage of patients receiving CBT+BA+CM attended to all therapy and midweek between sessions compared to those in the CBT+BA condition.
The CBT+BA and CBT+BA+CM treatments brought about significant reductions in both smoking and depression at the end-of-treatment
Despite both treatments promoted high abstinence rates and largely reduced depressive symptoms, results suggest that including a CM protocol could enhance smoking abstinence.

16. Addictive behaviors research group. University of Oviedo, Spain.
Contingency Management and Behavioral Activation for smokers with depression
Thanks for listening
Alba González-Roz, Sara Weidberg, Ángel García-Pérez, Víctor Martínez-Loredo & Roberto Secades-Villa
Addictive behaviors research group. University of Oviedo, Spain.
Alba González De La Roz
GRUPO DE CONDUCTAS ADICTIVAS
Universidad de Oviedo