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. 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

3. 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 1 st week –Motivation to quit 1 st week –Self-efficacy 1 st week Brief counseling (McCarthy et al., 2010, Addiction) –Self-efficacy 1 st month post-quit –Decline in perceived difficulty quitting over 1 st month post-quit 3

4. 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

5. 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

6. 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

7. 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?

8. 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)

9. 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

10. 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)

11. 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

12. 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 –Fagerstr öm Test of Nicotine Dependence M=5.3, SD=2.0, Range=1-9 –27% CO-confirmed abstinence 3 weeks post-quit

13. 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

14. 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

15. 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

16. 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 (V p =V d /(1+k base D)) tailored to baseline discounting rate (k base =1/D(V d /V p -1)) –Next sooner reward based on previous responses (midpoint between min and max indifference points) –Final k based on estimated indifference point at 8 th question (k EMA =1/D(V d /V p -1))

17. Smoking Cessation Laboratory Tracking Impulsive Choice and Behavior Sample Alarm Screen Alarm screen 17 Alert Friday, 7/13/2010 12:45 pm-1:00 pm Private Appointment Snooze Go To Clear 2210 83202138 GO

18. Smoking Cessation Laboratory Tracking Impulsive Choice and Behavior EMA Discounting Instructions 83202138 GO 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

19. 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 AB Would you prefer? 2A. $ 15.67 today 2B. $ 25.00 in 2 weeks Your choice: Previous Next AB

20. Smoking Cessation Laboratory Tracking Impulsive Choice and Behavior Additional Items 20 PAST 15 MINUTES... 12345 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

21. Smoking Cessation Laboratory Tracking Impulsive Choice and Behavior Sample ED Items 21 PAST 15 MINUTES... 12345 Disagree 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

22. 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 YesNo

23. 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 01234567890123456789

24. 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 items 24

25. Smoking Cessation Laboratory Tracking Impulsive Choice and Behavior MiniCog Next Login ID l______ Notes ____________ __________ __________ Sample Questions 25 MiniCog ______________________ Keyboard 123 456 789 (0) abc123Int’l Done 2210 83202138 GO

26. 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. 2210 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. GO 2-minute, 60-trial CPT-II DV=Commission error rate GO

27. Smoking Cessation Laboratory Tracking Impulsive Choice and Behavior EMA CPT-II Task F X H GO

28. Smoking Cessation Laboratory Tracking Impulsive Choice and Behavior Delay Discounting 7,204 records from 99 subjects

29. Smoking Cessation Laboratory Tracking Impulsive Choice and Behavior Delay Discounting

30. Smoking Cessation Laboratory Tracking Impulsive Choice and Behavior Delay Discounting *Jump

31. Smoking Cessation Laboratory Tracking Impulsive Choice and Behavior Delay Discounting *Jump *Slope

32. Smoking Cessation Laboratory Tracking Impulsive Choice and Behavior Delay Discounting *Jump Steeper in those high in cognitive instability *Slope Steeper in those high in cognitive instability

33. Smoking Cessation Laboratory Tracking Impulsive Choice and Behavior Delay Discounting Unrelated to initial cessation failure or abstinence 3 weeks post-quit

34. Smoking Cessation Laboratory Tracking Impulsive Choice and Behavior Behavioral Disinhibition 6,719 records from 91 subjects *Slope

35. Smoking Cessation Laboratory Tracking Impulsive Choice and Behavior Behavioral Disinhibition Baseline error rate related to 3-week abstinence; EMA rates not predictive

36. 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

37. 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

38. 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

39. Smoking Cessation Laboratory Tracking Impulsive Choice and Behavior Collaborators Rutgers –Gretchen Chapman –Haruka Minami –Krysten Williams –Vivian Yeh –Haewon Yoon U. Pittsburgh –Saul Shiffman 39 U. Wisconsin –Timothy Baker –Michael Fiore –Doug Jorenby –Daniel Lawrence –Megan Piper –Stevens Smith U. Missouri-Columbia –Thomas Piasecki

40. Smoking Cessation Laboratory Tracking Impulsive Choice and Behavior Questions? Comments? 40