Substance abusers have a high prevalence and rate of smoking with little success in quitting, so stronger approaches are needed to encourage attempts to quit smoking. Brief advice based on the NCI guidelines (BA), an approach designed to motivate cessation attempts, has shown some benefit for alcoholic smokers with comorbid drug use yet overall abstinence rates are low. Adding contingent monetary reinforcement to BA is one way to increase initial abstinence as a foundation for longer term abstinence. In a previous study, contingency management using immediate vouchers contingent on smoking abstinence (CM) increased abstinence relative to noncontingent voucher reinforcement (NR) during the voucher phase with little effect afterwards. Possible methods to increase effectiveness were piloted: Adding NRT greatly increased abstinence during and after CM while high payments had little additional benefit. However, since NRT with counseling is the basic standard of care for smoking cessation, what needs to be known is whether CM for smoking would increase the effectiveness of NRT plus counseling with substance abusers.
The aim of this study is to determine whether contingent reinforcement for smoking abstinence, compared to noncontingent reinforcement, increases the effectiveness of brief counseling and nicotine replacement on smoking abstinence of substance abusers in residential treatment. The proposed study will be a 2-group design in which 340 substance abusers who smoke 15 or more cigarettes per day receive BA (4 sessions) and NRT (8 weeks), and are randomized to 19 days (5 reduction days to shape initial abstinence + 14 abstinent reinforcement days) of CM for smoking vs. a matched NR condition (length designed to fit in the substance abuse program). NRT will be provided free to all. The BA (motivation message and cognitive-behavioral coping skills assistance) is adapted slightly for sobriety settings by directly addressing barriers and concerns expressed by substance abusers. Point-prevalence abstinence and substance use will be assessed at 1, 3, 6 and 12 months after starting treatment. Secondary aims evaluate effects of CM on potential mediators of effects on outcome including within-treatment abstinence, motivation level and tolerance for smoking discomfort. No previous study compared CM to NR for adult smokers when all have been provided NRT plus brief advice designed to motivate people to quit smoking. The potential significance is to add to knowledge about the most effective ways to maximize smoking cessation among substance abusers, important given that no methods are known to work with this difficult population.
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