This application (RFA # OB-03-003) extends our examination of self-determination theory (SDT) based counseling interventions to the issue of maintained abstinence from tobacco use. Two projects are proposed, both of which build on the results of our current trial. The first is a 32-month follow-up of the smoking status of patients in the current trial. The SDT intervention was effective at 6 months relative to community care, and, according to preliminary analyses, was also effective for maintenance at 18 months, but long-term (32-month) follow-up data are needed. The second project is a 3-cell clinical trial. The current results show that patients were four times more likely to quit by 6 months if they used medications known to be efficacious for cessation, so the trial will examine two extensions of the current intervention, both of which place greater emphasis on use of, and adherence to, cessation medications. The two arms will be compared to community care. Both arms involve two visits with a physician to discuss medications and side effects. In both interventions, counselors will address medication adherence. The two arms differ in that patients not ready to quit in one arm will receive a smoking reduction approach (with medications) in which they first try to reduce their smoking to half and then attempt cessation. In addition to greater emphasis on medications and examination of medication adherence as a mediator of maintained cessation, there will be two major changes in the intervention intended to facilitate long-term maintenance. First, the intervention will extend over 12 months (whereas the current one lasts only 6 months) with meetings during the additional time focusing on maintenance and relapse prevention. Second, at least one family member or best friend of each patient will be encouraged to meet with a counselor to learn how to be more autonomy supportive with the patient around issues related to tobacco. Our current results show that family autonomy support predicts cessation, and family members represent an important source of support for long-term maintenance of abstinence. Cessation and maintained abstinence will be examined with logistic regression and survival curve analyses. The SDT process model of maintained cessation will be tested using structural equation modeling, and cost-effectiveness analyses will be done for the interventions. ? ?
