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We report results from a single-blinded randomized controlled trial examining financial incentives for smoking cessation among 249 pregnant and newly postpartum women. Participants included 169 women assigned to best practices (BP) or BP plus financial incentives (BP + FI) for smoking cessation available through 12-weeks postpartum. A third condition included 80 never-smokers (NS) sociodemographically-matched to women who smoked. Trial setting was Burlington, Vermont, USA, January, 2014 through January, 2020. Outcomes included 7-day point-prevalence abstinence antepartum and postpartum, and birth and other infant outcomes during 1st year of life. Reliability and external validity of results were assessed using pooled results from the current and four prior controlled trials coupled with data on maternal-smoking status and birth outcomes for all 2019 singleton live births in Vermont. Compared to BP, BP + FI significantly increased abstinence early- (AOR = 9.97; 95%CI, 3.32-29.93) and late-pregnancy (primary outcome, AOR = 5.61; 95%CI, 2.37-13.28) and through 12-weeks postpartum (AOR = 2.46; CI,1.05-5.75) although not 24- (AOR = 1.31; CI,0.54-3.17) or 48-weeks postpartum (AOR = 1.33; CI,0.55-3.25). There was a significant effect of trial condition on small-for-gestational-age (SGA) deliveries (χ

This study examines whether tobacco dependence severity moderates the acute effects of reducing nicotine content in cigarettes on the addiction potential of smoking, craving/withdrawal, or smoking topography. Participants (N = 169) were daily smokers with mild, moderate, or high tobacco-dependence severity using the Heaviness of Smoking Index. Following brief abstinence, participants smoked research cigarettes varying in nicotine content (0.4, 2.4, 5.2, 15.8 mg nicotine/g tobacco) in a within-subject design. Results were analyzed using repeated measures analysis of co-variance. No main effects of dependence severity or interactions with nicotine dose were noted in relative reinforcing effects in concurrent choice testing or subjective effects on the modified Cigarette Evaluation Questionnaire. Demand for smoking in the Cigarette Purchase Task was greater among more dependent smokers, but reducing nicotine content decreased demand independent of dependence severity. Dependence severity did not significantly alter response to reduced nicotine content cigarettes on the Minnesota Tobacco Withdrawal Scale nor Questionnaire of Smoking Urges-brief (QSU) Factor-2 scale; dependence severity and dose interacted significantly on the QSU-brief Factor-1 scale, with reductions dependent on dose among highly but not mildly or moderately dependent smokers. Dependence severity and dose interacted significantly on only one of six measures of smoking topography (i.e., maximum flow rate), which increased as dose increased among mildly and moderately but not highly dependent smokers. These results suggest that dependence severity has no moderating influence on the ability of reduced nicotine content cigarettes to lower the addiction potential of smoking, and minimal effects on relief from craving/withdrawal or smoking topography.

To examine whether an efficacious voucher-based incentives intervention for decreasing smoking during pregnancy and increasing fetal growth could be improved without increasing costs. The strategy was to redistribute the usual incentives so that higher values were available early in the quit attempt.118 pregnant smokers in greater Burlington, Vermont (studied December, 2006-June, 2012) were randomly assigned to the revised contingent voucher (RCV) or usual contingent voucher (CV) schedule of abstinence-contingent vouchers, or to a non-contingent voucher (NCV) control condition wherein vouchers were provided independent of smoking status. Smoking status was biochemically verified; serial sonographic estimates of fetal growth were obtained at gestational weeks 30-34.RCV and CV conditions increased point-prevalence abstinence above NCV levels at early (RCV: 40%, CV: 46%, NCV: 13%, p=.007) and late-pregnancy (RCV: 45%; CV: 36%; NCV, 18%; p=.04) assessments, but abstinence levels did not differ between the RCV and CV conditions. The RCV intervention did not increase fetal growth above control levels while the CV condition did so (p.05).This trial further supports the efficacy of CV for increasing antepartum abstinence and fetal growth, but other strategies (e.g., increasing overall incentive values) will be necessary to improve outcomes further.

This report describes a systematic literature review of voucher and related monetary-based contingency management (CM) interventions for substance use disorders (SUDs) over 5.2 years (November 2009 through December 2014). Reports were identified using the search engine PubMed, expert consultations, and published bibliographies. For inclusion, reports had to (a) involve monetary-based CM; (b) appear in a peer-reviewed journal; (c) include an experimental comparison condition; (d) describe an original study; (e) assess efficacy using inferential statistics; (f) use a research design allowing treatment effects to be attributed to CM. Sixty-nine reports met inclusion criteria and were categorized into 7 research trends: (1) extending CM to special populations, (2) parametric studies, (3) extending CM to community clinics, (4) combining CM with pharmacotherapies, (5) incorporating technology into CM, (6) investigating longer-term outcomes, (7) using CM as a research tool. The vast majority (59/69, 86%) of studies reported significant (p < 0.05) during-treatment effects. Twenty-eight (28/59, 47%) of those studies included at least one follow-up visit after CM was discontinued, with eight (8/28, 29%) reporting significant (p < 0.05) effects. Average effect size (Cohen’s d) during treatment was 0.62 (95% CI: 0.54, 0.70) and post-treatment it was 0.26 (95% CI: 0.11, 0.41). Overall, the literature on voucher-based CM over the past 5 years documents sustained growth, high treatment efficacy, moderate to large effect sizes during treatment that weaken but remain evident following treatment termination, and breadth across a diverse set of SUDs, populations, and settings consistent with and extending results from prior reviews.

Background A majority of physicians do not adhere to all the elements of the evidence-based USPHS guideline on tobacco use and dependence treatment. Among physicians and clinic office managers in Vermont we assessed perceived barriers to guideline adherence. We then assessed attitudes towards a computer-mediated clinical decision support system (CDSS) to gauge whether this type of intervention could support performance of the guideline. Methods A random sample of 600 Vermont primary care and subspecialty physicians were surveyed with a mailed survey instrument. A separate survey instrument was mailed to the census of 93 clinic office managers. Results The response rates of physicians and clinic office managers were 67% and 76%, respectively. Though most physicians were aware of the guideline and had positive attitudes towards it, there was a lack of familiarity with Vermont's smoking cessation resources as 35% would refer smokers to non-existent counseling resources and only 48% would refer patients to a toll-free quit line. Time constraints and the perception that smokers are unreceptive to counseling were the two most common barriers cited by both physicians and office managers. The vast majority of physicians (92%) have access to a computer in their outpatient clinics, and 68% have used computers during the course of a patient's visit. Four of the eight information management services that a CDSS could provide were highly valued by both physicians and clinic office managers. Conclusions Interventions to improve adherence to the guideline should address the inaccurate perception that smokers are unreceptive to counseling, and physicians' lack of familiarity with resources. A CDSS may improve knowledge of these resources if the design addresses cost, space, and time limitations.

Background Previous research showed low-income African American women with limited access to breast screening information through mass media to have a low likelihood of obtaining screening. This report describes a controlled evaluation of a component of a community-based breast screening promotion program focused on increasing screening among low-income African American women. Methods A direct-contact screening promotion component tailored to the needs of low-income African American women was conducted between 1990 and 1997 in one of two matched Florida study areas. Before and after assessments of breast screening, behavior and psychosocial mediators of screening were examined using logistic regression analyses for 1201 women with differing levels of exposure to media information about breast screening. Results Recent/repeat mammography use increased significantly in the program area for women with limited access to media information, although there was no significant program impact on hypothesized psychosocial mediators of screening. Conclusions The program led to increased mammography use among low-income African Americans having limited access to screening information through the media. For these women, using direct contact to deliver educational messages and facilitation of access to services may be the best method available to promote regular mammography.

Background . It is unclear whether proactive telephone support enhances smoking cessation beyond the provision of nicotine replacement therapy alone. Methods . We randomly assigned 330 low-income women smokers to receive either free nicotine patches (control condition) or free nicotine patches with up to 16 weeks of proactive telephone support (experimental condition). All participants were assessed by telephone at baseline and at 2 weeks, 3 months, and 6 months post-baseline to determine smoking status. Results . Results revealed a significant effect for the telephone support at 3 months, with 43% of experimental versus 26% of control condition women reporting 30-day point prevalent abstinence ( P = 0.002). The difference was no longer significant at 6 months. A metaanalysis conducted with five randomized studies revealed a slight but non-significant long-term benefit of proactive telephone support when added to the provision of free nicotine patches for smoking cessation. Conclusions . This is the second study to demonstrate a short-term effect for proactive telephone support added to free nicotine replacement therapy; however, neither the current study, nor the metaanalysis including the four other published trials, confirmed a longer-term benefit.

Background. Physicians' advice to help pregnant women quit smoking during prenatal care has had mixed results. Training and prompting physicians to provide consistent advice and referral to on-site support might improve cessation rates. Methods. Pregnant women who smoked were randomly assigned to receive structured advice from their physician and referral to individual behavior change counseling during prenatal care or to receive brief advice to stop smoking and a quit smoking booklet at their first visit. Smoking status was measured by self-report, exhaled carbon monoxide, and urinary cotinine. Results. Compared with usual care, greater proportions of intervention group women reported not smoking at the 36th-week visit (14% vs 10%) and at 1 year postpartum (18% vs 11%), but these differences were not significant. However, significantly greater proportions of intervention group women reported either not smoking or reducing their cigarette consumption by 50% or more at their second visit (43% vs 29%,P= 0.02), at their 36th-week visit (40% vs 25%,P< 0.01), and at 1 year postpartum (26% vs 14%,P= 0.02). Conclusions. Physician training on how to gain a pregnant smoker's commitment to change her smoking behavior, an office prompt system, and individualized smoking behavior change counseling show promise in reducing smoking during pregnancy and postpartum, but practical methods to assist pregnant smokers between regular prenatal visits, as they attempt to quit, need to be developed.

To evaluate the efficacy of an Internet behavioral weight loss program; and determine if adding periodic in-person sessions to an Internet intervention improves outcomes.481 healthy overweight adults (28% minority) were randomized to one of 3 delivery methods of a behavioral weight loss program with weekly meetings: Internet (n=161), InPerson (n=158), or Hybrid (Internet+InPerson, n=162). Outcome variables were weight at baseline and 6 months and percent of subjects achieving a 5 and 7% weight loss. The study took place in two centers in Vermont and Arkansas from 2003 to 2008.Conditions differed significantly in mean weight loss [8.0 (6.1) kg vs. 5.5 (5.6) kg vs. 6.0 (5.5) kg], for InPerson, Internet, and Hybrid respectively, p0.01, n=462). Weight loss for InPerson was significantly greater than the Internet and Hybrid conditions (p0.05). Although the proportion reaching a 5% weight loss did not differ, the proportion losing 7% did differ significantly (56.3% vs. 37.3% vs. 44.4% for InPerson, Internet, and Hybrid respectively, p0.01).These results demonstrate that the Internet is a viable alternative to in-person treatment for the delivery and dissemination of a behavioral weight-control intervention. The addition of periodic in-person sessions did not improve outcomes.

Background. This study reports results of a controlled evaluation of a comprehensive community breast screening promotion program. This program promoted increased use of mammography, clinical breast examination, and breast self-examination through community organization, physician training, and public education. Methods. The program was conducted in one of three matched Florida study areas, with before and after assessment of breast screening behaviors, beliefs, and perceptions of women ages 40 and older. Baseline measures in 1990 were obtained by combining telephone and household survey data; follow-up measures using similar combined data were conducted with 4,096 women in 1997. Results. There was no evidence that the breast screening promotion program achieved higher levels of screening among women ages 40 and older in the program area. Mammography use and supportive beliefs and perceptions of mammography increased in all three study areas between 1990 and 1997. Conclusions. Among factors that may have reduced the differential impact of the program were public attention to breast cancer screening in the late 1980s throughout the U.S., effects of managed care, and limited penetration of a key program component. While the program was well received and served the community, its impact was overwhelmed by temporal trends observed in this study.

The process of developing a comprehensive community-based breast screening program for the Breast Screening Program Project is presented in this article. Behavior change theories were used to develop a program effects model which served as the conceptual foundation for a comprehensive breast screening program. This program would enlist professional and lay resources to promote breast screening through public and physician education and through improved access to mammography. Baseline survey data were used to focus program components on educational needs of women ages 40 and older for participating in regular mammography, clinical breast exam, and breast self-exam. The program effects model was also used as an evaluation framework to specify the intermediate changes that will be accomplished to reach a hypothesized 15% increase in screening participation between a study area receiving the program and two comparison areas. Results of this study will be of immediate value to other communities planning breast screening promotion programs.