First RCT of Web-Based Acceptance & Commitment Therapy For Smoking

Cessation: 3 Month Processes & Outcomes

Jonathan B. Bricker, PhDFred Hutchinson Cancer Research Center

University of Washington

Reach & Efficacy of Smoking Intervention Modalities

Reach(# of million using modality annually)

1m 2m 3m 4m

Efficacy(% Quit at

12 months)

30%

20%

10%

Individual

Web

Telephone

Group

Why do current interventions have low quit rates?

Interventions don’t focus on basic processes that lead people to smoke

and to relapse!

Basic Processes: Low Acceptance& Commitment

Low Acceptance at age 18 predicted a 2.75 times higher odds (p <.001) of smoking at age 20 (99% data retention; N = 3305; Bricker et al., 2011)

Low Commitment to Quitting predicted a 2.32 times higher odds (p <.01) of relapse 26 weeks after quit date (92% data retention; N = 157; Kahler et al., 2007)

Acceptance & Commitment Therapy (ACT) is a Potential

Solution to the Problem of Low Quit Rates

What is ACT?

Acceptance of our

“baggage”

Committed Action in valued

direction

Pathways to Acceptance

Mindfulness: Present-moment focused attention in the face of challenging circumstances

Defusion: Stepping back and watching the process of thinking

Self-as-Context: The “part” of us that is aware of what we think, feel, and sense

Pathways to Commitment

Values: What deeply matters; want you want your life to be about

Action: Doing what it takes, guided by what deeply matters

Acceptance & Commitment Lead to Life-Embracing Behavior

Change

Mindfulness

Defusion

Self as Context

Acceptance

Values

Commitment

Action

Life-Embracing Behavior Change

Web-Delivered ACT for Smoking Cessation

Phase II Trial of Web ACT vs. Current Standard for Smoking

Cessation (FHCRC Pilot Grant; PI: Bricker)

Aim 1: Show trial design feasibility: recruitment, study arm balance and retention

Aim 2: Assess ACT 3-month cessation process & outcomes compared with Smokefree

Comparison: Smokefree.gov

Current Standard: US Clinical Practice Guidelines and panel of experts

Most visited in US: 1.2 million annual visitors

Highest user satisfaction: Of all non-profit websites (Etter et al, 2006)

Benchmark 7-10% quit rate: consistent with other published website trials (Hutton et al., 2011)

Experimental Design

Aim 1 Results: Recruitment

Enrollment: 621 eligible, 302 consent, 222 randomized (94 per month)

Recruitment sources:

41%: Referring websites (e.g., Google Ads)

35%: Search engine results (e.g., “how to quit smoking”)

24%: Direct entry (e.g., media)

Aim 1 Results: Demographics at Baseline & Retention

BaselineCharacteristic

Smokefree.gov

(n=111)ACT

(n=111)

BaselineCompariso

np=value

3-monthRetention

Comparisonp=value

Age, mean (SD)

45.3 (13.1) 44.8 (13.6)

0.76 0.84

Male 35% 41% 0.36 0.15

Caucasian 90% 95% 0.20 0.32

Hispanic 3% 6% 0.20 0.53

Married 42% 45% 0.95 0.14

Working 60% 62% 0.78 0.67

HS or less educ

24% 19% 0.15 0.56

Aim 1 Results: Smoking & Social Env at Baseline & Retention

BaselineCharacteristic

Smokefree.gov

(n=111)ACT

(n=111)

BaselineCompariso

np=value

3-monthRetentionCompariso

np=value

Smoking Behavior

1st cig within 30 min of waking

82% 75% 0.25 0.58

Smokes more than

half pack per day

80% 76% 0.63 0.30

Smoked for 10 or more years

79% 81% 0.45 0.20

Quit attempts in past 12M, mean (SD)

1.4 (2.1) 1.5 (2.6) 0.61 0.36

Friend & Partner Smoking Close friends who smoke, mean (SD)

1.6 (1.6) 1.7 (1.5) 0.84 0.44

Living with partner

who smokes

26% 22% 0.53 0.33

Aim 2 Results: 3-Month Cessation Processes

ACT Smokefree p-value

Acceptance of physical cues, mean

2.38 1.81 0.001

Acceptance of emotional cues, mean

1.95 1.63 0.022

Acceptance of cognitive cues, mean

1.77 1.48 0.083

Number of quit attempts since randomization, mean

9.21 3.92 0.101

Nicotine dependence 18% 44% 0.036

Aim 2 Results: Quit Rate

3-Month Outcome ACT Smokefreep-

value

30-day quit rate 23% 10% 0.050

Conclusions

Aim 1: Feasible trial design.

Aim 2: Process results comport with ACT theoretical model & show lower nicotine dependence than Smokefree.

ACT’s 23% Quit Rate

Over double 10% Smokefree quit rate.

Over 2-3 times higher than typical website.

Rare evidence of tx website being more effective than comparison tx website.

Achieved without pharmacotherapy.

ResearchStaff