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Jonathan B. Bricker, PhDJonathan B. Bricker, PhDFred Hutchinson Cancer Research CenterFred Hutchinson Cancer Research Center
University of WashingtonUniversity of Washington
Telephone-Delivered ACT for Telephone-Delivered ACT for Adult Smoking Cessation: A Adult Smoking Cessation: A
Feasibility StudyFeasibility Study
Smoking is a Deadly Worldwide Smoking is a Deadly Worldwide BehaviorBehavior
21% of US adults smoke (CDC, 2006).
1.2 billion smokers worldwide (Mackay, 2006).
Kills 5 million per year now and 10 million per year by 2025 worldwide (Hatsumaki et al., 2008).
Smoking Leads to Loss of Valued Smoking Leads to Loss of Valued LivingLiving
Medical illnesses: multiple cancers, heart disease, stroke, COPD (CDC, 2006).
Work: absenteeism and discrimination (Bunn et al., 2006).
Stigma & Shame (Stuber et al., 2008).
Quitlines Address This Problem Quitlines Address This Problem
1-800-QUIT-NOW1-800-QUIT-NOW
Quitlines: Addressing Barriers to Quitlines: Addressing Barriers to ReachReach
Accessible: In US, 95% have a telephone, 85% have cell phones. (Pew Internet & American Life Project, 2009)
Available: All 50 States have a quitline as do most of Europe and Latin America
Cost-effective: Covered by insurance, Medicaid, or the state. Costs (about $350) less than face-to-face and with only 17% lower fraction of effectiveness.
Relatively brief: about 90 minutes total (3 to 9 sessions)
Many demographics make use: Men, minorities, poor
ProblemProblem:: Quitlines have limited Quitlines have limited effectivenesseffectiveness
§ 12-14% quit rates at 12 month post randomization (Stead et al., 2006).
§ We are not helping 86-88% of smokers to quit!
Why don’t they work well?Why don’t they work well?
A lack of attention to basic processes that lead people to smoke and to relapse!
Basic Processes: Avoidance & Basic Processes: Avoidance & Lack of CommitmentLack of Commitment
Avoidance Coping at age 18 predicted a 2.75 times higher odds (p <.001) of smoking two years later (99% data retention; N = 3305; Schiff, Bricker, et al., in review)
Lack of 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., 2006)
Acceptance & Commitment Acceptance & Commitment Therapy Directly Targets These Therapy Directly Targets These
Basic ProcessesBasic Processes
Acceptance Acceptance of your of your
“baggage”“baggage”
Committed Committed Action in Action in valued valued
direction direction
Promise of ACT for Smoking Promise of ACT for Smoking CessationCessation
1. ACT vs. NRT: N= 76; 21% vs. 9% biochemically verified 24-hour abstinence at 12-month follow-up (n.s. in ITT; Gifford et al., 2004)
2. ACT + FAP vs. Zyban: N = 302; 35% vs. 20% 30-day abstinence at 12-month follow-up (p <.05 in ITT; Gifford, Kohlenberg et al., in review)
Promise of ACT for Smoking Promise of ACT for Smoking CessationCessation
3. En Español: ACT vs. CBT: N = 81; 30% vs. 13% 30-day abstinence at 12-month follow-up (p <.05 in ITT; Hernandez-Lopez, Luciano, Bricker et al., 2009; Psychology of Addictive Behaviors)
Telephone Study AimsTelephone Study Aims
1. Determine adherence to ACT telephone protocol.
2. Determine participant receptivity to ACT intervention.
3. Examine change in ACT processes of (a) acceptance and (b) commitment.
4. Determine post treatment and 12-months post treatment abstinence rates.
Sample (N = 14)Sample (N = 14)1. Female: 40%
2. Minority: 53% (primarily African American)
3. Median age: 49
4. Low income: 64%
5. Depressed (MDE screen): 40%
6. Over half a pack per day: 64%
ProcedureProcedure1. Developed ACT telephone protocol (5-session; 90
minute total).
2. Recruited primarily from high-minority population of Dallas TX metro area.
3. Primary Eligibility: Adult daily smoker wishing to quit within the next 30 days.
Fidelity RatingsFidelity Ratings1. Intra- and inter-rater reliabilities: all Kappas = 1 (perfect agreement).
2. Overall Adherence & Overall Competence: 4.61 (SD: .63) & 4.81 (SD: .39) mean ratings (out of 1 to 5 rating).
3. Acceptance & Committed Action: 4.87 (SD: .35) & 4.83 (SD: .50) mean ratings.
4. Percent of calls meeting or exceeding benchmark rating of “4” or more ranged from 93% to 100%.
Schimmel-Bristow, Bricker et al. (2010; Society of Behavioral Medicine)
First evidence First evidence that ACT Can Be Briefly that ACT Can Be Briefly Delivered ViaDelivered Via Telephone Telephone
1. Mean length of contact time: 82 minutes
2. Mean number of counseling calls: 3.5 (33% had all five calls)
Participants Were Highly ReceptiveParticipants Were Highly Receptive
1. Felt respect by counselor: 100%
2. Intervention was a good fit: 86%
3. Intervention helped them quit: 86%
ACT Processes Changed ACT Processes Changed
1. Acceptance of physical cravings (p = .001), emotions (p = .048), and thoughts (p = .085) that cue smoking increased from baseline to end of treatment.
2. Commitment to quitting increased from baseline to end of treatment (p = . 01).
Telephone-Based ACT: Cessation Telephone-Based ACT: Cessation Results at Results at 20 Days20 Days Post Treatment Post Treatment
(93% retention)(93% retention)
1. 24-hour point prevalence: 43%
2. 7-day point prevalence: 29%
3. Harm reduction, from daily to less than daily smoking: 62%
Cessation Results at Cessation Results at 12-months12-months Post Post Treatment (93% retention)Treatment (93% retention)
1. 12-month prolonged quit: 29% (ITT) & 31% (with complete data)
2. No relapsing among any study participants
Bricker et al. (2010); Nicotine & Tobacco Research, 12, 454-458.
The Promise of Cessation/Process The Promise of Cessation/Process Results Results
1. Over double the 12% quit rate of adult quitline counseling (Stead et al., 2006)
2. Similar to all prior face-to-face ACT quit studies (30%-35%)
Future PlansFuture Plans1. Obtain funding to test effectiveness of telephone-
delivered ACT vs. CBT for smoking cessation.
2. Adapt & test protocol for other outcomes: alcohol & substance use, weight loss/stigma.
3. Once effectiveness data are available, disseminate telephone protocol, provide training to all interested clinicians, and implement in quitlines.
Fidelity MethodsFidelity Methods1. Adapted Hayes & Gifford ACT fidelity measure for the
telephone protocol.
2. 100% of the 54 counseling sessions coded by trained rater.
3. 20% random sample re-rated for intra-rater reliability.
4. 20% random sample rated by a second independent rater for inter-rater reliability.
