acceptance-based treatment for smoking cessation, 2004

8/12/2019 Acceptance-Based Treatment for Smoking Cessation, 2004

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B E H V I O R T H E R P Y 35 ,689-705 ,2004

Acceptance Based Treatme nt for Sm oking CessationE L I Z A B E T H V . G I F F O R D

Department of Veterans Affairs and Stanford University School o f MedicineB A R B A R A S K O H L E N B E R G

University of Nevada School o f MedicineS T E V E N C . H A Y E S

University of Nevada RenoD A V I D O . A N T O N U C C I OM E L I S S A M . P IA S E C K I

University of Nevada School o f MedicineM A N D R A L R A S M U S S E N - H A L L

University of Nevada RenoK A T H L E E N M . P A LM

Brown UniversityThis p i lo t s tudy appl ied a theore t ica l ly de r ived mo de l of acceptance-based t rea tmentprocess to sm oking cessa t ion , and com pared i t to a pharm acologica l t rea tment basedon a m e d i c a l de pe nde nc e mo de l . S e ve n t y - s i x n ic o t i ne-de pe nde n t smoke rs we re r a n -dom l y a s s i gne d t o one o f t wo t r e a tme n t s : Ni c o t i ne R e p l a c e me n t Tre a t me n t (NR T) ,o r a smok i ng - foc use d ve r s i on o f Ac c e p t a nc e a nd C om mi t me n t The ra py (AC T) .The re wer e no differences betw een cond it ions a t posttreatment; how ever, partic ipants

Data presen ted in th i s man uscr ip t w ere pa r t of El izabe th Gi fford ' s doc tora l d i sse r ta tion a t theUnivers i ty of Nevad a , Reno, which w as funded by a grant to El izabe th Gi fford f rom the Na t iona lIns t i tu tes of Hea l th , Na t iona l Cancer Ins t i tu te , CA84813. Prepara t ion of th i s manuscr ip t wasa lso supported in pa r t by grants f rom the Na t iona l Ins t i tu tes of Hea l th , Na t iona l Ins t i tu te onDra g A buse , DA08 634 a nd DA 13106 , a nd by t he De pa r t me n t o f Ve te ra ns A f fa ir s .

Addre s s c o r re sponde nc e t o E l i z a be th V. Gi f fo rd , C e n t e r fo r He a l t h C a re E va l ua t ion , VA P a l oAl t o He a l t h C a re S ys t e m S t a n fo rd Un i ve r s i t y S c hoo l o f M e d i c i ne , 795 W i l l ow R oa d / M P D152, Menlo Park , CA 94025; e -mai l : e l izgi f ford@earth l ink .ne t .

689 005 -7894 / 04 / 0689~ 70551 .00 / 0Copyright 2004 by Associationfor Advancementof BehaviorTherapyAll rights for reproduction n any for m reserved.


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i n t h e A C T c o n d i t i o n h a d b e t t e r l o n g - t er m s m o k i n g o u t c o m e s a t 1 - y e ar f ol l o w -u p .A s p r e d i c te d b y t h e a c c e p t a n c e p r o c e s s m o d e l A C T o u t c o m e s a t 1 y e a r w e re m e d i -a t e d by im pr ove m e n t s in a c c e p ta nc e - r e l a t e d sk il l s . W i thd r a w a l sym ptom s a nd ne ga -t i ve a ff e c t ne i t he r d i f f e r e d be tw e e n c on d i t i ons no r p r e d i c t e d ou t c om e s . R e su l t s w e r ec o n s i s t e n t w i t h t h e f u n c t i o n a l a c c e p t a n c e -b a s e d t r e a t m e n t m o d e l .

The 1960s and 1970s were the go lden age o f behav io r therapy deve lop-m e n t fo r s m o k i n g ce s s a t io n . M u l t i p le n ew t ech n o l o g i e s b a s ed o n b eh av i o ra lmodels resu l ted in no tab le improvements in ou tcomes (Sh i f fman , 1993a) .S i n ce t h a t t i m e , h o wev e r , t h e d ev e l o p m en t o f n ew b eh av i o ra l t h erap i e s h a ss l o wed (Ni au ra Ab ram s , 2 0 0 2; Sh i ffm an , 1 99 3a ). Ac co rd i n g t o Sh i f fm an(1993a) , th is redu c t ion ma y be a t t ribu ted to a sh i f t in focus f ro m behav io ra ls m o k i n g ce s s a t i o n t rea t m en t s t h a t a r e b a s ed o n u n i t a ry s p ec if i ed m e ch an i s m so f ch an g e t o m u l t i co m p o n en t , a th eo re t ica l g rab -b ag ap p ro ach es i n co rp o ra t-ing any tec hno log ies be l ieved to o f fe r he lp .W h i l e ap p l y in g co m b i n a t io n s o f h e l p fu l t r ea tm en t s s eem s j u st i fi ab le g i v ent h e s ev e re co n s eq u en ces o f s m o k i n g , a t h eo re t i ca l t r ea t m en t p ack ag es canobscure c la r i ty abou t c r i t ica l m ech an ism s o f cha nge (Sh i f fman , 1993a) . C lar -i ty abou t the p rocesses respons ib le fo r t rea tm en t e f fec t s l eads to be t te r under-s tand ing o f d i so rders and ex i s t ing t rea tme n ts , and leads to the deve lopme nt o fnew, more po we rfu l therap ies (Fo l le t te , 1995 ; Kazd in , 2001) . Recen t ly , a n um -ber o f inves tiga to rs have ca l led fo r a re tu rn to theo ry-d r ive n t rea tm en t deve l -o p m en t b a s ed o n b eh av i o ral m e ch an i s m s o f ac t i o n (N i au ra Ab ram s , 2 00 2;Rou nsav i l l e , Carro l l , O nke n , 2001) .Th e p re s en t s t u d y i s an i n v es ti g a ti o n o f a n ew t r ea t m en t fo r s m o k i n g b as edo n a s p ec i fi c b eh av io ra l t h eo ry o f ch an g e . Th e t r ea t m en t was d e s i g n ed fo rs m o k e r s w h o s e s m o k i n g i s m a i n t a i n ed b y e f fo r ts to av o id o r m o d i fy av e r si v ei n te rn a l ex p e r i en ces s u ch a s n eg a t i v e a f fec t an d o t h e r w i t h d rawa l s y m p t o m s .I t i s a bas ic behav io ra l p r inc ip le tha t avo id ing avers ive s t imul i can p rov iden eg a t iv e r e i n fo rcem en t fo r m a l ad ap t i v e b eh av io r . Fo r ex am p l e , t h e a l co h o l i cwh o d r i n k s t o av o i d o r r eg u l a t e n eg a t i v e a f f ec t r eap s i m m ed i a t e ben e f it s f ro mdr ink ing (Cong er , 1956 ; M ar la t t Go rdon , 1985).

Ev i d e n ce s u g g es ts t h a t t h e n eg a t iv e r e i n fo rcem en t av ai lab l e t h ro u g h av o i d -an ce i s a n i m p o r t an t co m p o n e n t o f n i co t i n e d ep en d e n ce (Sh i f fm an , 1 9 9 3b ).Neg a t i v e a f f ec t an d t h e n eg a t i v e r e i n fo rcem en t p ro d u c ed b y r ed u c t i o n s i nn eg a t i v e a f fec t a r e p o t en t p red i c t o rs o f s m o k i n g an d s m o k i n g r e l ap s e (B ran -don , 1994 ; Bran don , Ti f fany , O brem sk i , Baker , 1990) . Ne gat ive a f fec t i ss t ro n g l y a s s o c i a t ed w i t h s m o k i n g i n ep i d em i o l o g i ca l s t u d i e s (An d a e t a l . ,1990 ; Cinc i r ip in i, H ech t , He nn ingf ie ld , M anley , Kra m er , 1997), appears topred ic t t rea tm en t fa i lu re (Hal l , M uno z , Re us , Sees , 1993; Hal l e t a l .,1996), an d has pow erfu l psyc hop hys io lo g ica l in te rac t ions wi th n ico t ine andn i co t i n e w i t h d rawa l (New h o u s e P i a s eck i , 2 00 0; Po m er l eau Po m er l eau ,1984). In a re cen t s tudy o f 632 sm okers (K enford e t a l. , 2002) , pos tqu i t nega-t iv e a f f ec t was t h e s t ro n g est p red i c t o r o f r e l ap s e , ab o v e p h y s i o l o g i ca l d ep en -d e n c e s y m p t o m s a n d h i s to r y o f d r u g e x p o s ur e . S m o k i n g m a y b e m a i n t a in e d


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by avo id ing nega t ive a f fec t , and re lapse may be t r iggered by the des i re toredu ce nega t ive in te rna l s t a tes .

Th e cu r r en t p ro j ec t d ev e l o p ed an d ap p l i ed a b eh av i o ra l t rea t m en t b a s ed o na fu n c t i o n a l p ro ces s m o d e l t a rg e t in g n eg a t i v e ly r e i n fo rced av o i d an ce (G i f -fo rd , 1994, 2002a; Ko hlenberg Gi f fo rd , 1999). Th is m ode l spec i fi es tha tthe c r i t i ca l componen t o f the behav io r change p rocess i s the ab i l i ty torespo nd d i f fe re n t ly in the p rese nce o f nega t ive a f fec t and o ther in te rna l s ta tes;in add i t ion , the goa l o f trea tm en t is to shape accep tance- re la ted sk i ll s in o rderto reduce avo idance and increase cogn i t ive and behav io ra l f l ex ib i l i ty (Gi f -fo rd , 2 0 02 b ) . Th e re a r e fo u r co m p o n en t s t o t h e p ro cess m o d e l :1 . An in te rpersona l con tex t (e .g . , the therapy re la t ionsh ip ) tha t models ,

suppor t s , and re in fo rce s the deve lop m ent o f accep tance- re la ted sk il ls .2 . Cog ni t ive, affect ive, and phy siological sel f-d iscriminat ion skil ls tha t helpc l i en t s i d en t i fy t h e a s p ec t s o f t h e i r ex p e r i en ce t h a t h av e p rev i o u s l yo ccas i o n ed u n h ea l t h y b eh av i o r.3 . G uided expo sure to previously avoided internal expe riences , wi th responsepreven t ion .4 . Con s t ruc t ive behav io ra l ac t iva tion in the p resenc e o f p rev iou s ly avo idedthough ts an d fee l ings .T h i s m o d e l w a s u s e d t o g e n e r a t e a v e r s io n o f A c c e p t a n c e an d C o m m i t m e n tTh e ra p y (AC T) t a rg e ted t o ward s m o k e r s . AC T (Hay es , S t ro sah l , W i ls o n ,1 9 99 ) i s b a s e d o n a c o n t e x t u a l th e o r y o f c o g n i ti o n a n d b e h a v i o r ( H a y e s ,B a r n e s - H o l m e s , R o c h e , 2 0 0 1 ) a n d a i m s a t i n c r e a s i n g b e h a v i o r a l s e lf -con t ro l by fac i l i t a t ing ski ll s in acc ep t ing in te rna l exper iences a nd recon tex tu -al izing problem atic cogni t ions (see Hay es , 2004; th is issue) . Cl ients are taughtto make over t behav io ra l cho ices on the bas i s o f goa l s l inked to l i fe va lues ,an d n o t o n t h e b a si s o f s eek i n g to m o d i fy ce r t a in t h o u g h t s o r f ee l in g s .N i co t i n e R ep l acem en t T rea t m e n t (NR T) was c h o s en a s t h e co m p ar i s o nco n d i t i o n fo r th i s t r ea t m en t d ev e l o p m en t s tu d y . NR T i s a w i d e l y u s ed em p i r i -ca l l y s u p p o r ted t r ea t m en t b a sed o n a p h y s i ca l d ep en d en ce m o d e l (C i n c ir ip i n ie t a l . , 1997) . The phys ica l dependence model iden t i f i es tha t the bas i s fo rsmoking i s n ico t ine exposure , to le rance deve lopment , and resu l t ing wi th -d rawa l sym ptom s in the absence o f n ico t ine (Ken ford e t a l. , 2002) . N ico t ine-r ep l acem en t th e rap y p ro v i d es an a l te rn a ti v e fo rm o f n i co t in e i n t en d ed t ore l iev e w i t h d rawa l s y m p t o m s i n s m o k e r s ab s t a in i n g f ro m t o b acco (R i g o t ti ,2 0 0 2; W es t m aas , Na t h , B ran d o n , 2 0 0 0 ).Th e m o d e l u n d e r l y i n g NR T p ro v i d es a c l ea r co n t r a s t t o a fu n c t i o n a lacc ep t a n ce -b as ed t r ea t m en t m o d e l . Th e fo rm er t r ea t m en t i s b a s ed o n a l t er -i n g t h e f r eq u en c y o r i n t en s i ty o f w i t h d rawa l s y m p t o m s , w h i l e t h e l a t te r t rea t -m en t i s based on a l t e r ing the func t ion o f such exper ienc es . Th is d i rec t d i f fe r -en ce p e rm i t t ed p re l i m i n a ry t e s t i n g o f b o t h p ro ces s an d o u t co m e . Th ep h y s i o l o g i ca l d ep en d en ce m o d e l p red i c t s th a t p a r t ic i p an t s' w i t h d rawa l s y m p -t o m s r e l a t e to o u t co m e , an d t h a t th e N R T t r ea t m en t w i ll p ro d u ce b e t t e r o u t -c o m e s b y r e d u c in g w i th d r a w a l s y m p t o m s . T h e f u n c ti o n a l a c c e p t a n c e - b a s e d


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m ode l pred ic ts tha t pa r t ic ipan ts ' e f for t s to avoid re la te to ou tco m e , and tha tAC T t rea tm ent wi l l p roduce be t te r ou tcom es by reduc ing exper ien t ia l avoid-ance and the reby inc reas ing cogni t ive and b ehaviora l f lex ib i li ty .

ethodP a r t i c i p a n t s

On e hund red twen ty- four pa r t ic ipan ts co m ple ted sc reen ing . For ty-e igh tpa r t ic ipan ts e i the r were no t accepted or d ropped out be fore r andomiza t ion ;25 ou t o f th i s 48 were exc luded for smoking and n ico t ine dependence c r ite ria ,8 w ere exc luded for non sm oking s tudy c r i te r ia ( e .g . , cur ren t ly us ing a l te rna -t ive t r ea tments , ac t ive psychia t r ic condi t ions) , and 15 dec l ined t r ea tmentpr ior to a ss ignment . Seventy- s ix pa r t ic ipan ts were provided in formed con-sen t , r ando m ized , and began t r ea tment .S u b j e c t c h a r a c t e r i s ti c s . Fif ty-n ine pe rcen t o f pa r t ic ipan ts were female ,and 41% male . Almost a qua r te r o f the sample (23%) was e thn ic minor i ty ,and the remainder of the sample was Caucas ian . The la rges t pa r t ic ipan tm inor i ty groups were Hispanic (7%) and N a t ive Am er ican (7%) . Pa r t ic ipan tages ranged f rom 19 to 71 , wi th an ave rage age o f 43 S D = 11.68). Th irty -two pe rcen t o f pa r t ic ipan ts r epor ted an incom e above 29 ,999. F i f ty - sevenpercent o f pa rt ic ipan ts r epo r ted having a t tended a t l eas t som e co l lege , 17%repor ted comp le t ing h igh schoo l , and 4% repor ted som e h igh school o r le ss .S u b j e c t s m o k i n g h i s t o r i e s . Par t ic ipan ts r epor ted smoking an ave rage of21 .40 c iga re t te s pe r day S D = 7 .05). Pa r t ic ipan ts r epor ted an ave rage of fourqui t a ttempts la s t ing m ore than 1 day ov er the pas t 2 yea r s (M = 4 .0 , S D =6.86). Th e leng th of qu i t pe r iods va r ied wide ly , wi th the 25 th p e rcen t i le qu i t-t ing for 4 .13 days , the 50 th pe rcen t i le for 30 d ays , and the 75 th p e rcen t i le for180 days or more . For ty pe rcen t o f pa r t ic ipan ts r epor ted no prev ious t r ea t -m e n t f o r smok ing .P r o c e d u r e s

P a r ti c ipa n ts w e r e r e c r u i te d f r om the c om m uni ty t h rough ne w spa pe r a ndrad io adver t i sements , r e fe r ra l s f rom phys ic ians and agenc ies , and f lye r s .Af te r an in i tia l phon e sc reen w i th c l in ic pe r sonne l , par t ic ipan ts und erw ent asemis t ruc tured in te rv iew w i th s tudy psychia t r i s ts to sc reen for smok ing c r i te -r ia and cur ren t medica l o r psychia t r ic d iagnoses , inc lud ing ac t ive or r ecen tsubs tance use dependence or abuse d isorde r s , a h i s tory of psychos is , andm enta l re tardat ion (see Table 1 for inc lusion an d exclusio n cr iter ia) . Th e Fager-s t rom T e s t f o r N ic o t ine D e pe nde nc e ( F T N D ) , C A G E ( a b r i e f sc r e en ing que s-t ionna i re for p roblem dr ink ing; Buchsbaum, Buchanan , Centor , Schol l , &Law ton , 1991), B eck Dep ress ion Inventory (BD I) , and the BAI (B eck An xi -e ty Inventory) were used to c ross -va l ida te ce r ta in c r i te r ia in the in te rv iewscreening process ( e .g . , even i f pa rt icipan ts d id no t cho ose to d isc lose a prob-lem w i th a lcohol , CA GE scores of g rea te r than 2 were cause for exc lus ion) .Af te r sc reen ing , pa r t ic ipan ts were ran dom ly ass igned to: AC T o r NRT. Both


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ACCEPTANCE-BASEDTREATMENT FOR SMOKINGT A B L E 1

INCLUSIONAND EXCLUSIONCRITERIA

693

Inclusion Criteria Exclusion CriteriaSelf-identified nicotine-dependent smokerssmoking 10 cigarettes or more per day fo rat least 12 months with FTND scores of5 or more.Willing to be randomly assigned to treatment.Agree to con tinue with the project for the full7-week treatment period.Agree to participate in follow-up assessmentfor 1 year posttreatment.Agree no t to seek other treatment for smokingduring the 7-week active treatment period.Previous quit attem pt lasting at least 24 hours.

Previous or present diagnosis o f a psychoticdisorder.Borderline m ental retardation.Diagnosis of alcohol or drug dependencewithin the last year excluding nicotine).Under 18 years of age.Non-English speaking.History o f serious cardiac disease.Active peptic ulcer.Currently using tobacco products other thancigarettes.Currently using nicotine replacemen t products,including gum, patch, or medication such asfluoxetine, clonidine, bupsirone, doxepin.Skin allergies and/or active dermatologicalconditions involving large areas of the skinsurface.Currently receiving psychotherapy.Living with anyone who has been or is beingtreated by the UN R Sm oking Cessation

Clinic.Active affective disorders, including majordepressive disorder, bipolar disorder, oranxiety disorders.

t r e a t m e n t s l a s t e d 7 w e e k s w i t h p a r t i c i p a n t s v i s i t in g t h e c l in i c a t l e a s t o n c ep e r w e e k .NRTNRTproviders P a r t i ci p a n t s i n t h e N R T c o n d i t i o n w e r e t r e a te d b y a b o a r d -

c e r ti fi e d p s y c h i a t r is t w i t h e x t e n s i v e t ra i n i n g i n t h e m e d i c a l m a n a g e m e n t o fs m o k i n g c e s s a t i o n , i n c l u d i n g n i c o t i n e r e p l a c e m e n t t h e r a p i e s , a n d a p s y c h i a -t r y r e s i d e n t u n d e r h e r s u p e r v i s i o n . T h e s e t w o p r o v i d e r s h a d s t r o n g a l l e g i a n c et o t h e m e d i c a l m a n a g e m e n t o f s m o k i n g c e s s a t io n . T h e p r i m a r y p s y c h i a t r is tw a s o n 2 4 - h o u r c a l l t h r o u g h o u t t r e a t m e n t .NRTprotocol N i c o t i n e r e p l a c e m e n t w a s d e l iv e r e d v i a n i c o t i n e p a tc h e sp r o v i d e d f r e e o f c h a r g e t o p a r t i c i p a n t s . P a r t i c i p a n t s a t t e n d e d a n in i t ia l 1 . 5-h o u r g r o u p e d u c a t i o n m e e t i n g c o n d u c t e d b y t h e p s y ch i a tr i st , d u r i n g w h i c h a ne m p i r i c a l l y s u p p o r t e d t r e a t m e n t r at i o n a l e w a s p r e s e n t e d t o p a r t ic i p a n t s s e eb e l o w ) , a l o n g w i t h b a s ic a d v i c e o n q u i t ti n g s m o k i n g . P a r t i c ip a n t s w e r e p r o -v i d e d w i t h a 3 0 - m i n u t e q u e s t i o n - a n d - a n s w e r p e r i o d a n d r e c e iv e d i n s t ru c t i o n so n h o w t o r e a c h t h e d o c t o r i n th e e v e n t o f a n y c o n c e r n s . P a r t i c ip a n t s w e r ei n s t ru c t e d n o t t o s m o k e w h e n u s i n g t h e p a tc h .


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69 GIFFORD ET AL

D u r i n g t h e p a t ch ed u ca t i o n mee t i n g co n d u c t ed b y t h e s t u d y p s y ch i a t r i s t ,par t ic ipan t s w ere g iven the fo l low ing ra t iona l e ( f rom Ts oh e t a l . , 1997):O n e r ea s o n p eo p l e s m o k e i s t o o b ta i n n i co ti n e . N i co t i n ei s th e i n g r ed i en t i n t o b acco s mo k e b e l i ev ed to b e r e s p o n -s i b l e f o r ad d i c t i o n o r t o b acco d ep en d en ce . M an y s mo k -e r s f ee l b ad w h en t h ey s t o p s mo k i n g . Th ey may ex p e r i -ence cravings for cigaret tes , tension, i r r i tabi l i ty , sadness ,p rob lems wi th s l eep , and d i f f i cu l ty concen t ra t i ng . Theses y m p t o m s a r e p a rt ly t h e r e su lt o f n ic o ti n e w i t h d r a w a l -t h e r eac t i o n o f o u r b o d i e s t o t h e r emo v a l o f n i co t i n ew h e n w e a r e a ccu s t o m ed t o g e t ti n g i t.Somet imes , peop le wan t a c igare t t e i n spec i f i c s i t ua-t ions w here t hey a re used to sm oking , such as a f t e r a mealo r wh i l e d r iv ing . Prob lems wi th wi thdrawal and a des i r eto smoke in par t i cu l a r se t t i ngs may l ead to r e l apse . Thepatch can h e lp by main t a in ing a cons t an t (bu t l ow er t hansmoking) l eve l o f n i co t ine t h roughou t t he day . Us ing thepa tch resu l t s i n a r educed des i r e t o smoke and p rov idesan o p p o r t u n i t y f o r a n ew n o n s m o k e r t o p r ac t ice a ll o f t h en ew n o n s m o k i n g s k il ls w i t h o u t b e i n g b u r d en ed b y c r av -ings. (p. 16)

P a t ch s ch ed u l e w as d e t e r mi n ed b y g u i d e l i n e r eco mmen d a t i o n s ( F i o r e ,J o r en b y , B ak e r , K en f o r d , 1 9 9 2 ) , w i t h 2 2 m g p a tch es u s ed f o r 4 w e ek s f o l -l o w ed b y 1 1 mg p a t ch es f o r 3 w eek s . P a r t i c i p an t s r ece i v ed t h e f o l l o w i n gins t ruc t ions : (1 ) No smoking a l lowed whi l e on the pa t ch ; (2 ) App ly a pa t chi m m e d i a t e l y u p o n w a k i n g o n t h e q u i t d a y ; ( 3 ) W e a r e a c h p a t c h f o r 2 4h o u r s u n l e s s y o u a r e i n s t r u c t ed t o d o o t h e r w i s e b y t h e s t u d y p h y s i c i an ; ( 4 )U s e a n e w p a t c h e v e r y m o r n i n g ( d o n o t a p p l y a n e w p a t c h b e f o r e b e d t im e )an d p l ace t h e u s ed p a t ch i n t h e b o x f o r co l l ec t i o n a t t h e w eek l y ch eck - i n ;an d ( 5 ) Each d ay , ap p l y t h e n ew p a t ch t o an a r ea o f h a i rl e s s s k i n b e l o w t h en ec k an d ab o v e t h e w a i s t , ro t a ti n g p a t ch s i te s each d ay . P a r ti c i p an ts w e r et o l d to d i s co n t i n u e p a t ch u s e an d co n t ac t t h e s t u d y p h y s i c i an i f t h ey ex p e r i-en ced s k i n i r r i t a t i o n a t t h e p a t ch s i t e , ch es t p a i n , s t o mach p a i n , n au s ea , o rl i g h t - h ead ed n es s .Adherence Par t i c ipan t s r e tu rned to t he c l i n i c week ly in o rder t o r e tu rnu s ed p a t ch es an d t o r ece i v e n ew p a t ch es f o r th e f o l lo w i n g w e ek . Th e n u m b ero f u s ed p a t ch es w as r eco r d ed an d p a r ti c ip an t s w e r e i n t e r v i ew ed t o d e t e r mi n ead h e r en ce . N o n ad h e r en c e w as d e f i n ed a s f a il in g t o u s e a p a tch f o r 2 d ay s i n ar o w o r f o r mo r e t h an 3 n o n co n s ecu t i v e d ay s f o r t h e w eek . I f p a t ien t s w e r en o n ad h e r en t , t h ey co n s u l t ed w i t h th e s t u d y p h y s i c i an o n d o s ag e an d s mo k i n gs t a tus befo re r esum ing t r ea tmen t i n o rder t o ensure ap propr i a t e dosag e . I fr e s u mi n g t r ea t men t , p a r t i c i p an t s w e r e o n ce ag a i n p r o v i d ed w i t h t h e N R Tra t iona l e and pa t ch ins t ruc t ions .


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A C TA C T p r o v id e r s. Par t i c i p an t s i n t h i s co n d i t i o n were s een b y o n e o f fo u r

therap is ts ex per ie nced in ACT. On e o f these therap is ts w as a psych o log is t inth e d e p a r tm en t o f p s y ch i a try , t h e o th e r t h ree t h e rap is t s w e re ad v an ced d o c -to ra l s t u den t s i n t h e d ep a r tm en t o f p s y ch o lo g y .A C T p r o to c o l . Trea tme nt was de l ivered in seven 50-m inu te ind iv idua l ses -s ions and seven 90-minu te g roup sess ions . Par t i c ipan ts a t t ended one g roupan d o n e i n d iv id u al s e s s ion p e r w eek fo r 7 wee k s . T h e rap is t s co n d u c t ed tr ea t-m en t acco rd in g t o i n d iv id u a l an d g ro u p t r ea tm en t m an u a l s . T h e rap i s ts w e reenc oura ged to app ly the man ual in te rven t ions id iograph ica l ly , in line wi th thefu n c t i o n a l m o d e l a n d r e s u lt i n g ca s e co n cep tu a li za t io n s .I t i s a d i f f icu l t t ask to respond wi thou t smoking when confron ted wi thphys ica l sensa t ions o r em ot iona l s ta tes tha t p rev ious ly tr iggered smo king . Theoverarch ing goa l o f t rea tm en t was to p rov ide an in tens ive exper ien t ia l t ra in -i n g p ro g ram b as ed o n t h e fu n c t i o n a l m o d e l . T h u s t h e p ro to co l fo cu s ed o nhelp ing peop le no t ice the i r in te rna l t r iggers as the y occurred , change wh at theyco u ld an d accep t wh a t t h ey co u ld n o t ch an g e , m ak e p u b li c co m m i tm en t s t obeha v ing in a l ignm ent wi th the i r va lues , and p rac t ice a var ie ty o f cons t ruc t iveac t ions in response to these t r iggers . The p ro toco l had severa l empha ses andco m p o n en t s a im ed a t s h ap in g t h e s e r ep e rto ir e s :1 . In t erna l versus ex t erna l t r iggers . Therap is t s he lpe d c l ien t s iden t i fy the i rin ternal t r iggers , i .e . , thoughts , feel ings , and physiological sensat ionsassoc ia ted wi th sm oking . Therap is t s desc r ibed the ro le in te rna l t r iggersp lay in sm oking an d the i r re levance to the qu i t t ing p rocess .2 . P r o b l e m s w i t h c o n t r o l e f f o r t s . Therap is t s he lped c l ien t s iden t i fy tha te f fo r t s to con t ro l o r avo id in te rna l exper ien ce a re l inked to sm oking a ndto p ro b l em s wi th q u i tt in g . E x p e r i en ces f ro m p a r t i c i p an ts s m o k in g h i s -t o r ie s an d h i s t o ry o f s m o k in g a t t em p t s w e re co n s id e red ( e. g ., d rawin gou t the success o r fa i lu re o f p rev ious cessa t ion s t ra teg ies) . Th is sec t iono f t h e AC T p ro to co l was d es ig n ed t o h e lp c l i en ts i d en t i fy co n tro l -b as eds t ra teg ies and enhance mot iva t ion to t ry accep tance-based s t ra teg iesinstead.3 . Va lues go a l s an d barr i ers . Therapis ts h elped cfients clari fy their values ,def ine goa ls re la ted to the i r va lues , and iden t i fy bar r ie rs to ach iev ingthe i r goa ls . Goals were def ined as spec i f ic behav io ra l t asks re la ted toqu i t ting sm oking . Barr ie rs were d ef ined as though ts / fee l ings / sensa t ionstha t dera i l e f fo r ts to pe r fo rm the se tasks. Cl ien ts w ere aske d to iden t i fythe in te rna l exper iences mos t l ike ly to func t ion as bar r ie rs ( i . e . , thethough ts , fee l ings and sensa t ions mos t l ike ly to t r igger smo king o r a t t r i-t io n f ro m t r ea tm en t ) .4 . A c c e p t a n c e a n d w i l li n g n e s s . Therap is t s p rov ided the ra t iona le fo rapproach ing /accep t ing p rev ious ly avo ided in te rna l s t imul i , and fo r thesk i ll s t ra in ing fo rm at . Th roug h exerc i ses and m etaphors , c l i en t s iden t i -f i ed tha t there i s no t an in t r ins ic l ink be tw een fee l ings an d ac t ions , and


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9 GIFFORD ET AL

t h a t t h e p re s en ce o f av e r siv e in t e rn a l ex p e r i en ces i n an d o f t h em s e lv esdoes no t cons t i tu te a th rea t . (Cl ien ts had mu l t ip le p rog ram m ed oppor tu -n i t ies to expe r ience fee l ings and though ts fu l ly w i thou t ac t ing on them . )T h e p u rp o s e o f th i s co m p o n en t was t o r ed u ce m o t iv a t io n fo r av o idan tb eh av io r an d t o i n c rea s e t o l e ran ce fo r d i s co m fo r t .5 M ind fu lness sk i l ls Clients part ic ipated in experient ial exercises design edto d ev e lo p a s a fe an d co n s i s t en t p e r s p ec t iv e f ro m wh ich t o o b s e rv e an daccep t a l l ch an g in g i n n e r ex p e r i en ces . M in d fu ln es s t e ch n iq u es werein co rp o ra t ed d u rin g t h is p h as e i n o rd e r t o en h an ce aw aren es s o f p ro b -lemat ic s t imul i and a l so to expand awareness o f a l t e rna t ive fea tu res o ft h e i r ex p e r i en ce an d en v i ro n m en t i n o rd e r t o p ro m o te co g n i t i v e an dbeh avior al f lexibi li ty .

6 G r a d u a t e d e x p o s ur e Therap is t s he lpe d c l ien t s es tab l i sh ind iv idua l izedexposure h ie rarch ies . Dur ing these exposure sess ions c l ien t s exper i -en ced i n c rea s in g l ev e ls o f w i th d rawa l s y m p to m s an d av e r siv e i n te rn a ls ta tes . Therap is t s p rov ided suppor t and re in fo rc ed par t ic ipan ts con ta c twi th the i r p rev ious ly avo ided inn er exper ience s . The goa l o f th i s trea t -m en t co m p o n e n t was t o a l t e r th e av o id an t an d s m o k in g - re l a ted s tim u lu sfunc t ions o f in te rna l s timul i th rough ex t inc t ion and to add s t imulus func-t ions l inked to a l te rna t ive responses .7 S c h e d u l e d s m o k i n g I f reques ted by par tic ipan ts as par t o f the i r g raduatedex p o s u re h i e ra rch i e s , th e rap is t s p ro v id ed s m o k in g s ch ed u l e s acco rd in gto a lg o r i t h m s b as ed o n cu r ren t c l i en t s m o k in g an d h o u r s o f wak e fu l -n es s . Sch ed u l ed s m o k in g i n c rea s e s t h e l a t en cy b e tween t h e s t im u l ia s s o c i a t ed wi th s m o k in g an d t h e o ccu r ren ce o f s m o k in g r e s p o n s es .T h es e s t ru c tu red p e r i o d s o f d e l ay ed r e s p o n d in g p ro v id ed win d o ws i nwh ich t o p rac t i ce i d en t i fy in g an d r e s p o n d in g d i f f e ren t l y t o w i th d rawa lsym ptom s/ in te rna l t r iggers ou ts ide o f the t rea tm en t sess ion .8 C o g n i ti v e d e f u s i o n s k i ll s Clien ts par t i c ipa ted in a se r ies o f exerc i sesdes igned to iden t i fy and defu se cogn i t ive t r iggers , wi th par t icu la r emph a-s is on ra t iona l iza t ions fo r smo king . For ex am ple , c l ien t s we re taugh t tosee though ts as w hat they a re (more o r l ess he lp fu l descr ip to rs , depend ingon the spec i f ic cogn i t ion) , and n o t as w hat they sa y they a re ( in fa l l ib lyaccu ra t e r e fl ec ti o n s o f r ea l it y ) . T h e g o a l o f t h is co m p o n e n t was t o h e lpc l ien ts a l te r the func t ions o f cogn i t ions tha t l imi t ach ievem ent o f the i rbehav io ra l go a ls .

9 B e h a v i o r a l a c ti v a ti o n a n d c o m m i t m e n t C l i en t s p rac t i ced a r an g e o fadap t ive responses in the p rese nce o f nega t ive a f fec t and o ther in te rna lt r iggers . The goa l w as to shape f lex ib i li ty by de ve lop ing reper to i res tha tp rov ide rea l i s t i c behav io ra l a l t e rna t ives to smo king .T h e r a p i s t s u p e r v is i o n a n d a d h e r e n c e S. Ha yes , B . Kohlenberg , E . Gi f fo rd ,an d D . An to n u cc io s u p e rv i s ed t h e s t u d y t h e rap i st s i n w eek ly g ro u p s u p e rv i -s ion sess ions . Therap is t s a l so rece ived ind iv idua l superv is ion as reques ted .


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Spec i a l a t ten t ion w as pa id t o t herap i s t adherenc e i n o rder t o ensu re t ha t t her-ap i s ts i den t i f ied t he appropr i a t e func t iona l c l asses and d e l ivered t he AC Ti n t e r v en t i o n s a s i n t en d ed b y t h e t r ea t men t d ev e l o p men t t e am. T r ea t men ta t ten d an ce w as r eco r d ed a t t h e t i me o f tr ea tmen t s e s s i o n s , and co n f i r medwi th c l i n i c r eco rds .Mea s u r es

Par t i c ipan t s comple t ed assessmen t s a t i n t ake , week ly dur ing t he ac t i vet reatment phase, and at post treatme nt , 6-month fo l low-u p, and 1-year fo l low-up.The cu r ren t s t udy eva lua t ed t he da t a f rom in t ake , pos t t r ea tmen t , 6 -month ,and 1 -year fo l low-up t ime po in t s . Descr ip t ions o f the s tudy m easures a re p ro -v i d ed b e l o w .

The Avo idance and Inf lexibi li ty Scale (AIS; ~ = .93; Gif ford et a l . , 2002).Th e A I S i s a 1 3 - it em meas u r e d e s i g n ed t o ev a lu a t e s mo k e r ' s en d o r s em en t o favo idance s t r a t eg i es r e l a t ed t o smoking and smoking cessa t i on . High sco reson th is L ike r t - t ype sca l e desc r ibe an avo idan t s t r a t egy toward i n t e rna l exper i -ences and an i n f l ex ib l e l i nk be tween these exper i ences and smoking ( e .g . ,nega t ive a f f ec t nece ssar i l y l eads t o sm oking , and e f fo r t s t o qu i t a re d i r ec t edtowa rd avo id ing nega t ive a f f ec t ) . The m easu re ' s r e l iab i l it y was es t ab l i shed ina r ecen t s t ud y o f 306 par t i c ipan t s (Gi f fo rd e t a l. , 2002) .The Cl ien t Sa t i sfac t ion Q ues t io nna ire-3 (CSQ -3 ; a = .92 , Nguye n , A t tk i s -son , Stegner, 1983). The CSQ-3 measures c l i en t sa t i s f ac t i on wi th se rv i ces .I t ems i n c lu d e , To w h a t ex t en t h a s o u r p r o g r am m e t y o u r n eed s ? I t ems a r era t ed on a 4 -po in t L iker t sca l e , wi th h igher sco res i nd i ca t i ng g rea t e r c l i en tsat i sfact ion .Expired carbon monoxide . A i r s amp l e s to meas u r e ca r b o n m o n o x i d e ( C O )w er e o b t a i n ed b y t h e b r ea t h - h o l d i n g p r o ced u r e d e s c r i b ed i n I r v i n g , C l a r k ,C r o m b i e , an d S mi t h ( 1 9 8 8 ) . C o n cen t ra t io n s o f C O w er e u s ed t o co r ro b o r a t e24-hour po in t p reva l ence r epor t s o f smoking s t a tus du r ing t r ea tmen t and fo l -l ow-up . Read ings o f 11 par t s per mi l l i on o r l ess were def ined as t he non-sm oking r ange ( I rv ing e t a l. , 1988) .Fagers t rom Test fo r Nico t ine D epende nce (FT ND ; o~ = .56; Payne , Smi th ,M cCracken , McSherry , An tony , I994 ) . Th e F TN D i s a 5 - i t em s e l f - r ep o r tmea s u r e o f n i co t in e d ep en d en ce . It ems i n c lu d e , D o y o u s mo k e i f y o u a r e s oi ll t h at y o u a re in b ed mo s t o f t h e d ay ? Th i s meas u r e ev a l u a t e s s y mp t o m s o fn i co t in e d ep en d en ce .Pro f ile o f M ood S ta tes (PO M S; McNair , Lorr , Dropp leman , 1971) . T h ePO M S i s a 65 - i t em se l f- r eport m easure y i e ld ing s ix subsca l e sco res (depress ion-de j ec t i on , t ens ion-anx ie ty , anger - i r r i t ab i l i t y , confus ion , f a t i gue , and v igor )an d a To ta l M o o d D i s tu r b an ce S co r e . M c N a i r e t a l . (1 9 7 1 ) r ep o r t ed ex ce l len tin t e rna l cons i s t ency r e l i ab i l i t y , wi th va lues r ang ing f rom .89 t o .95 wi th insca l es . Pa t t en and M ar t in (1996) st a te t ha t t he PO M S shou ld be inc lude d inan y co mp a r i s o n o f t h e s e lf - rep o r t mea s u r e s o f t o b acco w i t h d r aw a l ( p . 1 05 ) .Shif fman Tobacco W ithdrawal Scale (STW S; Shi f fma n Jarvik , 1976).Th i s 2 5 - i tem s ca le a s s e s s e s cu r r en t s y m p t o m s f r eq u en t l y a s s o c i a t ed w i t h c i g -


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98 G I F F O R D E T A L

are t te wi thdraw al . The sca l e has go od in te rna l con s i s t ency , has been v a l ida t edin the s tud y o f wi thdraw al , and a l l ows fo r examina t ion o f r e la t i ve ly smal lch an g es i n w i t h d raw a l s y m p t o m a t o l o g y ( P a tt en & M ar t i n , 1 9 9 6 ).Treatment Confidence Questionnaire (TC Q; Co ndiotte Lichtenstein,1981). The T C Q i s a 47 - i t em se l f - r epor t m easure assess ing se l f - e f f i cacy ( i. e .,abi l i ty to res i s t smoking) in a var iety of speci f ic s i tuat ions . Par t icipants ratethe i r perc e ived p roba b i l i t y o f r es i s ti ng sm oking in each s i tua t i on on a 10 -po in t sca l e .Working All ianc e Inven tory (WAI; o~ = .93; H orva th Greenberg, 1989).Thi s 12 - i tem inven to ry i s bas ed on Bord in ' s co nce p t o f the a l l iance as a bon db e t w een t r ea t men t p r o v i d e r an d p a t i en t b a s ed o n s h a r ed t a s k s an d g o a l s .I t ems inc lude "my t rea tm en t p rov ider and I ag ree abou t t he t h ings wi l l needto do in t r ea tmen t t o he lp improve my s i t ua t i on ." Higher sco res i nd i ca t es t ronger endorse m en t o f t he t r ea tmen t r e l a t ionsh ip .Data Analys i s P lan

Th e p r i mar y o u t co me w as 2 4 - h o u r p o i n t p r ev a l en ce s mo k i n g s e l f - r ep o r tconf i rmed by CO. I f CO con t rad i c t ed se l f - r epor t , t he par t i c ipan t s were ca t e -g o r i zed a s s mo k e r s . I n th e p r e s en t s am p l e t w o p a r ti c ip an ts w h o d en i ed s mo k -i n g b u t h ad C O r ead in g s o f 3 7 p p m an d 2 8 p p m w e r e ca teg o r i zed a s s mo k e r s .Because t h i s s t udy i s a smal l i n i t i a l eva lua t ion o f a novel t r ea tmen t fo rs mo k e r s , e f f i c acy an a l y s e s w e r e co n d u c t ed f o r t h e p r i mar y o u t co mes . E f f i -cac y ana lyses r e f l ec t t he r esu lt s o f t r ea tmen t fo r those w ho par t i c ipa t ed andw h o s e d a t a w as co l l ec t ed . To co r r ec t f o r p o s s i b l e b i a s d u e t o mi s s i n g d a t a ,an a l y s e s o n f in a l o u t co me s w e r e a l s o p e r f o r med u s i n g g en e r a l ized e s t ima t i n gequat ions (GEE) to r ep l ace mi ss ing da t a . Accord ing to Hal l e t a l . (2001) ,t h e re a r e cav ea t s f o r th e u s e o f G E E f o r s ma l l s amp l e s w i t h n o n n o r ma l l y d i s-t r i bu t ed ou t comes , as " there i s l imi t ed i n fo rmat ion abou t t he e f f ec t s on t heda t a ana lys is w hen the assum pt ions a re v io l a t ed o r i f t he sample s i ze is smal l "(p . 196) . Therefo re , bo th se t s o f r esu l t s a re p resen t ed .Th e r ema i n i n g v a r i ab le s w e r e s eco n d a r y o u t co m es h y p o t h es i zed t o i mp ac tp r imary o u t come s : ( a ) wi thdrawal sym ptom s , (b ) nega t ive a f f ec t , and ( c ) expe-r ient ial avoidance and inf lexibi l i ty . I f these var iables were s igni f icant lyr e la t e d t o o u t c o m e , th e n m e d i a ti o n a l a n a l y s e s w e r e c o n d u c t e d a c c o r d i n g t ot h e a n a l y t i c s t r a t e g y p r o p o s e d b y B a r o n a n d K e n n y ( 1 9 8 6 ) . F i n a l l y , aM A N O V A w a s c o n d u c t e d o n A I S i t e m s t o f u rt h e r e v a lu a t e d i f f e r e n c e sb e t w e e n c o n d i ti o n s . F o l lo w - u p A N O V A c o m p a r i so n s w e r e s u b j e c t e d t oB o n f e r o n n i co r r ec t i o n s . E t a w as e s t i ma t ed t o ev a l u a t e e f f ec t s i z e s f o r t h ef o l l o w - u p co m p ar i s o n s .

esultsPrel iminary Analyses

Equivalenc e o f com parison groups. Tw o- t a i l ed t tes t s fo r con t inuous var i-ab l es and ch i - square fo r ca t egor i ca l var i ab l es r evea l ed no s ign i f i can t d i f f e r -


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e n c e s b e t w e e n c o n d i t i o n s a t b a s e l i n e i n d e m o g r a p h i c v a r i a b l e s ( a g e , g e n d e r ,i n c o m e , e d u c a t i o n , e t h n i c i ty , r e l a t i o n s h i p s t a t u s) , s m o k i n g v a r i a b l es ( n u m b e ro f c i g a r et te s s m o k e d , l e n g t h o f t i m e s m o k e d , F T N D s c o re s , p r e v i o u s t re a t-m e n t f o r s m o k i n g , n u m b e r o f p re v i o u s 2 4 - h o u r q u i t a tt e m p t s ), o r p a r tn e r s u p -p o r t . T w o - t a i l e d t t e s t s o n i n t a k e l e v e l s o f s e c o n d a r y p r o c e s s m e a s u r e s a l s os h o w e d n o s i g n i f i c a n t d i f f e r e n c e s b e t w e e n c o n d i t i o n s e x c e p t f o r a s ig n i f i c a n td i f f e r en c e b e t w e e n g r o u p s a t i n t ak e o n T r e a t m e n t C o n f i d e n c e Q u e s t io n n a i r e( T C Q ) s c o re s w i t h t h e A C T c o n d i t i o n s h o w i n g s l i g h t ly h ig h e r c o n f i d e n c el e ve l s t h a n th e N R T c o n d i t i o n , A C T M = 8 2 . 0 6 , SD = 2 6 . 1 5 , N R T M =7 0 . 0 5 , SD = 24 .49 , t (2 , 71 ) = 2 .02 , p = .047 . H ow eve r , t he re wa s no s ign i f i-c a n t d i f f er e n c e o n i n t a k e T C Q f o r t h o s e w h o c o m p l e t e d t r e at m e n t .Treatment attendance O f t h e 7 6 p a r t i c i p a n t s w h o e n t e r e d t r e a t m e n t , 6 2( 8 2 ) r e c e i v e d 3 o r m o r e w e e k s o f t r e a t m e n t , a n d 4 3 p a r t i c ip a n t s (5 7 )r e c e iv e d 5 o r m o r e w e e k s o f tr e a t m e n t . O f t h e 3 3 w h o e n t e r e d A C T t re a t-m e n t , 6 3 . 6 ( n = 2 1 ) c o m p l e t e d t r e at m e n t . O f t h e 4 3 w h o b e g a n t r e a t m e n ti n t h e N R T c o n d i t i o n , 6 1 . 9 ( 2 8 ) c o m p l e t e d t r e a t m e n t . T h e r e w a s n o d i f f e r -e n c e b e t w e e n c o n d i ti o n s o n n u m b e r o f w e e k s c o m p l e t e d : A C T M = 5 .0 9 ,SD = 1 .8 4 ; N R T M = 4 . 5 6 , SD = 2 .49 , t (2 , 74 ) = 1 .0 3 ,p = .306.Treatment acceptability T h e r e w e r e n o s i g n if i c a n t d i f f er e n c e s b e t w e e nc o n d i t i o n s o n tr e a t m e n t s a ti s f ac t io n ( C S Q ) , A C T M = 6 . 8 8, SD = 2 . 8 6 , N R TM = 7 .00 , SD = 2 .88 , t (2 , 62 ) = - . 16 , p = .88 . Po s t t r ea tm en t , A C T pa r t i c i -p a n t s e n d o r s e d b e t t e r r e l a t i o n s h i p s w i t h t h e i r t r e a t m e n t p r o v i d e r s a s m e a -s u r e d b y t h e W o r k i n g A l l i a n c e I n v e n t o r y ( W A I ) , A C T M = 6 3 .3 7 , SD =9 . 9 0 ; N R T M = 5 4 . 9 1 , SD = 9 .59 ; t (2 , 59 ) = 3 .3 7 , p = .001 .Attrition from assessment P o s t t r e a t m e n t d a t a w e r e c o l l e c t e d f r o m 6 2 p a r -t i c ipan t s (82 ) : 26 pa r t i c ipan t s in the A CT cond i t ion (79 ) and 36 pa r t i c ipan t si n t h e N R T c o n d i t i o n ( 8 4 ) p r o v i d e d a s s e s s m e n t i n f o r m a t i o n . T w e l v e - m o n t hd a t a w e r e c o l l e c t e d f r o m 5 5 p a r t i c i p a n t s : 2 0 p a r t i c i p a n t s i n t h e A C T c o n d i -t i o n ( 6 1 ) a n d 3 5 p a r t i c i p a n t s i n t h e N R T c o n d i t i o n ( 8 1 ) . C h i s q u a r e (X2)a n a l y s e s w e r e u s e d t o e v a l u a te t h e r a n d o m n e s s o f a t t ri ti o n f r o m a s s e s sm e n t .T h e r e w a s n o r e l a t io n s h i p b e t w e e n a s s e s s m e n t a t t ri ti o n a n d g e n d e r , i n c o m e ,p a r t i c i p a t i n g i n a n i n t i m a t e r e l a t i o n s h i p , e d u c a t i o n , o r e t h n i c i t y . T h o s e w h oc o m p l e t e d t r e a t m e n t i n b o t h c o n d i t i o n s w e r e s i g n if i c an t l y m o r e l i k e l y t o p r o -v i d e a s s e s s m e n t d a t a a t p o s t ( p = . 01 ) a n d a t 1 - y e a r f o l l o w - u p ( p = . 04 ) .A s s e s s m e n t a t t r i ti o n w a s n o t r e l a t e d to c o n d i t i o n a t p o s t . A l t h o u g h th e r e w a sm o r e a t t r i t i o n f r o m t h e A C T c o n d i t i o n , a t t r i t i o n a t 1 y e a r w a s n o t s i g n i f i -can t ly re l a t ed to cond i t ion , X2(76) = 4 .04 , p = .07 . In add i t ion , the re was nor e l a ti o n s h ip b e t w e e n a s s e s sm e n t a t tr i ti o n a n d p r i m a r y o r s e c o n d a r y o u t c o m ev a r i a b l e s , i n d i c a t i n g t h a t s m o k i n g s t a t u s a n d t r e a t m e n t p r o c e s s w e r e n o tr e l a t e d t o s t u d y a t t r it i o n .Intervention Effects on Smoking Status

Efficacy analysis smoking outcomes L o g i s t i c re g r e ss i o n s w e r e p e r f o r m e do n t r e a t m e n t c o n d i t i o n a n d q u i t s t a t u s a t p o s t t r e a t m e n t , 6 - m o n t h , a n d 1 - y e a rf o l l o w - u p . T h e a v e r ag e n u m b e r o f c ig a r e tt e s s m o k e d a t b a s e li n e w a s e n t e r e d


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700 GIFFORD ET AL.

into the equ ation as a covar ia te . Quit ra tes did no t dif fer s ignif icantly at post ,W ald X2(1, N = 62) = .05, p = .93, wi th 35 quit versus 33 in the NR Tcond it ion, or a t 6-m onth fol low -up, Wa ld X2(1, N = 65) = .67, p = .36 with23 qui t in the AC T condi t ion versus 11 in the NRT condi t ion . How ever ,the AC T condi t ion had s igni f icant ly be t ter outco mes a t 1-year fo l low-up,W ald X2(1, N = 55) = 4. 07 ,p = .04, OR = 4.2 CI 1.04-16.73) , wi th 35quit versus 15 in the NR T cond it ion (see Figu re 1).Estimated smoking outcomes. Of the or iginal 76 par t ic ipants, 6 par t ic i-pants had miss ing da ta a t a ll three t ime poin ts (pos tmeasurement ; 6 mon ths ;and 12 months) . Becaus e the GE E deve lops i ts e s t imates f rom previous da ta( impl ici t imputa t ion) , the miss ing da ta ana lyses were c onduc ted on 70 part ic-ipants. Of the 210 possible observations (70 par tic ipants a t three t ime points) ,28 observa tions were miss ing . Using SAS, the GEN M OD procedure was u ti -l ized wi th both con di t ion and t ime inc lud ed in the mode l as c lass va r iables .Al tho ugh the condi t ion was n ot s igni f icant (p = 0 .26), the odds ra tio of 1 .82([3 = 0.60) suggests that par t ic ipants in the AC T cond it ion were 82 morel ike ly to qui t sm oking than those in the cont ro l condi t ion .

To fur the r examine the im pac t o f the miss ing va lues , a logis t ic regressionwas conduc ted under the assumpt ion of a wors t -case scenar io in which a l lmiss ing da ta was conver ted to smoking s ta tus . We found tha t 9 .3 qui t in thecontro l condi t ion and 21.2 qui t in the ACT condi t ion at 1 year , produc ing arate ra t io of 2.28 ( .212/ .093; od ds ra t io = 2.62) . The refore , the par t ic ipants inthe AC T condi t ion were 2 .3 t imes more l ike ly to qui t compared to the cont ro lcondi t ion when the wors t -case scenar io was assumed for both condi t ions .The quit ra tes did no t dif fer s ignif icantly a t the end o f 12 mon ths, Wald X2(1,N = 76) = 2. 04 ,p = .15, OR = 2 .62 (CI = 0.7 0-9 .88 ) .

40353O

~ 2520

10

FIG 1

1 p= 05

I

Post Treatment 6-Month Follow Up 12-Month Follow UpAssessment

Quit rates at posttreatment , 6-month, and 12-month follow-up assessment for theACT and NRT treatment conditions.


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ACCEPTANCE-BASED TREATMENT FOR SMOKING 7 1

T h e l a c k o f s ig n i f i c a n t f i n d i n g m a y b e d u e t o th e s m a l l s a m p l e s i z e . G i v e nt h e o d d s r a t i o o f 2 . 6 2 ( a m e d i u m e f f e c t si z e) a n d a s a m p l e s i z e o f 7 6 , a t w o -s i d e d t e s t ( a l p h a . 05 ) h a s o n l y 3 1 p o w e r to d e t e c t a si g n i f i c a n t d i f f e r e n c e .T o a c h i e v e p o w e r a t t h e . 8 0 l e v e l w i t h t h e c u r r e n t s a m p l e s i z e w o u l d h a v er e q u i r e d a n o d d s r a t i o o f 5 .0 o r la r g e r , m e a n i n g t h a t p a r t ic i p a n t s i n o n e c o n d i -t i o n w o u l d h a v e t o h a v e b e e n f i v e o r m o r e t i m e s a s l i k e l y t o q u i t t h a n p a r t ic i -p a n t s i n t h e c o m p a r i s o n c o n d i t i o n . A d i f f e r e n c e o f t h is s i z e b e t w e e n a c t iv ec o m p a r i s o n s i s h i g h l y u n l i k e l y . F o r e x a m p l e , t h e o d d s r a t io f o r t h e d i f fe r e n c eb e t w e e n N R T a n d n o t r e a t m e n t o r p la c e b o i s 1 .7 4 ( 1 . 6 4 - 1 . 8 6 ) ( S i la g y , L a n -c a s t e r , S t e a d , M a n t , & F o w l e r , 2 0 0 4 ) ; t h e o d d s r a t i o f o r t h e d i f f e r e n c eb e t w e e n i n d i v i d u a l i ze d b e h a v i o r t h e r a p y a n d n o t r e a t m e n t o r m i n i m a l i n t er -v e n t i o n is 1 . 6 2 ( 1 . 3 5 - 1 . 9 4 ) ( L a n c a s t e r & S t e a d , 2 0 0 4 ).

I n s u m , w h e n e x a m i n i n g th e q u e s t i o n f r o m b o t h a w o r s t - c a se s c e n a r io a n df r o m t h e G E N M O D ' s i m p u t a ti o n o f m i s si n g v a lu e s , t h e A C T c o n d i ti o na p p e a r s t o p r o d u c e b e t t e r re s u l t s t h a n t h e c o n t r o l c o n d i t i o n . W h i l e t h e r e s u l t so f t h is a n a l y s i s s u g g e s t a p o s it iv e o u t c o m e f o r t h e A C T a p p r o a c h , c o n f i rm a -t o r y s t u d i e s s h o u l d b e u n d e r t a k e n .In terven t ion E f fec t s on Secondary Var iab les

Second ary ana lyses The p rospec t ive re l a t ionsh ips o f th ree s econda ry va r i -a b l e s t o s m o k i n g o u t c o m e s w e r e a s s e s s e d . T h e s e v a r i a b l e s w e r e m e a s u r e d a tt h e i r t i m e o f p r e s u m e d g r e a t e s t p o t e n c y : w i t h d r a w a l s y m p t o m s a n d n e g a t i v ea f f e c t w e r e m e a s u r e d i n t h e w e e k f o l l o w i n g q u i t d a t e f o r e a ch o f t h e c o n d i -t i o n s ; a v o i d a n c e a n d i n f l e x i b i li t y w e r e m e a s u r e d a t p o s t t r e a t m e n t a f t e r t h efu l l cou rse o f sk i l l s t r a in ing . 1

A f t e r c o n t r o l li n g f o r b a s e l i n e l e v e l o f c i g a re t te s s m o k e d , h i g h e r w i t h d r a w a ls y m p t o m s w e r e n o t s i g n i f i c a n t ly r e l a t e d t o q u i t s ta t u s , W a l d X2 (1 , N = 50) =.00 , p = .99 , no r we re h ighe r l eve l s o f neg a t ive a f fec t r e l a t ed to qu i t s t a tus a t1 y e a r , W a l d X2 (1 , N = 46 ) = .00 , p = .85 . Ho we ve r , l ow er l eve l s o f avo id -a n c e a n d i n f l e x i b i l it y s i g n i f i c a n t ly i n c r e a s e d l i k e l i h o o d o f s m o k i n g a b s ti -n e n c e , W a l d X2 (1 , N = 53 ) = .11 , p = .01 . Pa r t i c ipan t s wh o were q u i t a t 1y e a r h a d s i g n i f i c a n tl y l o w e r p o s t -A I S s c o r es ( M = 3 1 . 4 5, S D = 13 .01 )t h a n t h o s e w h o w e r e s m o k i n g ( M = 4 3 . 3 1 , S D = 10 .21 ) , t (2 , 74 ) =- 2 . 9 0 p = . 0 1 .M e d i a t i o n a l a n a l y s e s B e c a u s e t h e r e l a t i o n s h i p b e t w e e n a v o i d a n c e a n di n f l e x i b i l it y a n d o u t c o m e w a s s i g n i f ic a n t , w e w e n t o n t o t e s t w h e t h e r a v o i d -a n c e a n d i n f le x i b i li t y m e d i a t e d t h e t r e a t m e n t - o u t c o m e r e l a ti o n s h ip u s i n g t h es e ri e s o f re g r e s s io n a n a l y s e s s u g g e s t e d b y B a r o n a n d K e n n y ( 1 9 86 ) . I n k e e p i n gw i t h t h e a b o v e a n a l y s e s w e a l s o c o n t r o l l e d f o r i n t a k e n u m b e r o f c i g a r e t t e s .T h e r e l a t i o n s h i p b e t w e e n a v o i d a n c e a n d i n f l e x i b i l it y a n d c o n d i t i o n w a s s i g -n i f i c a n t , W a l d X2 ( 1 , N = 5 4 ) = . 4 2 , p = . 04 , O R = 1 .5 2 ( C I 1 . 0 2 - 2 . 2 6 ) , a sw a s t h e r e l a t io n s h i p b e t w e e n c o n d i t i o n a n d o u t c o m e , W a l d X2 (1 , N = 54) =1 .4 6 , p = . 0 50 , O R = 4 . 31 ( C I 1 . 0 0 - 1 8 . 5 5 ) . H o w e v e r , w h e n a v o i d a n c e a n d

I Regressio ns on these variables were also conducted at posttreatment with similar results.


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702 G I F F O R D E T A Li n f le x i b i li t y w a s a d d e d , c o n d i t i o n b e c a m e n o n s i g n i f ic a n t , W a l d X 2 1 , N --5 4 ) = 1 . 34 , p = . 1 1 , w h i l e th e r e l a t io n s h i p b e t w e e n a v o i d a n c e a n d i n f l e x ib i l -i t y a n d o u t c o m e r e m a i n e d s i g n if i ca n t , W a l d X2 (1 , N = 54) = .43 , p = .04 ,O R = 1 .5 4 ( C I 1 . 0 3 - 2 . 3 0 ) . A c c o r d i n g t o B a r o n a n d K e n n y ( 1 9 86 ) , th i s p a t-t e r n o f r e s u l ts i d e n t i f i e s a m e d i a t i o n a l e f f e c t , w i t h a v o i d a n c e a n d i n f l e x i b i l it ym e d i a t i n g t h e e f f e c ts o f t h e a c c e p t a n c e - b a s ed s m o k i n g t r e a t m e n t o n o u t c o m e .I t em ana lys i s o f t he Avo idance an d In fl ex ib il it y Sca le A o n e - w a y m u l t i v a r i -a te a n a l y s is o f v a r ia n c e ( M A N O V A ) w a s c o n d u c t e d t o d e t e r m i n e t h e e f fe c t o ft h e t w o c o n d i t i o n s o n e n d o r s e m e n t o f th e A I S i t e m s a t p o s t t r e a t m e n t . S i g n if i -c a n t d i f f e r e n c e s w e r e f o u n d b e t w e e n t h e g r o u p s o n t h e d e p e n d e n t i t e m s ,W i N s ' L a m b d a = . 5 1, F ( 1 3 , 4 9 ) = 3 . 6 4 , p < .0 1. T h e m u l t i v a r i a te ,q2 b a s e do n W i l k s ' L a m b d a w a s .4 9 , i n d i c a ti n g t h a t 4 9 % o f t h e m u l t i v a ri a te v a r ia n c eo f t h e A I S i t em s w a s a s s o c i a te d w i t h t h e g r o u p f a c to r . A n a l y s i s o f v a r ia n c e( A N O V A ) o n e a c h d e p e n d e n t v a r i a b l e w a s c o n d u c t e d a s f o l l o w - u p t e s t s t ot h e M A N O V A . T h e A N O V A o n t h e e m o t i o n a l a v o i d an c e it e m w a s s i g n i f ic a n ta f t e r co r re c t ing fo r f am i lyw ise e r ro r , F ( 1 , 67 ) = 10 .23 , p < .01 , nq2 = .14.T h i s i t e m f r o m t h e A I S s t a te s t h a t f o r s o m e i n d i v i d u a l s s m o k i n g i s r e l a te d t oc e r t a i n f e e l i n g s a n d a sk s , H o w i m p o r t a n t i s g e t t i n g r i d o f t h e s e f e e l i n g s ?T h e e t a v a l u e o f . 1 4 s i g n i f i e s a l a r g e e f f e c t s i z e f o r c o n d i t i o n , w i t h p a r t i c i -p a n t s i n t h e A C T c o n d i t i o n s i g n i f i c a n t l y l e s s l i k e l y to e n d o r s e t h e i m p o r t a n c eo f r e d u c i n g o r e l i m i n a t i n g e m o t i o n s a s s o c i a t e d w i t h s m o k i n g .

iscussionT h i s s t u d y p e r f o r m e d a n i n i ti a l i n v e s ti g a t io n o f p r o c e ss a n d o u t c o m e i n

t w o t r e a t m e n t s b a s e d o n c o n t r a s ti n g m o d e l s : A C T , b a s e d o n a f u n c t i o n a l m o d e lt a r g e t i n g a c c e p t a n c e s k i l l s ; a n d N R T , b a s e d o n a p h y s i o l o g i c a l d e p e n d e n c em o d e l t ar g e ti n g w i t h d ra w a l s y m p t o m s . W h e n e x a m i n i n g o u t c o m e s f r o m a ne f f i c ac y a n a l y s is , t h e A C T c o n d i t i o n p r o d u c e d b e t te r l o n g - t e r m r e s u l ts t h a nt h e N R T c o n d i t i o n . T h i s f i n d i n g w a s n o t s i g n i f i c a n t i n t h e i m p u t e d d a t a s e t ,a l t h o u g h w o r s t -c a s e l o n g - t e r m o u t c o m e s i n d i c a t e t h a t A C T p a r ti c ip a n t s w e r em o r e t h a n t w i c e a s l i k e l y t o q u i t c o m p a r e d t o t h e N R T c o n d i t i o n . A l a r g e r a n dm o r e p o w e r f u l r e p l i c a t io n s t u d y w i l l b e n e e d e d t o t e s t th e s e p r e l i m i n a r y r e s u lt s .T h e a c c e p t a n c e t h e o r y - b a s e d m o d e l i d e nt if ie s n e g a t i v el y r e in f o r c e d a v o i d -a n c e a s a m e c h a n i s m u n d e r l y i n g s m o k i n g , a n d a c c e p t a n c e - r e l a t e d s k i l l s a st h e g o a l o f t r e a t m e n t . A c c o r d i n g t o t h i s a p p r o a c h , i t is t h e i n d i v i d u a l ' sr e s p o n s e t o h i s o r h e r o w n d i f f i c u l t i n t e r n a l s t a te s t h a t i s a t is s u e . T h e f u n c -t iona l mode l d id rece ive p re l imina ry suppor t : an in f l ex ib le , avo idan t r e sponset o n e g a t iv e a f f e c t a n d w i t h d r a w a l s y m p t o m s p r e d i c t e d q u i t r at e s , w h i l e a b s o l u t el ev e ls o f w i t h d r a w a l s y m p t o m s a n d n e g a t i v e a f f e c t d i d n o t . I n o t h e r w o r d s , i tw a s t h e i n d i v i d u a l ' s r e s p o n s e t o t h e s e s y m p t o m s , o r t h e w a y i n w h i c h t h e s es y m p t o m s f u n c t i o n e d f o r t h a t in d i v i d u a l p e r s o n , w h i c h p r e d i c t e d s m o k i n g .R e s u l t s a l s o i n d i c a t e t h a t a v o i d a n c e o f i n t e r n a l s t i m u l i a n d c o n c o m i t a n ti n f le x i b il i ty m e d i a t e d t h e e f f e c ts o f A C T t r e a t m e n t o n s m o k i n g o u t c o m e s . I np a r t ic u l a r , A C T p a r t i c i p a n t s w e r e s i g n i f i c a n t l y l e ss l i k e l y t o e n d o r s e t h e


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