Incentives to Promote Smoking Cessation in Low SES Women

Cigarette smoking is the leading cause of preventable death in the United States, accounting
for one out of every five deaths (CDC, 2012). In particular, smoking prevalence rates are
high among socioeconomically-disadvantaged women; for example, over 40% of women with less
than 12 yrs education smoke, compared to 28% and 16% among those with some college and
undergraduate degrees (SAMHSA, 2010). Smoking cessation rates are particularly low among
low-SES women with co-occurring alcohol use disorders, and these substances are frequently
used together (Kahler et al., 2010; Businelle et al., 2013). Therefore, interventions that
reduce both alcohol and smoking among heavy alcohol-using women are vitally needed to reduce
rates of smoking-related morbidity and mortality in this vulnerable population.

Counseling approaches that incorporate problem solving, skills training and social support
are effective for reducing smoking in the general population (Fiore et al., 2008). However,
given the high rates of smoking among alcohol-using women, they may be inadequate for in this
population. Contingency management (CM) interventions, which provide tangible reinforcers
contingent upon smoking abstinence or reduction to a criterion level, are highly-efficacious
interventions for reducing cigarette smoking and other drug use in low-SES women (Higgins et
al., 2012). Within the theoretical framework of operant conditioning, increasing the
availability of an alternative reinforcer weakens the amount of control that the drug has
over the user's behavior, especially when obtaining the alternative reinforcer is contingent
on behaviors incompatible with drug use (Higgins, 1997). The tenets of CM interventions
include (1) arranging the environment such that the target behavior can be readily and
objectively detected, (2) providing a tangible reinforcer when the target behavior occurs,
and (3) withholding reinforcement when the target behavior does not occur (Higgins et al.,
1994).

Although CM interventions clearly are effective at promoting smoking reductions, there are
several challenges associated with translating CM into an effective clinical treatment for
smoking. Perhaps the most significant challenge is the frequent monitoring necessary to
objectively verify smoking abstinence using breath carbon monoxide (CO), the most convenient
objective measure of smoking status. Because of the short half-life of CO (5-6 hours), CO
levels must be measured at least twice per day in order to verify continuous abstinence.
Recent CM-smoking studies have addressed this feasibility challenge by providing study
participants with breath CO monitors and laptop computers or smartphones to use in their own
natural environments (e.g., Dallery, Raiff & Grabinski, 2013). Participants are taught how to
use their smartphones to text videos of themselves providing a breath CO level to a research
staff member, twice per day. After the study staff has determined that the breath CO sample
meets the abstinence criterion, participants are informed of the amount that they have earned
for that sample.

Given the high rates of smoking in low-SES women, investigating the additive impact of an
in-person brief counseling intervention and a phone-based CM intervention is an important
next step in examining effective methods to reduce the impact of smoking in this population.

Inclusion Criteria:

- Age 18+

- Smoke an average of at least ten cigarettes per day for at least 1 year

- Breath CO levels > 8 ppm

- >12 years of education

- Reliable and consistent access to a smart phone with video messaging capabilities

Exclusion Criteria:

- Intention to quit smoking in the next 30 days

- Currently seeking treatment for smoking cessation.

- Currently using nicotine replacement therapies or other pharmacotherapies as cessation
aid (intermittent use acceptable)

- No reliable access to a video-messaging smart phone

- Pregnancy