1. Does Web-Based ACT Help Smokers with Depressive Symptoms to Quit? Helen A. Jones University of Washington Fred Hutchinson Cancer Research Center, Seattle T. Fioreze

2. Smokers with Depressive Symptoms Large Subgroup of Smokers Prevalence of Smoking 43% 22% NCHS Data Brief, 2010

3. Smokers with Depressive Symptoms Population at Risk more likely to be heavy smokers more likely to remain lifetime tobacco users more likely to develop health issues associated with smoking

4. Smokers with Depressive Symptoms Have Low Quit Rate Brown et al. 2005

5. Barriers to Quitting cravings negative affect nicotine dependence

6. Acceptance & Commitment Therapy (ACT) is a Potential Solution to Increase Quit Rates for Smokers with Depressive Symptoms

7. How ACT Can Help?  ACT gives tools to deal with cravings by getting closer to them, instead of avoiding them  ACT helps to get unstuck from thoughts (associated with smoking or affect)  ACT helps to define values and reminds people of values guiding quitting

8. 45% of the original sample screened positive to depressive symptoms Research Design: Webquit

9. Research Design: Subanalysis Pilot Randomized Controlled Trial of Web-based ACT for Smoking Cessation (N=222) Secondary Analysis Smokers with Depressive Symptoms (N= 94) N= 94N= 222

10. Subanalysis of the First Web-Based ACT for Smoking Cessation  Aim 1: Determine impact on acceptance of smoking cues  Aim 2: Determine utilization and satisfaction  Aim 3: Determine smoking cessation rate at 3 months follow-up

12. Unhooking From Thought Triggers

13. Comparison: Smokefree.gov  Best practice: Panel of national scientific & clinical experts  Highest reach: over 1 million annual visitors  Highest user satisfaction: Of all non-profit websites (Etter et al, 2006)  Benchmark 7-10% quit rate: consistent with other major websites (e.g., Munoz, Graham)

14. Main Eligibility Criteria  age 18 or older  smokes at least five cigarettes daily for the past 12 months  wants to quit in the next 30 days  has at least weekly access to a high speed internet connection  not participating in other smoking cessation interventions

15. Selection criteria for secondary analysis :  Have answered “yes”  “In the past three months, did you have a period of one week or more when you lost interest in most things like work, hobbies and other things you usually enjoyed?” Depression Subsample Selection (Means-Christensen, Sherbourne, Roy-Byrne, Craske, & Stein, 2006)

16. Acceptance Scale: Description  Avoidance & Inflexibility Scale (AIS; Gifford): Willingness to experience physical sensations, cognitions, and emotions that cue smoking  Sample Items:  How much do you accept these bodily sensations?  Ratings: (1) Not at all to (5) Very Much (Cronbach’s α = 0.87 at baseline and 0.97 at follow-up)

17. Aim 1: Differences in Acceptance at 3-Months Follow Up ACT Theory-Based Acceptance, Mean (SD) ACT (n=20) Smokefree.gov (n=25) p-value Acceptance of physical triggers 3.30 (1.01)2.69 (0.75)0.033 Acceptance of emotional triggers 2.97 (0.81)2.63 (0.58)0.131 Acceptance of cognitive triggers 2.70 (1.13)2.57 (0.82)0.672 Acceptance total score3.03 (0.88)2.64 (0.57)0.104

18. Aim 2: Utilization Receptivity MeasuresWebQuit.orgSmokefree.gov nSummaryn p-value Utilization of assigned website, mean (SD) Length of each login, in minutes 2121.7 (13.8)189.4 (7.1)0.001 Times logged in197.9 (5.8)215.7 (6.1)0.14

19. Aim 2: Satisfaction Satisfaction with assigned website, n (%) n ACT n Smokefreep-value Satisfied overall 2 2015 (75 %)2111 (52 %)0.15 Recommend to friend 2113 (62 %)2114 (67 %)0.74 Overall Approach for quitting a good fit 2012 (60 %)218 (38 %)0.15 Utility of program’s quit plan 219 (43 %)226 (27 %)0.28

20. Aim 3: Quit Rates at 3 Months Follow Up 3-Month Outcome n ACT n Smokefree p- value 30-day quit rate2020%2512%0.42 Bricker et al. 2013 3-Month Outcome n ACT n Smokefree p- value 30-day quit rate5723%5810%0.05

21. Results Summary  ACT webquit.org increased overall acceptance  Length of each login was longer for Webquit  More smokers with depressive symptoms quit with ACT Webquit.org vs. Smokefree.gov

22. Limitations  Lack of power from this sub-analysis prevents definitive conclusions  Subscale screener for depressive symptoms was limited

23. Benefits of Web-Based ACT for Smokers with Depressive Symptoms  Increase acceptance of triggers  Webquit ACT is more appealing to smokers with depressive symptoms than the standard Smokefree  Webquit ACT showed similar high quit rate as in the original web-based ACT for general smokers

24. Future Plans  Replicate this study in a larger trial  Use a more comprehensive assessment for depressive symptoms to eventually assess changes in depressive symptoms  Investigate other symptoms by tailoring this intervention for people with mood disorders, like bipolar disorder

25. Discussion Question for you: What type of exercises do you think could be especially helpful for someone that is depressed and smoker?

26. Acknowledgement FHCRC Tobacco & Health Behavior Science Research Group: Katrina Akioka Madelon Bolling, PhD Jessica Harris, MA Jaimee Heffner, PhD Laina Mercer, MS Emily Whitish, MA Garret Zieve Rogers Viladarga, PhD Primary mentor: Jonathan Bricker, PhD Fundings: Fred Hutchinson Cancer Research Center University of Washington Undergraduate Research Mary Gates Endowment