First RCT of Web-Based Acceptance & Commitment Therapy For Smoking Cessation: 3 Month Processes & Outcomes Jonathan B. Bricker, PhD Fred 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 Baseline Characteristic Smokefree.gov (n=111) ACT (n=111) Baseline Comparison p=value 3-month Retention Comparison p=value Age, mean (SD)45.3 (13.1)44.8 (13.6) Male35%41% Caucasian90%95% Hispanic3%6% Married42%45% Working60%62% HS or less educ24%19%

Aim 1 Results: Smoking & Social Env at Baseline & Retention Baseline Characteristic Smokefree.gov (n=111) ACT (n=111) Baseline Comparison p=value 3-month Retention Comparison p=value Smoking Behavior 1 st cig within 30 min of waking 82%75% Smokes more than half pack per day 80%76% Smoked for 10 or more years 79%81% Quit attempts in past 12M, mean (SD) 1.4 (2.1)1.5 (2.6) Friend & Partner Smoking Close friends who smoke, mean (SD) 1.6 (1.6)1.7 (1.5) Living with partner who smokes 26%22%

Aim 2 Results: 3-Month Cessation Processes ACTSmokefreep-value Acceptance of physical cues, mean Acceptance of emotional cues, mean Acceptance of cognitive cues, mean Number of quit attempts since randomization, mean Nicotine dependence18%44%0.036

Aim 2 Results: Quit Rate 3-Month Outcome ACTSmokefreep-value 30-day quit rate23%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.

Research Staff