One-year follow-up results of the STARS for Families alcohol prevention program.

This study examined the 1-year follow-up effects of the STARS (Start Taking Alcohol Risks Seriously) for Families program, a 2-year preventive intervention based on a stage of acquisition model, and consisting of nurse consultations and parent materials. A randomized controlled trial was conducted, with participants receiving either the intervention or a minimal intervention control. Participants included a cohort of 650 sixth-grade students from two urban middle schools-one magnet (bused) and one neighborhood. Trained project staff administered questionnaires to students following a standardized protocol in the schools. For the magnet school sample, significantly fewer intervention students (5%) were planning to drink in the next 6 months than control students (18%), chi2 = 11.53, 1 d.f., P = 0.001. Magnet school intervention students also had less intentions to drink in the future, greater motivation to avoid drinking and less total alcohol risk than control students, Ps < 0.05. For the neighborhood school, intervention students (m = 7.90, SD = 1.87) had less total alcohol risk than control students (m = 8.42, SD = 1.83), F(1,205) = 4.09, P = 0.04. These findings suggest that a brief, stage and risk/protective factor tailored program holds promise for reducing risk for alcohol use among urban school youth 1 year after intervention, and has the unique advantage of greater 'transportability' over classroom-based prevention programs.

Effects of a stage-based alcohol preventive intervention for inner-city youth.

The purpose of this study was to examine first year outcomes of an alcohol preventive intervention within inner-city middle schools. Subjects consisted of 650 sixth grade students from one neighborhood inner-city school (n = 262) and one bused school (n = 388). At posttest, chi-square analyses showed that significantly fewer neighborhood intervention students initiated alcohol use, used alcohol during the past seven-day and thirty-day periods, drank heavily during the past thirty days, and drank over any period of time, compared to control students (p's < .05). Significant group x prior alcohol consequences interaction effects were found for bused students, showing those with past alcohol consequences who received the intervention had less intentions to use alcohol and less frequent use of alcohol (p's < .05). These results suggest that a brief, stage-based preventive intervention may result in significant reductions in alcohol initiation and consumption among some inner-city youth.

The role of feedback in the process of health behavior change.

OBJECTIVE: To offer a taxonomy of types of feedback and describe potential mechanisms of action particularly in the area of addictive behaviors. METHOD: Reviewed the literature to examine support for types-Generic, Targeted, and Personalized-and for mechanisms of feedback. RESULTS: Although it is not clear how it works, feedback is thought to offer important information, to create a sense of caring and helping relationship, to reach more directly decisional considerations, to increase engagement in the materials, to increase motivation, or to provide social comparison and norms. CONCLUSIONS: Avenues for future research in search of the most effective manner of using feedback to promote health behavior change are discussed.

Validating motivational readiness for exercise behavior with adolescents.

The stages of motivational readiness as conceptualized by the Transtheoretical Model have been widely used among adult samples to assess readiness for adopting exercise behavior. To date, little research has been conducted using a staging framework with adolescent samples. There is a need for validation of the staging framework prior to a substantial amount of research with this age group. The current article presents two studies assessing stage and reported exercise behavior (Study 1: n = 819; M age = 15.0 years, SD = 1.2; 51% men; Study 2: n = 184; M age = 18.6 years, SD = .5; 45% men). As hypothesized in both studies, reported exercise consistently varied as a function of stage classification; those in earlier stages of readiness reported less exercise than those in later stages. Staging algorithms showed good sensitivity to detect reported exercise; however, specificity was distinctly better with the algorithm that used a specific activity criterion and immediate intention, as opposed to irregular behavior, in defining the preparation stage. Results support the validity of the staging framework for measuring motivational readiness for exercise behavior among North American adolescents.

Using transtheoretical model profiles to differentiate levels of alcohol abstinence success.

Using data from 673 outpatient and 510 aftercare clients in Project MATCH, this study identified drinking-outcome-related differences in profiles across transtheoretical model (TTM) variables. Abstinent, moderate, and heavier drinking outcome groups were formed as a function of their 1-year posttreatment drinking behavior. Using profile analysis, group differences in the shapes of the mean profiles on TTM-related measures of stage and self-efficacy were found (a) for both the outpatient and aftercare populations and (b) at both the baseline and end-of-treatment time points. The use of cognitive and behavioral change processes during treatment was measured and the scores for each were included in the creation of the end of treatment profiles. The relation between number of TTM goals attained and probabilities of successful drinking outcome supports the usefulness of profile differences in predicting long-term drinking outcomes and can enable therapists to help clients set interim goals.

Results of a social norm intervention to prevent binge drinking among first-year residential college students.

The effects of a primary prevention social norm intervention on binge drinking among 1st-year residential college students were examined. Six hundred thirty-four students attending a medium-sized public university in the South were randomly assigned to receive a two-phase social norm intervention or the standard campus psychoeducational prevention program. At posttest, no differences were found between intervention and control group students on any of the alcohol use and alcohol-use risk factor measures. Significant subgroup differences were found by stage of initiating binge drinking behaviors, for frequency of alcohol use, F(3, 507) = 3.69, p = .01; quantity of alcohol use, F(3, 507) = 2.51, p = .05; and social norms, F(3, 505) = 2.53, p = .05. These findings suggest the need for tailoring social norm binge drinking interventions to students' stage of initiating heavy drinking and carefully monitoring for potential negative, as well as positive, effects of norm-based prevention messages.

The process of pregnancy smoking cessation: implications for interventions.

OBJECTIVE: There is a growing body of knowledge about the pregnant smoker and what happens as she goes through the pregnancy and postpartum periods. This article reviews the process of smoking cessation in the context of pregnancy. DATA SOURCES: Epidemiological data, extant reviews of the literature, and current original research reports are used to examine characteristics of the women and of the change process for those women smokers who quit, stop, or modify their smoking during pregnancy and the postpartum period. DATA SYNTHESIS: An analysis of the interaction of the process of smoking cessation with pregnancy was conducted to gain insight into the unique problems faced by the pregnant smoker and discover directions for intervention. CONCLUSIONS: Pregnancy and the postpartum period provide a window of opportunity to promote smoking cessation and smoke free families. Understanding obstacles and pathways for pregnancy and postpartum smoking cessation can guide implementation of effective existing programs and development of new ones. Recommendations include promoting cessation before and at the beginning of pregnancy, increasing delivery of treatment early in pregnancy, helping spontaneous and intervention assisted quitters to remain tobacco free postpartum, aiding late pregnancy smokers, and involving the partner of the woman smoker.

Application of motivational interviewing to prenatal smoking cessation: training and implementation issues.

OBJECTIVE: Three of the Smoke-Free Families projects incorporated motivational interviewing (MI) into prenatal smoking cessation interventions. This paper describes the process involved in training healthcare providers to use MI and the issues encountered in implementing the protocols. DESIGN: Health care providers at all three sites attended local training workshops in which they learned to apply the basics of MI to their study protocol. All sites followed a similar outline and schedule for training and monitoring. SETTINGS: The MI interventions were delivered through home visits in Boston, Massachusetts; phone based counselling calls to patients' homes in Southern California; and in urban and rural prenatal clinics throughout East Texas. PARTICIPANTS: Public health nurse and social work case managers, who were already employed by health care agencies, delivered the MI interventions. MEASURES: Pre- and postintervention assessments and feedback from trainers and investigators at all three sites. RESULTS: Providers were enthusiastic about the training workshops, which they rated as effective in preparing them to deliver the intervention. Barriers to implementation included difficulty in contacting patients and competing demands on providers' time. CONCLUSIONS: Conducting initial training for providers is the first step in developing skills to deliver motivational interventions. Additional time and resources are needed for ongoing skill building and monitoring of intervention delivery.

Ondansetron for reduction of drinking among biologically predisposed alcoholic patients: A randomized controlled trial.

CONTEXT: Early-onset alcoholism differs from late-onset alcoholism by its association with greater serotonergic abnormality and antisocial behaviors. Thus, individuals with early-onset alcoholism may be responsive to treatment with a selective serotonergic agent. OBJECTIVE: To test the hypothesis that drinking outcomes associated with early vs late-onset alcoholism are differentially improved by the selective 5-HT(3) (serotonin) antagonist ondansetron. DESIGN: Double-blind, randomized, placebo-controlled clinical trial. SETTINGS: University of Texas Health Science Center in Houston (April 1995-June 1998) and University of Texas Health Science Center in San Antonio (July 1998-December 1999). PARTICIPANTS: A total of 321 patients with diagnosed alcoholism (mean age, 40.6 years; 70.5% male; 78.6% white) were enrolled, 271 of whom proceeded to randomization. INTERVENTIONS: After 1 lead-in week of single-blind placebo, patients were randomly assigned to receive 11 weeks of treatment with ondansetron, 1 microg/kg (n = 67), 4 microg/kg (n = 77), or 16 microg/kg (n = 71) twice per day; or identical placebo (n = 56). All patients also participated in weekly standardized group cognitive behavioral therapy. MAIN OUTCOME MEASURES: Self-reported alcohol consumption (drinks per day, drinks per drinking day, percentage of days abstinent, and total days abstinent per study week); and plasma carbohydrate deficient transferrin (CDT) level, an objective and sensitive marker of transient alcohol consumption. RESULTS: Patients with early-onset alcoholism who received ondansetron (1, 4, and 16 microg/kg twice per day) compared with those who were administered placebo, had fewer drinks per day (1.89, 1.56, and 1.87 vs 3.30; P =.03, P =.01, and P =.02, respectively) and drinks per drinking day (4.75, 4.28, and 5.18 vs 6.90; P =.03, P =.004, and P =.03, respectively). Ondansetron, 4 microg/kg twice per day, was superior to placebo in increasing percentage of days abstinent (70.10 vs 50.20; P =.02) and total days abstinent per study week (6.74 vs 5.92; P =.03). Among patients with early-onset alcoholism, there was a significant difference in the mean log CDT ratio between those who received ondansetron (1 and 4 microg/kg twice per day) compared with those who received the placebo (-0.17 and -0.19 vs 0.12; P =.03 and P =.01, respectively). CONCLUSION: Our results suggest that ondansetron (particularly the 4 microg/kg twice per day dosage) is an effective treatment for patients with early-onset alcoholism, presumably by ameliorating an underlying serotonergic abnormality. JAMA. 2000;284:963-971

Postpartum return to smoking: staging a "suspended" behavior.

Two hundred fifty-six pregnant women who had quit smoking were classified into the precontemplation (PC), contemplation (C), preparation (PA), or action (A) stages of change for postpartum smoking cessation based on a 3-item algorithm assessing personal goals, self-efficacy, and smoking behavior. Logistic regression and event history analyses indicated group differences in return to smoking at 6 weeks and 3, 6, and 12 months postpartum. The percentage of women who returned to postpartum smoking was highest in the precontemplation stage and decreased with each subsequent stage, that is, at 6 weeks 83% of PCs, 64% of Cs, 35% of PAs, and 24% of As had returned to smoking. Results lend support for the stages of change for postpartum smoking abstinence. Stage-based interventions may be developed to assist women in maintaining abstinence postpartum.

Generalizability of project MATCH: a comparison of clients enrolled to those not enrolled in the study at one aftercare site.

Project MATCH is a national, randomized clinical trial of alcoholism treatment matching. The generalizability of Project MATCH has been questioned, as well as efficacy trials in general. This study investigates at one site whether there were differences between clients who participated in MATCH and others not entered into the study. Significant differences were found on three inclusion/exclusion related variables: plans to move, available transportation, and locator provision. Significant but rather small differences were also found on age and education. There were no significant differences on a large number of demographic and problem severity measures. In addition, the Alcohol Use Disorders Identification Test scores suggest that those included in the MATCH sample actually had more serious alcohol involvement than those who were ineligible or declined participation. Overall, the differences found do not appear to threaten the generalizability of the study.

Effects of a brief alcohol preventive intervention for youth attending school sports physical examinations.

This pilot study examined the feasibility and efficacy of a brief alcohol misuse preventive intervention for 178 7th-9th grade junior high school students attending sports physical examinations at three schools during the Summer of 1997. At 6-month posttest, fewer suburban intervention youth intended to use alcohol during the next 6 months (chi2 = 7.01, 1 df, p = .01), and fewer rural intervention youth used alcohol during the past 30 days (chi2 = 4.65, 1 df, p = .04), compared to control youth. When suburban and rural school samples were collapsed, intervention youth had significantly lower alcohol use on three of four measures than control subjects (p's < .05).

Predicting the therapeutic alliance in alcoholism treatment.

OBJECTIVE: Prediction of the therapeutic alliance in alcoholism treatment (as rated by the client and by the therapist) was examined in light of a range of potentially relevant factors, including client demographics, drinking history, current drinking, current psychosocial functioning and therapist demographics. METHOD: The data were gathered in Project MATCH. The present analyses were based on data from 707 outpatients and 480 aftercare clients assigned to one of the three Project MATCH treatments. Potential predictor variables were evaluated by first examining bivariate linear relationships between the variables and ratings of the alliance, and then entering blocks of these predictors into multiple linear regression equations with alliance ratings as the dependent variables. All analysis incorporated adjustments for the nonindependence of ratings pertaining to clients seen by the same therapist. RESULTS: In simple regressions evaluating bivariate relationships, outpatients' ratings of the alliance were positively predicted by client age, motivational readiness to change, socialization, level of perceived social support and therapist age, and were negatively predicted by client educational level, level of depression, and meaning seeking. Therapist ratings in the outpatient sample were positively predicted by the client being female and by level of overall alcohol involvement, severity of alcohol dependence, negative consequences of alcohol use, and readiness to change. Among aftercare clients, ratings of the alliance were positively predicted by readiness to change, socialization and social support, and were negatively predicted by level of depression. Therapist ratings of the alliance in the aftercare sample were positively predicted by the client being female and therapist educational level, and were negatively predicted by pretreatment drinks per drinking day. Of the variables having significant bivariate relationships with alliance scores, only a few were identified as significant predictors in multiple regression equations. Among outpatients, client age and motivational readiness to change remained positive predictors and client education a negative predictor of client ratings of the alliance, while client gender remained a significant predictor of therapist ratings. Among aftercare clients, readiness to change and level of depression remained significant predictors of client ratings, while none of the variables remained a significant predictor of therapist ratings. CONCLUSIONS: While the data indicate that several client variables predict the nature of both the client's and therapist's perception of the therapeutic alliance, the significant relationships are of modest magnitude, and few variables remain predictive after controlling for causally prior variables. The strongest relationship identified in both the outpatient and aftercare samples is that between clients' motivational readiness to change and their ratings of the alliance.

Effectiveness of Agency for Health Care Policy and Research clinical practice guideline and patient education methods for pregnant smokers in medicaid maternity care.

OBJECTIVE: The purposes of this study were (1) to determine the extent to which tobacco exposure assessment and new patient education methods, derived from a meta-analysis and the Agency for Health Care Policy and Research guideline recommendations, could be provided routinely by trained Medicaid maternity care staff members and (2) to document the behavioral impact of these interventions among pregnant smokers. STUDY DESIGN: After 265 pregnant smokers were assigned at their first visit to an experimental group (n = 139) or a control group (n = 126), they received standardized risk information and were advised to quit smoking. The experimental group also received evidence-based patient education methods, including the videocassette Commit to Quit During and After Pregnancy, the publication A Pregnant Woman's Guide to Quit Smoking, and a brief counseling session. Self-report and saliva cotinine assessments of tobacco exposure were performed at baseline and at the end of pregnancy. RESULTS: A significantly higher percentage of patients quit smoking in the experimental group (17.3%) than in the control group (8.8%). CONCLUSIONS: The application of principles of organizational development and quality improvement at the management and clinical practice levels and the delivery of evidence-based health education methods by trained prenatal care providers significantly increased smoking cessation rates among pregnant Medicaid recipients.

On a roll: the process of initiation and cessation of problem gambling among adolescents.

As gambling becomes more accessible and acceptable in society, problems associated with gambling and gaming have begun to affect ever increasing numbers of adolescents. Although restricted from most forms of gambling by law, many adolescents are finding a path into problem gambling. Some are becoming compulsive gamblers early in their gambling career, facing a future filled with consequences and problems. Understanding the pathway or process by which these adolescents become engaged in gambling behavior and how they can extricate themselves from this addictive behavior can enhance the efficiency and effectiveness of our interventions. This article offers a perspective on the initiation and cessation of compulsive gambling using the basic elements of the process of intentional behavior change outlined in the Stages of Change from the Transtheoretical Model. The process of initiation of a problematic behavior is similar to the process of modification or cessation of a problematic behavior in terms of these stages of change. With adolescents it is important to distinguish between the process of initiation, which has implications for prevention of gambling problems, and the process of cessation, which often necessitates the assistance of treatment. Creating interventions that parallel the process of change offers the potential for personalizing and potentiating efforts to reduce the prevalence and consequences associated with compulsive or pathological and problem gambling. Application of this model to gambling behavior offers a heuristic that is intriguing and requires substantiation through rigorous research.

Prevention and harm reduction for chemical dependency: a process perspective.

Clinical psychology is often on the periphery of treatment and prevention efforts to stop substance abuse and dependence. This article describes the current status of prevention research and practice, outlines a process perspective on the initiation and cessation of drug use and abuse, and offers some new ideas about how psychology can and should become involved in the prevention of chemical dependency. Psychologists are faced with the precursors and consequences of chemical dependency on a daily basis. With improved training and increased awareness, and aided by a process perspective, psychology and psychologists can play an important role in preventing the onset of chemical dependency, creating early interventions to stop the process of initiation, and becoming more involved in treatment and harm-reduction efforts. Psychologists have the basic training and the biopsychosocial orientation that could make them effective agents for primary, secondary, and tertiary prevention of chemical dependency.

Psychiatric severity and behavior change in alcoholism: the relation of the transtheoretical model variables to psychiatric distress in dually diagnosed patients.

Treatment programming for individuals diagnosed with a chronic mental illness and an alcohol use disorder could be enhanced by employing techniques that focus on those change process variables that are most strongly related to psychiatric distress. Prochaska and DiClemente's transtheoretical model (TTM) provides a useful framework within which to study these relations. The associations between psychiatric severity and the TTM constructs of stages and processes of change, decisional balance, temptation, and self-efficacy were measured among 132 alcohol-dependent patients in a public mental health clinic's outpatient dual diagnosis program. Participants' scores on the Temptation subscale of the Alcohol Abstinence Self-Efficacy Questionnaire are strongly related to psychiatric severity: The more psychiatric distress a person is experiencing, the more he or she is tempted to drink, particularly in situations that trigger negative affect. Decisional balance considerations are also related to psychiatric severity: The higher participants scored on the Global Severity Index of the Brief Symptom Inventory, the more importance they placed on the negative aspects, or cons, of drinking. Subjects with more psychiatric distress also scored higher on the maintenance stage of change subscale, possibly indicating an increased fear of relapse and struggle to maintain sobriety.

Predictors of smoking cessation during pregnancy.

AIMS: The purpose of this study was to determine predictors of smoking cessation from a sample of pregnant Medicaid recipients. Of special interest was whether patient stage of change, based on the transtheoretical model, was predictive of smoking behavior change during pregnancy. PARTICIPANTS/SETTING: The sample was drawn from a cohort of pregnant smokers who were participants in a prospective, randomized clinical trial conducted in four public health maternity clinics in Birmingham, Alabama, USA. DESIGN/MEASUREMENTS: The 435 participants entered prenatal care on or before their 24th week of gestation and had saliva collected for cotinine assays at baseline and follow-up. In this secondary analysis, descriptive statistics defined the sample, cross-tabulation procedures identified a preliminary set of predictor variables, and discriminant function analyses predicted group membership--quitter or smoker. FINDINGS/CONCLUSIONS: Discriminant function analyses revealed that patient baseline cotinine value, duration of smoking habit, self-efficacy, exposure to environmental tobacco smoke, and exposure to patient education methods were predictive of non-smoking status assessed during the third trimester of pregnancy.

Six-month outcomes of an alcohol prevention program for inner-city youth.

Six-hundred and fifty 6th grade students were randomly assigned with the intervention group receiving the STARS for Families Program, an alcohol reduction program consisting of standardized health consultations provided by nurses and mailed follow-up information. The control group received minimum information. Students in the study attended either a neighborhood or a bused inner-city middle school. Students receiving the intervention had significantly less intentions to use alcohol in the future and less alcohol quantity. The study suggests that brief, provider-involved interventions may be a viable school based approach to prevention.