A pilot randomized controlled trial of smartphone-assisted mindfulness-based intervention with contingency management for smokers with mood disorders.

Cigarette smoking disproportionately affects individuals with mood disorders, but smoking cessation interventions have modest effects in this population. Home mindfulness practice during abstinence incentivized via contingency management (CM) may help those in affective distress quit smoking. METHOD: Adult smokers receiving outpatient psychiatric treatment for mood disorders were randomized to receive a smartphone-assisted mindfulness-based smoking cessation intervention with contingency management (SMI-CM, n = 25) or enhanced standard treatment (EST, n = 24) with noncontingent rewards. Participants in SMI-CM were prompted to practice audio-guided mindfulness five times per day for 38 days (vs. no comparison intervention in EST), and received monetary incentives for carbon monoxide (CO) ≤ 6 ppm. The primary outcome was biochemically verified 7-day point prevalence abstinence rates 2, 4, and 13 weeks after a target quit day. RESULTS: Of the 49 participants, 63.3% were Latinx and 30.6% Black; 75.5% reported household incomes < $25,000. Abstinence rates for SMI-CM were 40.0%, 36.0%, and 16.0% versus 4.2%, 8.3%, and 4.2% in EST at weeks 2, 4, and 13. A generalized estimating equations (GEE) model showed significant overall differences in abstinence rates in SMI-CM versus EST (adjusted odds ratio [AOR] = 8.12, 95% CI = 1.42-46.6, p = .019). Those who received SMI-CM reported significantly greater reduction in smoking-specific experiential avoidance from baseline to 3 days prior to quit date (ß = -7.21, 95% CI = -12.1-2.33, p = .006). CONCLUSIONS: SMI-CM may increase cessation rates among smokers with mood disorders, potentially through reduced smoking-specific experiential avoidance. SMI-CM is a promising intervention, and warrants investigation in a fully powered randomized controlled trial (RCT). (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Readiness to Quit Smoking among Smokers in Substance Use Treatment: Associations with Stress, Substance Use Severity, Relapse Concerns and Gender.

Smoking prevalence among individuals in substance use treatment remains higher than in the general population. Given that many smokers in substance use treatment are reluctant to quit smoking, it is important to understand the factors that impede smokers' readiness to quit. The current study used baseline data from a randomized controlled trial involving 60 adult smokers receiving substance use treatment to investigate relations between the severity of substance use problems (SSUP), perceived stress (PS), concerns about relapse (i.e., concerns that quitting smoking would hurt one's recovery process (CR)), and readiness to quit smoking. This study also investigated moderating roles of concerns about relapse and gender. Regression analyses showed a significant main effect of concerns about relapse on readiness to quit in the next 30 days, but no effect for either severity of substance use problems, perceived stress, or the SSUPxCR interaction. There were significant interaction effects between PS and both gender and CR. Among men and those with lower concerns about relapse, higher perceived stress was significantly associated with lower readiness to quit. Findings suggest that psychoeducation to alleviate concerns that quitting smoking could limit substance use recovery could be beneficial. Stress management interventions may be especially beneficial to men.

Relationships among Self-Efficacy, Quality of Life, Perceived Vulnerability, and Readiness to Quit Smoking in People Living with HIV.

Smoking-related diseases (e.g., lung cancer) are the leading cause of mortality in HIV-infected patients. While many PLWH who smoke report a desire to quit, a majority of them have low readiness to quit. This study used logistic and linear regression to examine the relations among two (continuous vs. binary) measures of readiness to quit, smoking cessation self-efficacy (SE), quality of life (QoL), and perceived vulnerability (PV) using baseline data from 100 PLWH who smoke who participated in a clinical trial. Results showed no significant main effects (SE, QoL, and PV) or interaction effects (SE × QoL and SE × PV) on a continuous measure of readiness to quit. However, a follow-up analysis revealed that SE had a curvilinear effect on readiness to quit such that self-efficacy was positively associated with readiness to quit except at the highest levels of self-efficacy where readiness to quit declined. Greater SE significantly increased the likelihood of reporting readiness to quit (yes/no) among those with low QoL or high PV. For PLWH who smoke, improving self-efficacy may increase readiness to quit especially among those with lower quality of life. Psychoeducation tailored to PLWH designed to reduce unrealistic invulnerability to smoking-related diseases along with interventions that target self-efficacy may improve readiness to quit.

Sustained Care Smoking Cessation Intervention for Individuals Hospitalized for Psychiatric Disorders: The Helping HAND 3 Randomized Clinical Trial.

Importance: Smoking among individuals with serious mental illness (SMI) represents a major public health problem. Intervening during a psychiatric hospital stay may provide an opportunity to aid engagement in smoking cessation treatment and facilitate success in quitting. Objective: To examine the effectiveness of a multicomponent, sustained care (SusC) smoking cessation intervention in adults with SMI receiving inpatient psychiatric care. Design, Setting, and Participants: The Helping HAND 3 randomized clinical trial compared SusC with usual care (UC) among individuals with SMI who smoked daily and were receiving inpatient psychiatric care in Austin, Texas, in a single hospital. The study was conducted from July 2015 through August 2019. Interventions: The UC intervention involved brief smoking cessation information, self-help materials and advice from the admitting nurse, and an offer to provide nicotine replacement therapy during hospitalization. The SusC intervention included 4 main components designed to facilitate patient engagement with postdischarge smoking cessation resources: (1) inpatient motivational counseling; (2) free transdermal nicotine patches on discharge; (3) an offer of free postdischarge telephone quitline, text-based, and/or web-based smoking cessation counseling, and (4) postdischarge automated interactive voice response calls or text messages. Main Outcomes and Measures: The primary outcome was biochemically verified 7-day point-prevalence abstinence at 6-month follow-up. A secondary outcome was self-reported smoking cessation treatment use at 1, 3, and 6 months after discharge. Results: A total of 353 participants were randomized, of whom 342 were included in analyses (mean [SD] age, 35.8 [12.3] years; 268 White individuals [78.4%]; 280 non-Hispanic individuals [81.9%]; 169 women [49.4%]). They reported smoking a mean (SD) of 16.9 (10.4) cigarettes per day. Participants in the SusC group evidenced significantly higher 6-month follow-up point-prevalence abstinence rates than those in the UC group (8.9% vs 3.5%; adjusted odds ratio, 2.95 [95% CI, 1.24-6.99]; P = .01). The number needed to treat was 18.5 (95% CI, 9.6-306.4). A series of sensitivity analyses confirmed effectiveness. Finally, participants in the SusC group were significantly more likely to report using smoking cessation treatment over the 6 months postdischarge compared with participants in the UC group (74.6% vs 40.5%; relative risk, 1.8 [95% CI, 1.51-2.25]; P < .001). Conclusions and Relevance: The findings of this randomized clinical trial provide evidence for the effectiveness of a scalable, multicomponent intervention in promoting smoking cessation treatment use and smoking abstinence in individuals with SMI following hospital discharge. Trial Registration: ClinicalTrials.gov Identifier: NCT02204956.

Peer Support for Post Intensive Care Syndrome Self-Management (PS-PICS): Study protocol for peer mentor training.

AIMS: The primary aim of the Peer Support for Post Intensive Care Syndrome Self-Management (PS-PICS) peer mentor training trial is to determine the feasibility for peer mentor training to connect new ICU survivors with survivors who have made successful recoveries. Secondary aims are to also examine peer mentor eligibility, recruitment and retention rates and assess changes in participant knowledge of Post Intensive Care Syndrome (PICS), reported symptoms and health-related quality of life. DESIGN: Prospective clinical feasibility trial. METHODS: This study received funding from the National Institutes of Health funded P30 Center for Excellence (2014-2020). Up to 20 adult patients who have had an ICU stay of 3 days or longer more than 3 months ago will be enrolled into the study. Participants will undergo a 6-week peer mentor training program to learn how to promote healthy self-management behaviours, social connections, and well-being using motivational interviewing (MI). Participants will complete surveys about their recovery at 3 points during the study: prior to training, 6 weeks post-training and 3 months post-training. Survey questions will be used to assess trends in participant social isolation, depression, functional status, and self-management behaviours. DISCUSSION: Enrollment closes by December 2020. As a feasibility trial, power sufficient for hypothesis testing will not be available. However, study operations and intervention fidelity contribute to future research knowledge and participant characteristics and longitudinal outcomes will yield data on intervention feasibility. This study is the first use of embedding peer-led motivational interviewing training into a peer support intervention for ICU survivors. IMPACT: Current self-management interventions are limited for ICU survivors and do not sufficiently address barriers to promoting self-management behaviours or improving their health status, well-being and cost of health. This study will provide data to develop and implement interventions for the self-management of PICS-related symptoms and sequelae.

Adaptation of a sustained care cessation intervention for smokers hospitalized for psychiatric disorders: Study protocol for a randomized controlled trial.

BACKGROUND: Individuals with serious mental illness (SMI) smoke at disproportionately higher rates than those without SMI, have lifespans 25-32 years shorter, and thus bear an especially large burden of tobacco-related morbidity and mortality. Several recent studies demonstrate that smokers with SMI can successfully quit smoking with adequate support. Further evidence shows that using technology to deliver sustained care interventions to hospitalized smokers can lead to smoking cessation up to 6 months after discharge. The current comparative effectiveness trial adapts a technology-assisted sustained care intervention designed for smokers admitted to a general hospital and tests whether this approach can produce higher cessation rates compared to usual care for smokers admitted to a psychiatric inpatient unit. METHODS: A total of 353 eligible patients hospitalized for psychiatric illness are randomized by cohort into one of two conditions, Sustained Care (SusC) or Usual Care (UC), and are followed for six months after discharge. Participants assigned to UC receive brief tobacco education delivered by a hospital nurse during or soon after admission. Those assigned to SusC receive a 40-min, in-hospital motivational counseling intervention. Upon discharge, they also receive up to 8 weeks of free nicotine patches, automated interactive voice response (IVR) telephone and text messaging, and access to cessation counseling resources lasting 3 months post discharge. Smoking cessation outcomes are measured at 1-, 3- and 6-months post hospital discharge. CONCLUSION: Results from this comparative effectiveness trial will add to our understanding of acceptable and effective smoking cessation approaches for patients hospitalized with SMI.

Rationale, design and pilot feasibility results of a smartphone-assisted, mindfulness-based intervention for smokers with mood disorders: Project mSMART MIND.

BACKGROUND: Although individuals with psychiatric disorders are disproportionately affected by cigarette smoking, few outpatient mental health treatment facilities offer smoking cessation services. In this paper, we describe the development of a smartphone-assisted mindfulness smoking cessation intervention with contingency management (SMI-CM), as well as the design and methods of an ongoing pilot randomized controlled trial (RCT) targeting smokers receiving outpatient psychiatric treatment. We also report the results of an open-label pilot feasibility study. METHODS: In phase 1, we developed and pilot-tested SMI-CM, which includes a smartphone intervention app that prompts participants to practice mindfulness, complete ecological momentary assessment (EMA) reports 5 times per day, and submit carbon monoxide (CO) videos twice per day. Participants earned incentives if submitted videos showed CO≤6ppm. In phase 2, smokers receiving outpatient treatment for mood disorders are randomized to receive SMI-CM or enhanced standard treatment plus non-contingent CM (EST). RESULTS: The results from the pilot feasibility study (N=8) showed that participants practiced mindfulness an average of 3.4times/day (≥3min), completed 72.3% of prompted EMA reports, and submitted 68.0% of requested CO videos. Participants reported that the program was helpful overall (M=4.85/5) and that daily mindfulness practice was helpful for both managing mood and quitting smoking (Ms=4.50/5). CONCLUSIONS: The results from the feasibility study indicated high levels of acceptability and satisfaction with SMI-CM. The ongoing RCT will allow evaluation of the efficacy and mechanisms of action underlying SMI-CM for improving cessation rates among smokers with mood disorders.

Development and preliminary pilot evaluation of a brief tablet computer intervention to motivate tobacco quitline use among smokers in substance use treatment.

BACKGROUND AND OBJECTIVES: The majority of individuals in substance use disorder (SUD) treatment also smoke cigarettes; yet, the availability of smoking cessation services in SUD treatment remains limited. In this study, we developed and piloted a brief intervention for smokers in SUD treatment intended to motivate engagement in tobacco quitline treatment (TIME-TQ). METHODS: First, we interviewed 19 smokers in SUD treatment to inform the development of TIME-TQ (Phase 1). Second, we delivered a prototype TIME-TQ to 16 smokers in the same SUD treatment program and followed them for 3 months post-discharge (Phase 2). RESULTS: Feedback from Phase 1 participants was used to refine response choices and video segments included in the prototype TIME-TQ. Phase 2 participants rated TIME-TQ high on relevance, interest, respectfulness, and helpfulness. Additionally, they reported significant increases in readiness to quit and perceived importance of quitting after receiving TIME-TQ. A total of 8 of the 16 accepted a quitline referral, and 8 of 13 reached for follow-up (four referral acceptors, four decliners) reported efforts to quit or reduce smoking during the follow-up period. However, only three received quitline counseling and none achieved a sustained period of abstinence. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Our results suggest that TIME-TQ activated these patients to quit smoking, but our referral method (standard fax referral) was unsuccessful in helping participants fully engage in quitline treatment or achieving a period of abstinence. SCIENTIFIC SIGNIFICANCE: We are now conducting an RCT to evaluate TIME-TQ with a revised referral procedure intended to increase treatment engagement and, ultimately, abstinence rates. (Am J Addict 2017;26:587-594).

Distress Tolerance Treatment for Weight Concern in Smoking Cessation Among Women: The WE QUIT Pilot Study.

Fear of gaining weight after quitting cigarette smoking is a major barrier to smoking cessation among women. Distress tolerance, which refers to one's ability and willingness to tolerate physical and emotional discomfort, predicts successful behavior change. Novel interventions rooted in Acceptance and Commitment Therapy (ACT) have emerged that aim to increase distress tolerance and engagement in values-oriented behavior. In this study, we developed a 9-week, group-based distress tolerance intervention for weight concern in smoking cessation among women (DT-W). Using an iterative process, we piloted DT-W with two small groups ( n = 4 and n = 7) of female weight-concerned smokers. Results indicated that we successfully established the feasibility and acceptability of DT-W, which was well-attended and well-received. Biochemically verified 7-day point-prevalence abstinence rates at post-intervention, 1, 3, and 6 months were 64%, 36%, 27%, and 27%, respectively. We are now evaluating DT-W in a randomized controlled trial.

A preliminary randomized controlled trial of a distress tolerance treatment for opioid dependent persons initiating buprenorphine.

BACKGROUND: Buprenorphine opioid agonist treatment (OAT) has established efficacy for treating opioid dependency but early relapse rates are high and are often associated with withdrawal-related or emotional distress. METHODS: To determine whether a novel distress tolerance (DT) intervention during buprenorphine initiation decreases opioid relapse, we conducted a preliminary randomized controlled trial with opioid-dependent outpatients. Participants received buprenorphine-naloxone induction and 3-months of maintenance buprenorphine plus seven, 50-min manualized, individual sessions (DT vs. health education (HE) control) over a 28-day period, linked to clinician medication dosing visits, and beginning 2 days prior to buprenorphine induction. Primary outcomes included use of illicit opioids (positive defined as any self-reported use in the prior 28 days or detected by urine toxicology) and treatment drop out. RESULTS: Among 49 participants, the mean age was 41 years, 65.3% were male. Persons randomized to DT had lower rates of opioid use at all three monthly assessments, and at 3-months, 72% of HE participants were opioid positive compared with 62.5% of DT participants. Rates of dropout were 24% and 25% in the HE and DT arms, respectively. CONCLUSIONS: This distress tolerance treatment produced a small, but not statistically significant reduction in opioid use during the first three months of treatment although no differences were found in drop-out rates between conditions. If replicated in a larger study, DT could offer clinicians a useful behavioral treatment to complement the effects of buprenorphine.

A pilot study of a distress tolerance treatment for opiate-dependent patients initiating buprenorphine: rationale, methodology, and outcomes.

Buprenorphine, an opioid that is a long-acting partial opiate agonist, is an efficacious treatment for opiate dependence that is growing in popularity. Nevertheless, evidence suggests that many patients will lapse within the first week of treatment and that lapses are often associated with withdrawal-related or emotional distress. Recent research suggests that individuals' reactions to this distress may represent an important treatment target. In the current study, we describe the development and outcomes from a preliminary pilot evaluation (N = 5) of a novel distress tolerance (DT) treatment for individuals initiating buprenorphine. This treatment incorporates exposure-based and acceptance-based treatment approaches that we have previously applied to the treatment of tobacco dependence. Results from this pilot study establish the feasibility and acceptability of this approach. We are now conducting a randomized controlled trial of this treatment that we hope will yield clinically significant findings and offer clinicians an efficacious behavioral treatment to complement the effects of buprenorphine.

Daily self-weighing within a lifestyle intervention: impact on disordered eating symptoms.

OBJECTIVE: To determine whether daily self-weighing (DSW) is associated with disordered eating (DE) symptoms within an adult lifestyle intervention (LI), and to examine changes in DE symptoms during the 18-month trial. METHOD: One-hundred and seventy-eight adults (53% female, 90% White, 52.0 ± 8.6 years, BMI = 35.0 ± 4.4 kg/m2) were enrolled in a randomized trial testing 2 dietary prescriptions within a LI (standard vs. limited dietary variety). Both arms were taught DSW and had the same contact schedule and calorie and activity goals. Frequency of weighing and DE were assessed at 0, 6, 12, and 18 months. Analyses controlled for treatment arm. RESULTS: At baseline, 16.3% of participants reported weighing ≥ daily compared with 83.7%, 72.3%, and 68.2% at 6, 12, and 18 months, respectively. There was no relationship between change in frequency of self-weighing and change in DE symptoms at any time point. Further, there were no significant differences between those who weighed ≥ daily versus < daily on DE composite scores at baseline or 6 months; at 12 and 18 months participants who weighed ≥ daily reported lower DE scores compared with those who weighed < daily (p = .008 and .043 at 12 and 18 months, respectively). Participants who weighed ≥ daily achieved better weight losses than those weighing < daily at 12 and 18 months (p = .003 and <.001). There was a significant reduction over time in DE symptoms (p < .0001) and a reduction in odds of meeting criteria for Binge Eating Disorder (BED; ps < .001). CONCLUSIONS: Daily self-weighing did not appear to be related to increased disordered eating behavior and was associated with better weight loss outcomes.

Limiting variety in non-nutrient-dense, energy-dense foods during a lifestyle intervention: a randomized controlled trial.

BACKGROUND: Dietary variety is a factor that influences consumption but has received little attention in obesity treatment. OBJECTIVE: This study examined the effect of limiting the variety of different non-nutrient-dense, energy-dense foods (NND-EDFs) (i.e., chips, ice cream, cookies) on dietary intake and weight loss during an 18-mo lifestyle intervention. DESIGN: Two hundred two adults aged 51.3 ± 9.5 y with a BMI (in kg/m2) of 34.9 ± 4.3 (57.8% women, 92.2% white) were randomly assigned to 1 of 2 interventions: Lifestyle (1200-1500 kcal/d, ≤30% of energy as fat; n = 101) or Lifestyle + limited variety (LV) (limit variety of NND-EDFs, i.e., 2 choices; n = 101). Both interventions involved 48 group sessions. Dietary intake, NND-EDF hedonics, NND-EDF variety in the home, and weight were assessed at 0, 6, 12, and 18 mo. RESULTS: Intent-to-treat analyses showed that the Lifestyle+LV group consumed less variety (P < 0.01) and energy daily (P < 0.05) from NND-EDFs than did the Lifestyle group at 6, 12, and 18 mo. The Lifestyle+LV group consumed less total energy daily (P < 0.05) at 6 mo than did the Lifestyle group. The Lifestyle+LV group reported less (P < 0.05) NND-EDF variety in the home at 6 and 18 mo than did the Lifestyle group. The hedonics of one chosen NND-EDF decreased more (P < 0.05) in the Lifestyle+LV group. Despite these effects, no difference in percentage weight loss occurred at 18 mo (Lifestyle+LV: -9.9 ± 7.6%; Lifestyle: -9.6 ± 9.2%). CONCLUSIONS: Limitations in dietary variety decreased intakes in the targeted area but did not affect weight loss. Limiting variety in more areas may be needed to improve weight loss and weight-loss maintenance. This trial was registered at clinicaltrials.gov as NCT01096719.

Feasibility, cost, and cost-effectiveness of a telephone-based motivational intervention for underserved pregnant smokers.

This study reports on the evaluation of the feasibility, cost, and cost-effectiveness of a proactively provided telephone-based motivational smoking cessation intervention to an underserved population of pregnant smokers who may or may not receive ongoing prenatal care. As part of the New England SCRIPT randomized clinical trial comparing the efficacy of three types of smoking cessation interventions for pregnant smokers, one-third of the women (n = 358) received a motivational telephone counseling intervention (MI) delivered by trained counselors using a semistructured protocol. Although this population was very mobile, the MI counselors were able to reach 86% of the women with at least one call and 46% received all three calls. The group receiving three MI calls had a cotinine-confirmed quit rate of 23%. Cost-effectiveness analyses for those women receiving telephone counseling supported the net benefit in favor of the three phone calls compared with the women who did not receive any telephone calls, with an effectiveness to cost ratio of 1:US dollars 84. Our results suggest that telephone-based motivational smoking cessation counseling may be a feasible and cost-effective method for low-income pregnant smokers enrolled in prenatal care.

Brief behavioral therapies reduce early positive airway pressure discontinuation rates in sleep apnea syndrome: preliminary findings.

Sleep apnea syndrome (SAS) is a serious disorder with significant daytime consequences. Treatment for SAS most commonly takes the form of positive airway pressure (PAP). Although effective, PAP adherence is often below expectations. Previous studies have suggested that the provision of information on the importance of PAP use can enhance adherence. In this study, we compare 2 brief behavioral approaches-traditional education (ED) and a motivational enhancement therapy (MET)-designed from theories of behavior change to standard clinical care. PAP discontinuation and adherence are the primary outcome measures. Both brief therapies decreased PAP discontinuation compared to standard care. The MET therapy performed best under the condition of flexible delivery of PAP, although differences were not statistically significant. Implications are discussed.

The family check-up: a pilot study of a brief intervention to improve family functioning in adults.

Many barriers exist for families seeking appropriate treatment for family problems. In an effort to minimize some of these barriers, we developed the Family Check-Up, a brief two-session family intervention. The Family Check-Up is based on the Drinker's Check-Up and consists of assessment, feedback, discussion, and goal setting. The purpose of the intervention is to help families identify and become motivated to make needed changes in any aspect of their family functioning. We conducted an open pilot trial of the Family Check-Up with 32 families. Our data suggest that the Family Check-Up (1) is sought out by the target audience, namely those with family problems; (2) is sought out by people with elevated depression symptoms or a history of treatment for depression or anxiety; (3) is feasible to conduct; (4) is acceptable to families; and (5) may be associated with changes in family functioning and depression symptoms over time. These results suggest that further research, particularly a randomized clinical trial, is warranted.

Home health care nurses as a new channel for smoking cessation treatment: outcomes from project CARES (Community-nurse Assisted Research and Education on Smoking).

BACKGROUND: Clinical guidelines for smoking cessation may not be sufficient for helping some subgroups of smokers quit. Incorporating smoking cessation into home-based medical care can proactively reach high-risk smokers who may not have access to (or spontaneously seek) smoking cessation. METHOD: Home health care nurses (N = 98) were randomly assigned to deliver either Motivational Enhancement (ME; Motivational Interviewing + Carbon Monoxide Feedback) or Standard Care (AHCPR Guidelines for smoking cessation) to their patients. Seventy percent of patients were eligible and willing to participate (N = 273; 54% female, mean age = 57 years, 83% Caucasian, 41% < high school education). The study was conducted in Providence, RI, USA from 1998 to 2003. RESULTS: Biochemically verified continuous abstinence rates at the 12-month follow-up were 4.2% (SC) and 8.7% (ME) for intent to treat analyses, and 5.2% (SC) and 11.8% (ME) using all available cases (P > 0.05). ME reported more quit attempts and significantly greater reductions in the number of cigarettes smoked per day at all follow-ups through 12 months of post-treatment (all P values < 0.05). CONCLUSIONS: Use of an existing public health channel such as home health care to reach smokers who vary in their motivation to quit could have the potential for large public health impact.

Motivational interviewing in community-based research: experiences from the field.

Motivational Interviewing (MI) has been established as an effective psychotherapeutic treatment for problem drinking in clinical settings. Consequently, there is a growing interest in applying MI to facilitate change across other health behaviors, such as tobacco use, eating habits, and physical activity in a variety of community-based research settings. These extended applications pose new challenges regarding implementation and evaluation. For instance, investigators must consider how best to train intervention counselors; implement strategies for preserving the MI spirit, despite limited client contact time; incorporate adjunctive strategies that support brief MI sessions; and develop a plan for monitoring and evaluating MI treatment fidelity. This article highlights specific examples of how several behavior change research projects applied MI across a variety of settings and populations, provides lessons learned from our experience as a collaborative workgroup, and offers strategies for consideration in future community-based research.

Examples of implementation and evaluation of treatment fidelity in the BCC studies: where we are and where we need to go.

Treatment fidelity plays an important role in the research team's ability to ensure that a treatment has been implemented as intended and that the treatment has been accurately tested. Developing, implementing, and evaluating a treatment fidelity plan can be challenging. The treatment fidelity workgroup within the Behavior Change Consortium (BCC) developed guidelines to comprehensively evaluate treatment fidelity in behavior change research. The guidelines include evaluation of treatment fidelity with regard to study design, training of interventionists, delivery and receipt of the intervention, and enactment of the intervention in real-life settings. This article describes these guidelines and provides examples from four BCC studies as to how these recommended guidelines for fidelity were considered. Future work needs to focus not only on implementing treatment fidelity plans but also on quantifying the evaluations performed, developing specific criteria for interpretation of the findings, and establishing best practices of treatment fidelity.

Clinical management of poor adherence to CPAP: motivational enhancement.

Adherence to continuous positive airway pressure (CPAP) in patients with sleep apnea hypopnea syndrome (SAHS) is poor. Previous studies have attempted to identify specific barriers to treatment, but none has identified the sole cause for the problem. We outline a behavioral approach to the problem of CPAP adherence that is based on the theories of the transtheoretical model and social cognitive theory. We used these theories to guide the development of an intervention based on the methods of motivational interviewing. We present our motivational enhancement therapy for CPAP (ME-CPAP) here, with some brief pilot data to show its efficacy. Finally, we outline some strengths and weaknesses of taking a behavior change approach to the problem of poor CPAP adherence.