Field Test of a Hybrid Finite-Difference and Analytic Element Regional Model.

Regional finite-difference models often have cell sizes that are too large to sufficiently model well-stream interactions. Here, a steady-state hybrid model is applied whereby the upper layer or layers of a coarse MODFLOW model are replaced by the analytic element model GFLOW, which represents surface waters and wells as line and point sinks. The two models are coupled by transferring cell-by-cell leakage obtained from the original MODFLOW model to the bottom of the GFLOW model. A real-world test of the hybrid model approach is applied on a subdomain of an existing model of the Lake Michigan Basin. The original (coarse) MODFLOW model consists of six layers, the top four of which are aggregated into GFLOW as a single layer, while the bottom two layers remain part of MODFLOW in the hybrid model. The hybrid model and a refined "benchmark" MODFLOW model simulate similar baseflows. The hybrid and benchmark models also simulate similar baseflow reductions due to nearby pumping when the well is located within the layers represented by GFLOW. However, the benchmark model requires refinement of the model grid in the local area of interest, while the hybrid approach uses a gridless top layer and is thus unaffected by grid discretization errors. The hybrid approach is well suited to facilitate cost-effective retrofitting of existing coarse grid MODFLOW models commonly used for regional studies because it leverages the strengths of both finite-difference and analytic element methods for predictions in mildly heterogeneous systems that can be simulated with steady-state conditions.

Lifetime characteristics of participants and non-participants in a smoking cessation trial: implications for external validity and public health impact.

BACKGROUND: Detailed information about the characteristics of smokers who do and do not participate in smoking cessation treatment is needed to improve efforts to reach, motivate, and treat smokers. PURPOSE: The aim of this study is to explore a broad range of characteristics related to participation in a smoking cessation trial. METHODS: Eligible smokers were recruited from a longitudinal birth cohort. Participants and non-participants were compared on a broad range of sociodemographics, smoking, psychiatric and substance abuse disorders, personality, and prospective measures from early childhood. Eligible smokers were compared to a matched regional subsample of the Behavioral Risk Factor Surveillance System (BRFSS). RESULTS: Few differences were observed, most of which were statistically significant but not clinically meaningful. Compared to non-participants, participants were more likely to be single, have lower income, be more nicotine-dependent, be more motivated to quit, and have higher levels of depressed mood and stress even after covariance of gender, income, and marital status. Sociodemographic differences between participants and the BRFSS sample reflect the skew toward lower socioeconomic status in the original birth cohort. CONCLUSIONS: The encouraging conclusion is that smokers who enroll in cessation trials may not differ much from non-participants. Information about treatment participants can inform the development of recruitment strategies, improve the tailoring of treatment to individual smoker profiles, help to estimate potential selection bias, and improve estimates of population impact.

Effects of motivational interviewing on smoking cessation in adolescents with psychiatric disorders.

OBJECTIVE: To test the hypothesis that among adolescent smokers hospitalised for psychiatric and substance use disorders, motivational interviewing (MI) would lead to more and longer quit attempts, reduced smoking, and more abstinence from smoking over a 12 month follow up. DESIGN: Randomised control trial of MI versus brief advice (BA) for smoking cessation, with pre- and post-intervention assessment of self efficacy and intentions to change, and smoking outcome variables assessed at one, three, six, nine, and 12 month follow ups. SETTING: A private, university affiliated psychiatric hospital in Providence, Rhode Island, USA. PATIENTS OR OTHER PARTICIPANTS: Consecutive sample (n = 191) of 13-17 year olds, admitted for psychiatric hospitalisation, who smoked at least one cigarette per week for the past four weeks, had access to a telephone, and did not meet DSM-IV criteria for current psychotic disorder. INTERVENTIONS: MI versus BA. MI consisted of two, 45 minute individual sessions, while BA consisted of 5-10 minutes of advice and information on how to quit smoking. Eligible participants in both conditions were offered an eight week regimen of transdermal nicotine patch upon hospital discharge. MAIN OUTCOME MEASURES: Point prevalence abstinence, quit attempts, changes in smoking rate and longest quit attempt. Proximal outcomes included intent to change smoking behaviour (upon hospital discharge), and self efficacy for smoking cessation. RESULTS: MI did not lead to better smoking outcomes compared to BA. MI was more effective than BA for increasing self efficacy regarding ability to quit smoking. A significant interaction of treatment with baseline intention to quit smoking was also found. MI was more effective than BA for adolescents with little or no intention to change their smoking, but was actually less effective for adolescents with pre-existing intention to cut down or quit smoking. However, the effects on these variables were relatively modest and only moderately related to outcome. Adolescents with comorbid substance use disorders smoked more during follow up while those with anxiety disorders smoked less and were more likely to be abstinent. CONCLUSIONS: The positive effect of MI on self efficacy for quitting and the increase in intention to change in those with initially low levels of intentions suggest the benefits of such an intervention. However, the effects on these variables were relatively modest and only moderately related to outcome. The lack of overall effect of MI on smoking cessation outcomes suggests the need to further enhance and intensify this type of treatment approach for adolescent smokers with psychiatric comorbidity.

Socioeconomic status over the life course and stages of cigarette use: initiation, regular use, and cessation.

STUDY OBJECTIVE: To investigate the association between multiple indicators of socioeconomic status (SES) over the life course and three stages of cigarette use: initiation, regular use, and cessation. DESIGN: Prospective birth cohort study. SETTING: Providence, Rhode Island. PARTICIPANTS: Subjects (n=657) aged 30 to 39 were offspring of participants in the Brown University cohort of the United States National Collaborative Perinatal Project started in 1959. MAIN RESULTS: A significantly increased risk of smoking initiation was observed among people from lower socioeconomic backgrounds. Low SES in childhood also increased the risk for progression to regular smoking, and was associated with a reduced likelihood of smoking cessation. Progression to regular smoking and smoking persistence were also associated with lower adult SES. CONCLUSIONS: Socioeconomic conditions over the life course accumulate to produce increased rates of smoking uptake and reduced rates of cessation among lower SES people. Addressing SES gradients in smoking will require persistent and extended intervention over multiple life stages.

Naltrexone and cue exposure with coping and communication skills training for alcoholics: treatment process and 1-year outcomes.

BACKGROUND: Promising treatments for alcoholics include naltrexone (NTX), cue exposure combined with urge-specific coping skills training (CET), and communication skills training (CST). This study investigated the effects of combining these elements as treatment adjuncts. METHODS: A 2 x 2 design investigated the effects of CET combined with CST, as compared with an education and relaxation control treatment, during a 2-week partial hospital program (n = 165) followed by 12 weeks of NTX (50 mg/day) or placebo during aftercare (n = 128). Drinking outcomes were assessed at 3, 6, and 12 months after discharge from the partial hospital. Process measures included urge, self-efficacy (confidence about staying abstinent in risky situations), and self-reported coping skills. Medically eligible alcohol-dependent patients were recruited. RESULTS: Among those compliant with medication on at least 70% of days, those who received NTX had significantly fewer heavy drinking days and fewer drinks on days that they drank than those receiving placebo during the medication phase but not during the subsequent 9 months. CET/CST-condition patients were significantly less likely to report a relapse day and reported fewer heavy drinking days at the 6- and 12-month follow-ups than patients in the control treatment. Interactions of medication with behavioral treatments were not significant. Process measures showed that NTX resulted in lower weekly urge ratings, and those in CET/CST used more of the prescribed coping skills after treatment, reported fewer cue-elicited urges, and reported more self-efficacy in a posttest role-play test. Drinking reductions at 3, 6, and 12 months correlated with more use of coping skills, lower urge, and higher self-efficacy. CONCLUSIONS: The results suggest the probable value of keeping alcoholics on NTX for longer periods of time and the importance of increasing compliance with NTX. They also support the earlier promising effects of CET and CST as adjuncts to treatment programs for alcoholics by maintaining treatment gains over at least a year. The value of the urge-specific and general coping skills and of self-efficacy and urge constructs was demonstrated in their association with drinking outcomes.

Smoking-cessation counseling in the home. Attitudes, beliefs, and behaviors of home healthcare nurses.

BACKGROUND: Despite advances in smoking treatment, cessation rates remain stagnant, possibly a function of the lack of new channels to reach heavily addicted smokers. This cross-sectional study examined home care nurses' attitudes, beliefs, and counseling behaviors regarding counseling their home care patients who smoke. METHODS: Home healthcare nurses (N=98) from the Visiting Nurse Association of Rhode Island were randomly selected to participate in a study helping home-bound medically ill smokers to quit. At baseline, nurses completed a questionnaire that assessed a constellation of cognitive factors (self-efficacy, outcome expectations, perceived effectiveness, risk perception, motivation, and perceived patient adherence) as correlates of self-reported nurse counseling behaviors. RESULTS: Nurses with higher outcome expectations spent more time counseling their patients about quitting (p<0.04). Nurses' self-efficacy was the only variable associated with consistent counseling (p<0.05). While the majority of nurses "asked and advised" their patients, a minority of nurses "assisted or arranged" follow-up. Perceived importance of counseling was associated with a greater likelihood of asking, advising and assisting (p<0.05). None of the nurses who currently smoked (n=13) provided follow-up to their patients. Nurses who reported higher levels of both risk perception (regarding the harmful effects of smoking) and perceived effectiveness were more likely to recommend the nicotine patch. CONCLUSIONS: Attitudes and beliefs about smoking are significantly associated with nurse counseling behaviors. Helping nurses to overcome their barriers to smoking counseling may open up new channels for smoking intervention.

Will healthcare take tobacco addiction seriously? Using policy to drive practice.

Despite being the leading preventable cause of disability, death, and economic burden on society, tobacco-use detection and treatment is yet to be taken as seriously as the prevention and treatment of chronic diseases or other addictive behaviors (eg, hypertension, diabetes, alcohol/substance abuse, and mammography screening). This paper outlines the process of intervening at the policy level to incorporate tobacco-use screening and treatment in health practice. The National Committee for Quality Assurance (NCQA) call for new measures presented a window of opportunity. The NCQA report card (the Health Plan Employer Data Information Set [HEDIS]) is the most widely used and influential performance measure in managed care. Consequently, a 6-month process consisting of an expert panel review of research evidence and consensus building was initiated. Two measures were submitted to NCQA: (1) a primary measure based on chart review of tobacco-use screening and treatment implementation and (2) an adjunctive measure of population prevalence of tobacco use and physician advice to quit, based on a self-report survey of members. HEDIS eventually accepted the second measure. The mixed results, potential impact on societal disease burden and cost savings, and the lessons learned from the process are discussed.

Does completing a craving questionnaire promote increased smoking craving? An experimental investigation.

The authors evaluated whether completing a multi-item assessment of smoking craving (the Questionnaire of Smoking Urges [QSU]) promoted increases in smoking craving. A sample of 39 regular smokers was randomly assigned to 1 of 3 manipulations (each of 3 min duration): (a) complete the QSU-Brief (10 items), (b) complete a noncraving questionnaire that was structurally identical to the QSU-Brief (scale-based control), and (c) a time-based control. Participants responded to an oral question assessing their degree of craving immediately before and after the manipulations. Results indicated that the QSU did not promote increases in craving compared to the 2 control conditions. Despite continuing debate over the most appropriate self-report measure of craving, investigators who use the QSU-Brief can be reasonably sure that the scores that result are not biased due to reactivity effects.

Cue exposure with coping skills training and communication skills training for alcohol dependence: 6- and 12-month outcomes.

AIMS: Cue exposure treatment (CET) has shown promise in preliminary studies with alcoholics, and Communication Skills Training (CST) has been found beneficial, especially in intensive treatment programs. The aim of the present study was to investigate the effects of CET and CST in a larger controlled study when both were added to intensive treatment programs. DESIGN AND INTERVENTIONS: A 2 x 2 design investigated the effects of CET with urge coping skills training compared to a meditation-relaxation control, and CST compared to an education control when all were added to intensive treatment programs for alcoholics. SETTING: The sites were the inpatient or partial hospital substance abuse treatment programs at a private psychiatric hospital, a state-funded residential facility and a VA medical center. PARTICIPANTS: Patients diagnosed with alcohol dependence without active psychosis were eligible. MEASUREMENTS: Participants were assessed for quantity and frequency of drinking, alcohol cue-reactivity, responses to high risk simulations and urge specific coping skills. FINDINGS: Of 100 treated patients, 86% provided 6-month and 84% provided 12-month follow-up data. Patients who received either CET or CST had fewer heavy drinking days in the first 6 months than control patients. In the second 6 months, CET continued to result in fewer heavy drinking days among lapsers and interacted with CST to decrease quantity of alcohol consumed. CST resulted in fewer alcohol-related problems reported at 12 months. CET resulted in greater reductions in urge to drink in a measure of simulated high-risk situations. CET also resulted in greater reports of use of coping strategies during the follow-up, and many of the urge-specific strategies taught in CET were associated with reduced drinking. CONCLUSIONS: Both CET and CST continue to show promise as elements of comprehensive alcohol treatment programs. Limitations and directions for future research are discussed.

Cognitive-behavioral treatment for depression in smoking cessation.

Cigarette smokers with past major depressive disorder (MDD) received 8 group sessions of standard, cognitive-behavioral smoking cessation treatment (ST; n = 93) or standard, cognitive-behavioral smokiig cessation treatment plus cognitive-behavioral treatment for depression (CBT-D; n = 86). Although abstinence rates were high in both conditions (ST, 24.7%; CBT-D, 32.5%, at 1 year) for these nonpharmacological treatments, no main effect of treatment was found. However, secondary analyses revealed significant interactions between treatment condition and both recurrent depression history and heavy smoking ( > or =25 cigarettes a day) at baseline. Smokers with recurrent MDD and heavy smokers who received CBT-D were significantly more likely to be abstinent than those receiving ST (odds ratios = 2.3 and 2.6, respectively). Results suggest that CBT-D provides specific benefits for some, but not all, smokers with a history of MDD.

Cognitive avoidance as a method of coping with a provocative smoking cue: the moderating effect of nicotine dependence.

Both nicotine dependence and coping are important determinants of smoking cessation, yet little is understood about mechanisms that link the two. This laboratory study investigated how nicotine dependence moderates execution of an avoidance coping strategy. High and low dependent smokers were exposed to a provocative smoking cue (in vivo) under two instructional sets: cognitive avoidance coping and no coping. Contrary to hypotheses, high dependent smokers reported greater increases in perceived self-efficacy to not smoke and also demonstrated greater facility in processing coping/nonsmoking-related information on a reaction time task, compared with low dependent smokers. These counterintuitive findings are discussed in terms of how nicotine dependence may affect the cognitive process of coping.

Individual differences in responses to the first cigarette following overnight abstinence in regular smokers.

We utilized cluster analysis to identify individual differences in response to the initial effects of smoking following overnight abstinence among 183 regular smokers. Participants smoked three cigarettes (1 mg nicotine, spaced 30 min apart) in standardized fashion and completed questionnaires about their subjective responses to each cigarette. Heart rate was monitored throughout the procedure. Participants were grouped into two clusters based on their reported subjective effects and heart rate changes to the first cigarette. Clusters differed in terms of greater increases in heart rate, reports of dizziness, sweating, unpleasantness, nausea, and buzzing sensations in one group compared to the other group. The smokers showing increased responses developed greater acute tolerance to the effects of smoking subsequent cigarettes on subjective negative effects and heart rate, and experienced greater negative affect after quitting. These results are partially consistent with a nicotine sensitivity interpretation or a tolerance model of the effects of initial smoking.

A content analysis of smoking craving.

The purpose of this study was to conduct a content analysis of smoking craving in order to investigate more precisely the subjective nature of the construct with the goal of informing assessment. Thirty-two smokers interested in cessation treatment provided free response written descriptions of the level of craving they normally experience. These responses were analyzed for subjective content along five theoretical domains: physiological, affective, cognitive, behavioral, and synonyms (of craving). Although there were no differences in the relative proportion of broad content terms smokers used to describe their craving (e.g., cognitive versus affective), this analysis revealed considerable diversity in the specific terms smokers used. Some smokers described their craving in purely physiological terms whereas others used primarily cognitive terms, and still others used affective terms. To assume that smoking craving is qualitatively similar across persons, then, may mask important variations that define the individual experience of craving.

Effect of different cue stimulus delivery channels on craving reactivity: comparing in vivo and video cues in regular cigarette smokers.

Exposure to smoking cues reliably produces increases in craving compared to exposure to appropriately matched neutral cues. While different types of stimuli have been used as cue materials in such studies, the channel through which cues are delivered is not often varied in a systematic fashion in smoking research. This study compared the effect of exposure to active in vivo cues compared to two cues, matched for content and time, delivered via videotape on self-reported smoking craving. Results revealed that active in vivo cues produced the highest Craving ratings. followed next by active video cues, and last by neutral video cues. These results suggest that craving is sensitive to stimulus delivery channel and that video presentation of smoking cues is a viable manipulation option in cue reactivity studies.

Stages of change versus addiction: a replication and extension.

Data from the Working Well trial (n = 2379) were used to test the capacity of 19 variables to predict smoking cessation at 1- and 2-year follow-ups. Among the core constructs of transtheoretical model (TTM), stage of change was the best predictor. The processes of change and the pros and cons of smoking were relatively ineffective predictors. Among other variables, self-efficacy, cigarettes per day, duration of longest quit attempt during the previous year, and the contemplation ladder were the most effective stand-alone predictors. A composite of cigarettes per day and quit duration was particularly effective for predicting cessation. Consistent with Farkas et al. (Farkas AJ, Pierce JP, Zhu SH, Rosbrook B, Gilpin EA, Berry C, Kaplan RM, Addiction 91:1271-1280, 1996), multivariate analyses including the composite variable (cigarettes per day and quit duration) and the stages of change revealed the composite variable to be the better predictor of cessation.

Human immunodeficiency virus infection, AIDS, and smoking cessation: the time is now.

Treatments for persons who are infected with human immunodeficiency virus (HIV) or who have developed AIDS have advanced to the point where death is no longer the inevitable outcome of diagnosis. Combination antiretroviral therapy has made HIV infection less of a terminal condition and more of a medically manageable chronic disease. Thus, efforts to improve the health status and quality of life of HIV-infected persons have become one of the highest treatment priorities for the next decade. Cigarette smoking is highly prevalent among HIV-infected persons, and quitting smoking would greatly improve the health status of these individuals. However, to date, no studies have evaluated the efficacy of a smoking-cessation intervention specifically tailored to this population. This article reviews the evidence and rationale for advancing smoking-cessation treatments specifically tailored to the needs of HIV-infected persons and provides recommendations for future treatment studies.

Transdisciplinary concepts and measures of craving: commentary and future directions.

A new theoretical model of craving is needed that uses a common language and standardized measures. The new conceptual model must fully integrate discoveries from cellular biology, neuroscience, animal and human laboratory, cognitive-behavioral social learning and socio-cultural disciplines. A transdisciplinary synthesis can then guide methods and measurement development. Mapping the structural pathways and interactions among mediators and moderators of craving will improve the diagnostic and prognostic tools in order to inform new treatments and prevention strategies.

Brief coping skills treatment for cocaine abuse: 12-month substance use outcomes.

Patients (N = 108) in a study of cocaine-specific coping skills training (CST), which was found to reduce cocaine use during a 3-month follow-up, were followed for an additional 9 months. CST involved coping skills training in the context of high-risk situations. Control treatment used meditation-relaxation. Both were added to comprehensive private substance abuse treatment. Patients in CST who relapsed had significantly fewer cocaine use days than did the control group during the first 6 months, then both conditions did equally well. Patients in CST also drank alcohol more frequently in the last 6 months than did contrast patients but did not differ in heavy drinking days. For cocaine use outcomes, no interaction of treatment was found with gender, education, route of administration, drug use severity, sociopathy, or depression. Implications include the need to investigate different lengths and combinations of treatment.