A pilot trial of In vivo NRT sampling to increase medication adherence in community corrections smokers
Introduction
Cigarette smoking prevalence rates within the U.S. have declined from 45% in the 1960s to about 18.1% of the population identified as current smokers over the past few years (CDC, 2014). However, smoking prevalence remains much higher in criminal justice populations (70–80%) (Cropsey et al., 2010, Cropsey et al., 2008). Nearly 12.3% of all current smokers are involved in the criminal justice system (Carson and Sabol, 2012, Cropsey et al., 2010). Few interventions have been tested with this population despite the fact that these smokers have high rates of comorbid mental and medical problems that are directly impacted by smoking (Carson and Sabol, 2012, Covey et al., 2007, U.S. Department of Health and Human Services, 1998). The few cessation trials that have been conducted demonstrate smoking abstinence rates of about 12% at one year follow-up (Cropsey et al., 2015, Cropsey et al., 2008). Adherence to medication in these studies was low, with less than half of participants taking the medications or using the NRT to optimal benefit (Cropsey et al., 2008, Cropsey et al., 2015).
Most people attempt to quit smoking without use of any medication (CDC, 2011), and among those who use, 69% prematurely quit medication use (Balmford, Borland, Hammond, & Cummings, 2011). Adherence to cessation medication is particularly problematic among individuals from disadvantaged populations, which predominate the criminal justice system (Balmford et al., 2011, Ferguson et al., 2011, Shiffman et al., 2008). African American smokers report less lifetime use of smoking cessation medications, and report more concerns about addiction potential, efficacy, and interactions with other medications relative to White, non-Hispanic smokers (Carpenter et al., 2011, Ryan et al., 2011, Shiffman et al., 2008, Shiffman et al., 2008). Negative perceptions of the healthcare system, low belief in the efficacy of medication, difficulty accessing services, and cost collectively undermine best practice medication use (Cutler and Everett, 2010, Kiortsis et al., 2000, Pieh-Holder et al., 2012, Roebuck et al., 2011, Sewell et al., 2012). Interventions to improve adherence in these populations have been identified as the single best means to address health disparities (Simeonova, 2013). In fact, adherence to smoking cessation pharmacotherapies more than triples the rate of abstinence (Cropsey et al., 2015, Shiffman et al., 2008, Raupach et al., 2014), highlighting the critical importance of developing interventions to increase medication adherence.
The majority of interventions designed to increase medication adherence have been psychoeducational and demonstrate small effects with little resultant behavioral change (DeFulio and Silverman, 2012, Demonceau et al., 2013, Halpern et al., 2013, McDonald et al., 2002, Van Camp et al., 2013, Viswanathan et al., 2012a, Viswanathan et al., 2012b). Similarly, medication adherence interventions in non-forensic samples that provide psychoeducation to increase adherence have been shown to increase attitudes and intentions to use NRT, but do not result in behavioral changes such as cessation (Ferguson et al., 2011, Juliano and Brandon, 2004, Mooney et al., 2006). Experiential sampling of NRT can improve perceptions of NRT over psychoeducation alone, but prior tests of this approach have not investigated effects on medication adherence and subsequent cessation (Schneider et al., 2006, Schneider et al., 2008). However, experiential interventions such as nicotine sampling with practice quit attempts (PQA) have resulted in changes in behavioral outcomes such as use of NRT, quit attempts, and cessation (Carpenter et al., 2011, Jardin et al., 2014). Nicotine sampling interventions provide an opportunity for smokers to try cessation medications for an abbreviated period (1–2 weeks), to learn more about the quit process, but with no pressure for immediate abstinence (Carpenter et al., 2011, Jardin et al., 2014). One limitation of this approach is that it still relies on the individual to use the NRT on their own with no assurance that they actually ever sample it. Additionally, if the individual experiences any unpleasant side effects, they may discontinue medication after only brief use. Thus, a more regimented, prescribed sampling experience could yield a stronger response.
The primary aim of this study was to pilot test a novel, experiential precessation treatment approach designed to increase NRT adherence during a subsequent quit attempt among smokers under community corrections supervision (e.g., probation, parole, etc.), who represent a disenfranchised group of smokers with poor medication adherence and low cessation outcomes. A secondary aim of this study was to examine smoking reduction and abstinence to determine potential effects of the intervention on smoking cessation behavior. Treatment involved NRT use under supervised, instructed conditions, and discussion surrounding NRT-related expectancies, negative side effects, and positive outcomes (e.g., relief from withdrawal and craving). Between sessions, experimental intervention participants were dispensed a week of medication to use for PQAs and to acclimate to the medication. It was hypothesized that this experiential approach coupled with PQAs would yield superior rates of NRT adherence and smoking cessation relative to standard behavioral therapy with combination NRT. It is important to note that the Control group received the same level of evidence-based medications, but did not undergo the structured, guided in vivo sampling experience.
Section snippets
Participants
Participants responded to flyers advertising the study at the community corrections office in Birmingham, Alabama. One hundred and seven participants were screened on the phone for inclusion and 47 smokers were scheduled for in-person screening. This study received approval from the University of Alabama at Birmingham Institutional Review Board and all participants provided written, informed consent prior to study procedures (see CONSORT diagram Fig. 1). Inclusion criteria included current
Demographics
The groups were largely comparable on most demographic and smoking characteristics. In vivo participants had significantly less education relative to Control participants. African American smokers were overrepresented in the In vivo group relative to the Control condition, although this difference only approached significance (p < 0.06). No differences between the two groups were found on prior quit attempts (p = 0.78). No other significant differences between the groups were noted. Race and
Discussion
This pilot trial of In vivo NRT sampling demonstrated initial feasibility and acceptability as evidenced by good retention through the intervention phase. The ability to administer NRT in-session with strong subjective improvements (craving, withdrawal) confirms the feasibility of providing an in-session experience with NRT that could be administered and detected in a relatively brief intervention. The In vivo sampling experience easily lends itself to widespread dissemination. The intervention
Funding information
This study was funded by the UAB Department of Psychiatry funds.
Conflict of information
All authors declare that they have no conflicts of interest.
Contributors
Peter S. Hendricks, Ph.D., Samantha Schiavon, M.A., Aaron Sellers, Morgan Froelich, Richard C. Shelton, M.D., Matthew J. Carpenter, Ph.D.
Acknowledgements
None.
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