<%BANNER%>

Internet-Based Group Contingency Management to Promote Abstinence from Cigarette Smoking

Permanent Link: http://ufdc.ufl.edu/UFE0044689/00001

Material Information

Title: Internet-Based Group Contingency Management to Promote Abstinence from Cigarette Smoking
Physical Description: 1 online resource (68 p.)
Language: english
Creator: Meredith, Steven E
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2012

Subjects

Subjects / Keywords: cigarette -- contingency -- group -- incentive -- internet -- smoking -- social -- support -- tobacco
Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: In contingency management (CM) interventions, monetary incentives are contingent on evidence of drug abstinence. Typically, incentives (e.g., “vouchers”) are contingent on individual performance. In Experiment 1,we programmed vouchers contingent on group performance and evaluated an Internet-based group CM intervention to promote smoking cessation. Thirteen participants were divided into 5 teams (n = 2-3 per team). Each participant submitted video recordings of breath carbon monoxide (CO) measures twice daily via the Internet. Teammates could monitor each other’s progress and communicate through an online peer support forum. During a 10-day Abstinence Induction condition, vouchers available on concurrently arranged independent and interdependent group contingencies were awarded to participants for CO samples indicative of abstinence (i.e., negative samples). Less than 1% of CO samples submitted during a baseline control condition were negative, compared to 57% submitted during Abstinence Induction. Experiment 2 isolated the effects of the monetary and social components of group CM. Thirty-two participants were divided into teams (n = 3 per team)and submitted breath CO measures twice daily during three 5-day within-subject treatment conditions. During the interdependent contingency condition, participants earned vouchers each time they and their teammates submitted negative samples.During the independent contingency condition, participants earned vouchers each time they submitted negative samples, regardless of their teammates’ performance. During the no vouchers condition, no monetary incentives were contingent on abstinence. Half of the participants (n= 16) could communicate with their teammates through an online discussion forum.Forum access did not improve primary treatment outcomes. Significantly more negative samples were submitted when vouchers were contingent on individual performance (56%)or team performance (53%) relative to when no vouchers were available (35%; F = 6.9, p = 0.002). Differences in the acceptability and cost of independent and interdependent contingencies are discussed.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Steven E Meredith.
Thesis: Thesis (Ph.D.)--University of Florida, 2012.
Local: Adviser: Dallery, Jesse.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2012
System ID: UFE0044689:00001

Permanent Link: http://ufdc.ufl.edu/UFE0044689/00001

Material Information

Title: Internet-Based Group Contingency Management to Promote Abstinence from Cigarette Smoking
Physical Description: 1 online resource (68 p.)
Language: english
Creator: Meredith, Steven E
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2012

Subjects

Subjects / Keywords: cigarette -- contingency -- group -- incentive -- internet -- smoking -- social -- support -- tobacco
Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: In contingency management (CM) interventions, monetary incentives are contingent on evidence of drug abstinence. Typically, incentives (e.g., “vouchers”) are contingent on individual performance. In Experiment 1,we programmed vouchers contingent on group performance and evaluated an Internet-based group CM intervention to promote smoking cessation. Thirteen participants were divided into 5 teams (n = 2-3 per team). Each participant submitted video recordings of breath carbon monoxide (CO) measures twice daily via the Internet. Teammates could monitor each other’s progress and communicate through an online peer support forum. During a 10-day Abstinence Induction condition, vouchers available on concurrently arranged independent and interdependent group contingencies were awarded to participants for CO samples indicative of abstinence (i.e., negative samples). Less than 1% of CO samples submitted during a baseline control condition were negative, compared to 57% submitted during Abstinence Induction. Experiment 2 isolated the effects of the monetary and social components of group CM. Thirty-two participants were divided into teams (n = 3 per team)and submitted breath CO measures twice daily during three 5-day within-subject treatment conditions. During the interdependent contingency condition, participants earned vouchers each time they and their teammates submitted negative samples.During the independent contingency condition, participants earned vouchers each time they submitted negative samples, regardless of their teammates’ performance. During the no vouchers condition, no monetary incentives were contingent on abstinence. Half of the participants (n= 16) could communicate with their teammates through an online discussion forum.Forum access did not improve primary treatment outcomes. Significantly more negative samples were submitted when vouchers were contingent on individual performance (56%)or team performance (53%) relative to when no vouchers were available (35%; F = 6.9, p = 0.002). Differences in the acceptability and cost of independent and interdependent contingencies are discussed.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Steven E Meredith.
Thesis: Thesis (Ph.D.)--University of Florida, 2012.
Local: Adviser: Dallery, Jesse.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2012
System ID: UFE0044689:00001


This item has the following downloads:


Full Text

PAGE 1

1 INTERNET BASED GROUP CONTINGENCY MANAGEMENT TO PROMOTE ABSTINENCE FROM CIGARETTE SMOKING By STEVEN E. MEREDITH A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2012

PAGE 2

2 2012 Steven E. Meredith

PAGE 3

3 To Mildred Hurlburt

PAGE 4

4 ACKNOWLEDGMENTS Michael Grabinski developed the software used in this research. Brantley Jarvis, Claire Spieler, Aaron Dumas, Amanda Watts, Alexa Vasquez, and Holly Wiggins helped with participant recruitment and data collection. Financial support was provided by the B.F. Skinner Foundation, the Society for the Advancement of Behavior Analysis, the American Psycholog ical Association, and the National Institute on Drug Abuse. I would also like to thank my grandmother, Mildred Hurlburt, for her encouragement and support of my college education. I thank my parents Douglas and Kathryn Meredith, for helping me achieve my ( expensive) academic goals I thank Matthew Locey for introducing me to the Experimental Analysis of Behavior. I thank my undergraduate and graduate advisor, Jesse Dallery, for challenging me to be a better scientist. Finally, I thank all the faculty a nd students in the Behavior Analysis program at the University of Florida for their guidance and inspiration.

PAGE 5

5 TABLE OF CONTENTS page ACKNOWLEDGMENTS .................................................................................................. 4 LIST OF TABLES ............................................................................................................ 7 LIST OF FIGURES .......................................................................................................... 8 ABSTRACT ..................................................................................................................... 9 CHAPTER 1 INTRODUCTION .................................................................................................... 11 2 EXPERIMENT 1 ..................................................................................................... 16 Methods .................................................................................................................. 16 Participants ....................................................................................................... 16 Materials ........................................................................................................... 18 Set up ............................................................................................................... 18 TM and CO Monitoring Procedure ........................................................... 19 Online Peer Support Forum .............................................................................. 20 Experi mental Design and Conditions ............................................................... 21 Baseline (A) ............................................................................................... 22 Tapering (B) ............................................................................................... 22 Abstinence induction (C) ............................................................................ 23 Exit Interview .................................................................................................... 23 Data Analysis ................................................................................................... 24 Results .................................................................................................................... 25 CO Data ........................................................................................................... 25 Contingent Reinforcement Earned ................................................................... 26 Support Forum Data ......................................................................................... 27 Treatment Acceptability Data ........................................................................... 28 GEQ Score ....................................................................................................... 28 Discussion .............................................................................................................. 28 3 EXPERIMENT 2 ..................................................................................................... 38 Methods .................................................................................................................. 38 Participants ....................................................................................................... 38 Materials ........................................................................................................... 39 Set up ............................................................................................................... 40 v8TM and CO Monitoring Procedure ........................................................... 40 Experimental Design ........................................................................................ 40 BetweenSubject Treatment Conditions ........................................................... 41 Forum access. ........................................................................................... 41

PAGE 6

6 No forum access. ....................................................................................... 41 Within Subject Treatment Conditions ............................................................... 42 No vouchers. .............................................................................................. 42 Independent contingency. .......................................................................... 42 Interdependent contingency ....................................................................... 43 Exit Interview .................................................................................................... 44 Data Analysis ................................................................................................... 44 Participant characteristics .......................................................................... 44 Primary outcome measures ....................................................................... 44 Secondary measures ................................................................................. 45 Results .................................................................................................................... 46 CO Data ........................................................................................................... 46 Contingent Reinforcement Earned ................................................................... 48 Support Forum Data ......................................................................................... 49 Treatment Acceptability Data ........................................................................... 50 GEQ and NTB Measures .................................................................................. 50 Discussion .............................................................................................................. 51 4 GENERAL DISCUSSION ....................................................................................... 57 LIST OF REFERENCES ............................................................................................... 62 BIOGRAPHICAL SKETCH ............................................................................................ 68

PAGE 7

7 LIST OF TABLES Table page 2 1 Participant charact eristics. .................................................................................. 33 2 2 Forum Posts. ...................................................................................................... 34 2 3 Treatment acceptability. ..................................................................................... 35 3 1 Participant characteristics. .................................................................................. 54 3 2 Percentage of negative samples. ....................................................................... 54

PAGE 8

8 LIST OF FIGURES Figure page 2 1 Withi n subject breath CO level (ppm) ................................................................. 36 2 2 Percentage of samples negative for breath CO ................................................. 37 3 1 Percentage of negative samples across conditions.. .......................................... 55 3 2 Percentage of negative sa mples across weeks in treatment .............................. 55 3 3 Consecutive negative samples.. ......................................................................... 56

PAGE 9

9 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy INTERNET BASED GROUP CONTINGENCY MANAGEMENT TO PROMOTE ABSTINENCE FROM CIGARETTE SMOKING By Steven E. Meredith August 2012 Chair: Jesse Dallery Major: Psychology In contingency management (CM) interventions, monetary incentives are contingent on evidence of drug abstinence. Typically, incentives (e.g., vouchers) are conting ent on individual performance. In Experiment 1, we programmed voucher s contingent on group performance and evaluated a n Internet based group CM in tervention to promote smoking cessation. Thirteen participants were divided into 5 teams ( n = 2 3 per team). Each participant submitted video recordings of breath carbon monoxide ( CO ) measure s twice daily via the Internet. Teammates could monitor each others progress and communicate through an online peer support forum. During a 10day Abstinence Induction condition, voucher s available on concurrent ly arranged independent and interdependent group contingencies were awarded to participants for CO samples indicative of abstinence (i.e., negative samples ) Less than 1% of CO samples submitted during a baseline control condition were negative, compared to 57% submitted during Abstinence Induction. Experiment 2 isolate d the effects of the mone tary and social components of group CM. Thirty two participants were divided into teams ( n = 3 per team) and submitted breath CO measures twice daily during three 5day within subject treatment conditions During the i nterdependent contingency

PAGE 10

10 condition, participa nts earned voucher s each time they and their team mates submitted negative samples. During the independent contingency condi tion, participants earned voucher s each time they submitted negative samples, regardless of their team mates performance. During the no vouchers condition, no monetary incentives were contingent on abstinence. Half of the participants ( n = 16) could communicate with their teammates through an online discussion forum Forum access did not improve primary treatment outcomes. Significantly more negative samples were submitted when voucher s were contingent on individual performance (56%) or team performance (53% ) relative to when no voucher s were available (35%; F = 6.9, p = 0.002). D ifferences in the acceptability and cost of i ndependent and interdependent contingencies are discussed.

PAGE 11

11 CHAPTER 1 INTRODUCTION Cigarette smoking is the leading cause of preventable morbidity and mortality in the United States, resulting in 443,000 deaths each year and costing $193 billion in annual healthrelated economic losses ( US Department of Health and Human Services, 2004). Although 70% of smokers report a desire to quit, less than 7% ar e successful each year d espite the availability of an increasing number of over the counter and prescription pharmacotherapies (Fiore et al., 2008; Schwartz, 1992) Thus, s everal researchers have argued that more intensive behavioral inter ventions are need ed to curb the smoking epidemic (Fiore et al.; Sigmon, Lamb, & Dallery, 2008; Stitzer, 1999). Contingency management (CM) is one such intervention. CM interventions typically deliver monetary incentives to substance users contingent on objective evidence of drug abstinence (see Higgins, Silverman, & Heil, 2008 for a review ). This incentivebased treatment strategy emerged from the field of operant psychology (i.e., behavior analysis). Thus, r esearchers and practitioners who utilize this treatment approach, rely on a conceptually systematic framework consisting of traditional operant learning theory (Skinner, 1938, 1953, 1957) and more contemporary theories of choice that emerged from this paradigm including delay discounting (Mazur, 1987) and behavioral ec onomic theories ( Hursh, 198 4 ). CM capitalizes on the fundamental observation that drug use, like any other operant behavior, is influenced by the consequences it produces (Bigelow & Silverman, 1999; Griffiths, Bigelow, & Henningfield, 1980; Schuster & Thom pson, 1969). Thus, when using CM knowledge gleaned from a vast literature of laboratory and clinical research

PAGE 12

12 on operant behavior can be applied to the treatment of drug use (Higgins, Budney, & Bickel, 1994). Operant theory predicts that as long as incent ives are available in sufficient magnitude and delivered on a schedule incompatible with drug use, they can be used to promote abstinence from any abused substance (Roll, Higgins, & Badger, 1996). In many CM interventions designed to promote abstinence fro m cigarette smoking, incentives exchangeable for goods or services are delivered to smokers contingent on biochemical verification of smoking reduction or cessation. Breath carbon monoxide (CO) is often used for verification of abstinence because it is a relatively immediate and acute measure of smoking status. This method of CM has been shown to promote smoking cessation in a number of studies (e.g., Alessi, Badger, & Higgins, 2004; Dallery, Glenn, & Raiff, 2007; Dunn et al., 2008; Higgins et al., 2004; R oll & Higgin s, 2000; Roll et al. 1996; Tidey, ONeill, & Higgins, 2002). Moreover CM has been shown to promote abstinence from cocaine opiates, alcohol, marijuana, and polydrug use (Lussier, Heil, Mongeon, Badger, & Higgins, 2006; Stitzer & Petry, 2006) In fact, a n extensive literature consisting of empirical reports spanning several decades as well as independent reviews of the substance abuse treatment literature suggest that CM is one of the most efficacious treatments available for drug dependence ( Dutra et al., 2008; McGovern & Carroll, 2003; Prendergast, Podus, Finney, Greenwell, & Roll, 2006). Despite robust evi dence attesting to the efficacy of CM as a substance abuse treatment, this behavioral intervention is used by community based treatment providers only 1125% of the time (Benishek, Kirby, Dugosh, & Padovano, 2010 ; McGovern, Fox, Xie, & Drake, 2004). One possible barrier to dissemination is response effort. Frequent

PAGE 13

13 assessment of substance use is an important feature of CM program s, requirin g considerable effort from both patients and practitioners. In the case of cigarette smoking, breath CO samples must be collected at least twice daily to accurately assess smoking status. This frequent schedule of assessment is necessary due to the short h alf life of breath CO (i.e., about 3 6 hours; Benowitz et al., 2002; Deller, Stenz, Forstner, & Konrad, 1992; Joumard, Chiron, Vidon, Maurin, & Rouzioux, 1981) and to minimize delays between reinforcement and alternative nondrug behavior (Bigelow & Silver man, 1999). However, r outine clinic visits m ight not be feasible for many patients due to distance, lack of transportation, clinic hours, or other practical constraints. To overcome these obstacles, Dallery and colleagues developed an Internet based CM program to promote smoking cessation (Daller y & Glenn, 2005; Dallery, Glenn, & Raiff 2007 ; Dallery, Meredith, & Glenn, 2008; Reynolds Dallery, Shroff, Patak, & Leraas, 2008; Stoops et al., 2009). Participants submitted video breath CO measures twice dail y via user friendly Internet technology, and abstinence was reinforced with vouchers exchangeable for goods from various Internet vendors. The Internet based system successfully overcame distance as a barrier even promoting abstinence among smokers living in rural Appalachia, Kentucky (Stoops et al. ). Although the Internet based treatment model allowed researchers to circumvent several barriers to implementing CM in an out patient setting this model did not address other potential limitations associated wi th incentivebased treatment. For example, several authors have argued that incompatibility between CM and standard care is a substantial barrier to dissemination (Hartzler, Lash, & Roll, 2012; Roll, Madden, Rawson, & Petry, 2009). Although CM is typically evaluated under controlled conditions

PAGE 14

14 when it is delivered to individual substance users, m any substance abuse treatment programs rely on group oriented therapies, including the 12 step approach (Benishek, et al. 2010). Th us integrating CM with groupcentered treatment may help promote dissemination. Indeed, s everal researchers have recently begun investigating methods for integrating CM into group therapy (Petry, Weinstock, & Alessi, 2011; Petry, Weinstock, Alessi, Lewis, & Diekhuas, 2010). One strategy is to program monetary incentives contingent on group therapy attendance (Alessi Hanson, Wieners, & Petry, 2007; Ledgerwood, Alessi Hanson, Godley, & Petry, 2008). Another promising strategy is to integrate monetary group contingencies into the incentive schedules used to promote drug abstinence (Kirby, Kerwin, Carpendo, Rosenwasser, & Gardner, 2008). Several types of group contingencies have been described in the applied behavior analysis literature (Cooper, Heron, & Heward, 2007; Litow & Pumro y, 1975). I ndependent group contingencies are arranged when programmed consequences are contingent on individual performance, but the contingencies are appli ed simultaneously to all members of a group. Dependent and Interdependent g roup contingencies are t hose in which the behavior of one or more group member determine s the consequences received by at least one other group member (Speltz, Shimamura, & McReynolds, 1982, p. 533). One advantage of these contingencies is that they may promote social support s uch as cooperation or abstinencecontingent praise ( Gresham & Gresham, 1982; Williamson, Williamson, Watkins, & Hughes, 1992). S ome evidence suggests that social incentives such as these may promote smoking cessation (Baha & Le Fa ou, 2010; Chen White, & P andina, 2001; Christakis & Fowler, 2008; Cohen & Lichtenstein, 1990; Hennrikus et al., 2010; Ji et al., 2005; Mermelstein, Cohen,

PAGE 15

15 Lichtenstein, Baer, & Kamarck 1 983; M lle r Pedersen, Villebro, & N rgaard, 2003; Westmaas, Wild, & Ferrence, 2002). Moreover, research indicates that practitioners are m ore willing to adopt treatments that use social incentives over those that use tangible incentives (Kirby, Benishek, Dugosh, & Kerwin, 2006). The purpose of Experiment 1 was to develop and test an Internet based group CM program to promote smoking cessation. We integrated independent and interdependent group contingencies and an online peer support forum into an existing Internet based intervention (Stoops et al., 2009). T his experiment demonstrated the feasibility, acceptability, and preliminary efficacy of Internet based group CM However, data from this experiment could not be used to assess the independent effects of social support and monetary group contingencies on smoking cessation. Thus, Experiment 2 was conducted to isolate the effects of these variables on cigarette smoking.

PAGE 16

16 CHAPTER 2 EXPERIMENT 1 Methods Participants Participants were 13 healthy smokers (4 Female) recruited from Gainesville FL and surrounding communities through print media and word of mouth. Qualified applicants were between 18 and 60 years of age, had Internet access from their home, reported a minimum 2year smoking history, and expressed a desire to quit smoking (i.e., answered affirmatively to the question, Do you want to quit smoking? ; Perkins, Stitzer, & Lerman, 2006). Interested applicants were screened over the phone for basic qualifying criteria such as having home Internet access and being a current smoker. Qualified applicants were scheduled for an inperson intake session. During intake, applicants provided informed consent and completed several questionnaires, including a psychosocial history survey which contained questions related to demographics, smoking history, drug use, psychological and physical health, and the Fagerstrm Test for Nicotine Depen dence (FTND). The FTND is a 6 item questionnaire that assesses nicotine dependence with a scale ranging from 010 (higher scores representing greater dependence; Fagerstrm & Schneider, 1989). Urine samples were collected during intake and analyzed for the presence of cocaine, benzodiazepines, and opiates. Applicants were excluded from participating in the study if th ey showed evidence of current alcohol dependence or drug use, smoked marijuana more than twice per month, or reported a history of medical or psychiatric illness that, in our judgment, would

PAGE 17

17 interfere with study participation. Women were disqualified if th ey were pregnant or breastfeeding. The University of Florida Institutional Review Board approved all study procedures. A total of 15 participants were recruited. These participants were divided into small groups or teams (n = 23). Three teams were compr ised of 3 participants. However, because 1 participant could not be contacted prior to the set up procedure, and another participant withdrew from the study during baseline (citing cancellation of her Internet service provider as the reason for her withdrawal), two teams completed the study with only 2 participants each. Only data for the 13 participants (4 female) who completed the study are included in the Results. Individual participant characteristics are presented in Table 2 1. Participants were assig ned to their teams based on the order in which they qualified to participate in the study. According to self report data collected at Set up none of the participants knew each other prior to study commencement. However, if a participant knew someone else who was participating in the study, a policy was in place to assign those participants to different teams. There were a number of reasons that only unfamiliar participants were assigned to the same team. First, familiar participants could potentially provi TM Group Support Forum; thus, researchers would be unable to collect data on such interactions if they occurred. Second, social interactions could possibly turn aggressive outside of the online forum; therefore, it was important to take extra precautions to protect participants anonymity and confidentiality. Third, familiarity with teammates could be an important independent variable that should be investigated in future studies.

PAGE 18

18 Participants assigned to the same team were required to begin the study on the same day; thus, teammates could not begin participating until a group of 3 qualified applicants was ready to participate. Consequently, relatively small team sizes were employed to minimize the delay between study qualification and the onset of treatment. Materials Carbon monoxide monitors (Bedfont piCO+ Smokerlyzer) were loaned to each participant. Webcams (Creative Live! Cam Optia) and laptops (Asus Eee PC) were also loaned to those par ticipants who needed them; however, most participants used their own webcams and/or computers. For security purposes, copies of participants drivers licenses were obtained, and participants were asked to sign an off campus property contract stating that they would return the equipment. All equipment was returned. Set up Before the intervention began, researchers set up the necessary equipment in participants residences and demonstrated how to use the software, including how to submit a video CO sample and how to post a comment on the online peer support forum. Participants were then required to practice both of these tasks in the presence of a researcher. Participants were also provided with the National Cancer Institutes booklet, Clearing the Air (a guide to quitting smoking; http://www.smokefree.gov/pubs/ Clearing TheAir_acc.pdf ), and an instruction manual that included a detailed description of all study procedures. Participants wer e required to pass a quiz demonstrating that they read and understood all st udy procedures (Silverman, Chutuape, Bigelow, & Stitzer 1999).

PAGE 19

19 TM and CO Monitoring Procedure Participants were asked to submit video samples of breath CO measur ements twi ce daily (minimum 8 h inter sample interval). TM, a web based application, enabled collection of the videos. Participants logged into the secure TM website using the unique usernames and passwords that were assigned to each of them at s et up. After logging in, the website directed participants to a personalized homepage. From this homepage, participants could access several features of the website, including their account history which listed any incentives earned or spent during the study, a link to an online peer support forum through which they could communicate with teammates, a quantitative progress graph (a graphical representation of CO levels submitted over the course of the study), a link to teammates quantitative progress graphs, and a Post Video button that was active only if participants had not yet submitted two videos that day and if 8 hr had passed since the last video submission. When participants were ready to submit a sample, they clicked on the Post Video button and followed the simple stepby step, onscreen instructions. After turning on the CO monitor and webcam, participants were instructed to complete the following steps: 1) take a deep breath, 2) activate the countdown feature of the CO monitor, 3) hold breath for 15 s, 4) exhale into the monitor loud enough for the audible hiss to be detected by the microphone, and 5) show the digital display of the final CO level to the webcam. Participants would then manually enter the CO measurement into the website using the computer keyboard. Although participants were instructed to follow this series of steps to ensure that accurate CO measurement was obtained, the procedure was relatively quick and easy; that is, it took less than 2 m to complete, and most

PAGE 20

20 participants learned the steps after only one or two practice submissions. A software feature allowed playback of the videos so participants could review the content. Once participants were satisfied with their videos, they could click the Post button. The website i mmediately directed them to a screen that thanked them for submitting the sample and, when appropriate, informed them of any incentives earned for submitting the sample. Participants were then directed back to their homepage which included an updated quantitative progress graph and account history. Participants were notified during set up that attempts to falsify a sample were easily detected and would lead to dismissal from the study. Online Peer Support Forum From their homepages, participants could click a link that would direct them to the TM Group Support Forum. Here they could post comments or read comments posted by their teammates or by the forum moderator (participants were unable to view or reply to the comments made by participants ass igned to other teams) Each post could be viewed by every member of the team and the forum moderator. Participants were instructed to use their usernames, not their real names, on the forum. Participants also received the following guidelines for communica ting via the online peer support forum: Make sure your posts are supportive in nature. Posts that are discouraging or offensive will not be allowed. Keep in mind you want to help encourage other group members to quit smoking. You should congratulate them when they make progress toward this goal! Posts that were considered negative by the moderator were removed from the discussion thread (only one comment met the c riteria for a negative post, Table 2 2).

PAGE 21

21 The moderator posted comments on the forum approxim ately twice per experimental condition. These posts were similar across teams and often included re minders of condition changes or smoking cessation tips and strategies recommended by the Clearing the Air booklet (i.e., informational support [Cohen, 2004] ) and praise for meeting treatment goals (i.e., emotional support [Cohen] ) Participants also had access to their teammates quantitative progress graphs TM homepage. This feature allowed participants to see when their teammates met their goals, so they could provide them with appropriate social consequences through the forum (e.g., abstinencecontingent praise) Experimental Design and Conditions A within subject, nonconcurrent multiple baseline design was used to evaluate performance during three conditions. Baseline (A) was followed by two treatment conditions: tapering (B) and abstinence induction (C). The introduction of the first treatment condition occurred after different baseline durations across teams. Th at is, one team experienced a 2day baseline, another team experienced a 3day baseline, and so on, up to 6 days. This arrangement specifies a multiple baseline design. The power of the multiple baseline design is derived from demonstrating that behavior change occur s when, and only when, the intervention is directed at a particular individual or team (Barlow, Nock, & Hersen, 2009). Thus, if the intervention is efficacious, the design will show that the change in the independent variable, and not some other factor, resulted in the change in the dependent variable relative to baseline. The influence of other factors such as history or self monitoring can be ruled out by replicating the effect across multiple individuals or teams with differing baseline durations.

PAGE 22

22 A non concurrent design was chosen to minimize the delay participants experienced between study qualification and participation. Requiring all teams to begin the intervention simultaneously would have substantially increased the delay between the participant application process and the onset of treatment. Therefore, not all teams began the intervention at the same time; rather, each team began as soon as 3 applicants qualified and were ready to participate. Baseline (A) This condition lasted between 2 and 6 day s across teams. No incentives were available during baseline; however, participants had access to all other features of the intervention (i.e., Internet based monitoring, teammates quantitative progress graphs, TM Group Support Forum, the Cleari ng the Air booklet, etc.). Tapering (B) During this 4 day condition, monetary incentives (i.e., electronic vouchers exchangeable for goods) were contingent on specified reductions in breath CO (Dallery et al., 2007). The reductions were determined as fol lows. First, the average baseline CO was calculated for each participant. Then, progressively lower CO values were calculated such that over eight samples, the last tapering criterion (i.e., goal) was 4 ppm (the abstinence threshold used in the current study; Javors et al. 2005). An independent group contingency was arranged such that each participant who submitted a CO sample less than or equal to his/her tapering goal earned a $1.50 voucher. In addition, an interdependent group contingency was arranged such that each participant earned a $1.50 team bonus voucher if and only if every member of the team met their respective tapering goal for the scheduled sample. Two concurrently arranged contingencies, such as these, specify a mixed contingency arrangement.

PAGE 23

23 Abstinence induction (C) During abstinence induction, the final 10 days of the intervention, an independent contingency was arranged such that participants earned vouchers on an escalating schedule of reinforcement (Roll et al., 1996) contingent on submission of breath CO samples indicative of abstinence. Participants earned a $1.50 voucher for the first CO Each consecutive negative sample resulted in a $.25 increase in voucher value. In other words, the first negative sample resulted in a $1.50 voucher, the second resulted in a $1.75 voucher, the third resulted in a $2.00 voucher, and so on. If a participant missed a sample submission or submitted a positive sample, the value of the voucher contingent on the next negative sample was reset to the initial amount (i.e., $1.50; Roll & Higgins, 2000). The voucher magnitude then returned to the highest previous level following two consecutive negative sample submissions. An interdependent group contingency was concurr ently arranged such that each time every member of a team submitted a negative sample, they all received a $3.00 team bonus voucher. Exit Interview An exit interview was conducted with each participant within 1 week following study completion. Researchers collected equipment and participants complete d several questionnaires including a behavioral change inventory and a treatment acceptability questionnaire. Participants also completed the Group Environment Questionnaire (GEQ), a 5 item questionnaire with a 9point Likert scale modified from an instrument developed by Estabrooks and Carron (1999) to assess group cohesion (higher scores representing greater cohesion among group members). Finally, participants completed a questionnaire documenting any communication with group members outside the

PAGE 24

24 online peer support forum. There were no reported instances of external communication between participants. Researchers discussed voucher earnings and purchases with participants at the exit interview. During Set up, participants were instructed to notify researchers if they wished to make a purchase with their vouchers during the study; however, none of the participants made any purchases until after they completed the study. Items were purchased from online vendors ( e.g., Amazon.com) and gift cards were purchased from local businesses (e.g., Best Buy). Participants could not purchase firearms, alcohol, or tobacco products with their vouchers. Data A nalysis A one way repeated measures analysis of variance (ANOVA) was calculated on the percentage of breath CO measures ppm (negative samples) with condition (baseline, tapering, and abstinence induction) as a factor. The mean percentage of negative samples was calculated for each condition, with missing samples consi dered positive. Planned pairwise comparisons of the mean percentage of negative CO samples were then made with the Bonferroni procedure between baseline and tapering, baseline and abstinence induction, and tapering and abstinence induction. Pearson product moment correlations were calculated to detect correlations between breath CO measures and potential predictors of treatment success, including: age, income, FTND score, CO at intake, years smoked, and average number of cigarettes smoked per day prior to i ntake. Correlations were also calculated to detect relationships between breath CO measures and GEQ score. In addition, the data were analyzed for correlations between breath CO measures and various variables related to quantity and quality of support foru m posts, including: the number of posts created by

PAGE 25

25 an individuals teammates, the number of posts created by his/her entire team (i.e., including his/her own posts), the percentage of posts rated as positive that were created by an individuals teammates, and the percentage of posts rated as positive that were created by his/her team. Finally, correlations were calculated to detect relationships between GEQ score and quality and quantity of support forum posts. Support forum posts were rated as positive, negative, or neutral based on a scale developed by Speltz et al. (1982). Positive posts were defined as compliments; statements of friendship, concern, congratulations, gratitude, or encouragement; statements of excitement about quitting; and/or requests or offers for assistance or instruction. Neutral posts were defined as posts that reflect general discussion and/or nondirected posts. Negative posts were defined as namecalling or swearing at peers, ridiculing a peers lack of progress, threats of physical aggression, posts that reflect disgust or disapproval, and/or posts intended to antagonize or frighten peers. A single post often included multiple comments. If a post contained both positive and neutral comments, the post was rated as positive. If a pos t contained a negative comment and positive and/or neutral comments, the post was rated as negative. Two independent observers rated all forum posts. Interobserver agreement (IOA) was calculated by subtracting the number of disagreements from the total num ber of posts, dividing this number by the total number of posts, and multiplying by 100. Results CO Data There was a significant effect of condition on breath CO ( F = 25.77; p < 0.001). Figure 2 1 shows the CO data for each participant. Reductions in CO were reliably observed across participants during tapering and abstinence induction relative to

PAGE 26

26 baseline. Ten participants (C30, M39, K43, K59, B60, J25, K27, E33, D63, and S45) abstinence induction. Four of these participants (C30, M39, K27, and S45) day abstinence induction condition (these 4 participants also reported smoking 0 cigarettes during the previous 7 days on a behavioral change inventory administered during the exit interview). M48 showed substantial reductions in breath CO, but no period of continuous abstinence. E66 showed initial reductions in CO during tapering and at the onset of abstinence induction, but immediately thereafter returned to near baseline CO levels and repeatedly missed sample submissions. The intervention had little effect on T47s CO who, like E66, also missed several sample submissions during abstinence induction. Figure 22 shows that less than 1% of CO samples that were submitted during baseline were negative; whereas, 57% of samples that were submitted during abstinence induction were negative (missing samples were considered positive). Bonferronis planned comparisons revealed a sig nificant increase in the percentage of negative CO samples in abstinence induction relative to baseline and relative to tapering. These comparisons did not, however, reveal a significant difference in the percentage of negative CO samples between baseline and tapering conditions. Pearson product moment correlations revealed no significant relationships between percentage of negative CO samples submitted during abstinence induction and any of the pot ential predictor variables we tested Contingent Reinforce ment E arned Participants who submitted breath CO samples twice per day for 14 days during the tapering and abstinence induction conditions had 28 opportunities to earn vouchers.

PAGE 27

27 On average, participants met the independent contingency of reinforcement on 60% of these occasions and the interdependent contingency on only 29% of these occasions. During abstinence induction, participants met the interdependent contingency requirement on 46% of negative sample submissions. In other words, although 100% of negat ive samples submitted during abstinence induction resulted in a voucher, the majority of these submissions did not result in a team bonus voucher. If participants met the independent and interdependent contingency criteria on each available opportunity, th ey could earn $161.50 each over the course of the study. Participants earned an average of $58.38 each ( SD = 39.36). Thus, the average daily cost in vouchers was $4.17 per participant during the 14day treatment. Eleven of 13 participants purchased gift ca rds from local businesses with their vouchers. The remaining 2 participants elected to have specific items (e.g., electronics, tools, etc.) shipped to them from online vendors. Support Forum D ata Over the course of the study, 128 posts were made by participants on the online peer support forum ( M = 9.8, SD = 5.7). Sixty five percent of posts were rated as positive, 34% were rated as neutral, and less than 1% were rated as negative (IOA = 87%). Table 2 2 shows the percentage of positive, neutral, and negative posts, the number of each type of post recorded during the study, and several samples of TM Group Support Forum. A modest correlation was found between the percentage of negative CO samples submitted during abstinence induction and the percentage of team support forum posts during the same condition that were rated as positive ( r = .696, p = .008). This relationship was no longer observed, however, when participants own forum posts were

PAGE 28

28 removed from analys is. That is, there was no significant correlation between the percentage of negative CO samples submitted by a participant during abstinence induction and the percentage of his/her teammates support forum posts that were rated as positive ( r = .503, p = 08). No other relationships were observed between the quantity or quality of forum posts and CO. Treatment A c ceptability D ata Table 2 3 shows data collected from the treatment acceptability questionnaire. The Internet based intervention was rated as easy t o use ( M = 82.7, SD = 17.9) and convenient ( M = 77.9, SD = 14.5). On average, participants rated the quantitative progress graph as the most favorable treatment component ( M = 86.6, SD = 19.7), and the moderated online peer support forum as the l east favor able component ( M = 54.3, SD = 24.7). Participants ratings of how much they liked earning vouchers based on their teams performance ( M = 76.9, SD = 22) were not significantly different than their ratings of how much they liked earning vouchers based only on individual performance ( M = 83.3, SD = 17.2; F = 0.965; p = 0.35). GEQ S core Mean GEQ score was 5.7 ( SD = 1.8), representing, on average, moder ate group cohesion across teams. No correlations were observed between GEQ scores and forum posts or between GEQ scores and CO. Discussion The results of Experiment 1 suggest that combining group contingencies and online peer support with Internet based CM to promote abstinence from cigarette smoking is a feasible treatment strategy. Reliable reductions in breath CO were observed across participants during treatment conditions relative to baseline, and 10 out

PAGE 29

29 of 13 partic ipants demonstrated some sustained period of abstinence during the 10day abstinence induction condition. Figure 2 1 shows that reductions in breath CO were a function of the experimenter arranged contingencies and not some other variable (e.g., history or self monitoring). When vouchers wer tapering and during abstinence induction, the majority of participants began submitting negative CO samples. Despite each team experiencing variable baseline durations, 9 of the 12 participants who submitted at least one negative sample (C30, M39, K43, M48, K59, B60, K27, E33, and E66) submitted the first one on the last day of tapering or on the first day of abstinence induction. Thus, the multiple baseline design not only allowed us to evaluate the feasibil ity of the intervention, it also allowed us to demonstrate preliminary efficacy. The results of the study also indicate that group CM is an acceptable form of treatment. On average, participants reported liking all of the treatment components, including the interdependent contingency ( Table 2 3). In fact, participants reported that they liked earning vouchers contingent on their teams performance ( M = 76.9, SD = 22) almost as much as they liked earning vouchers independent of their teams performance ( M = 83.3, SD = 17.2). This was somewhat unexpected given that vouchers contingent on team performance were earned far less frequently than those contingent on individual performance. Yet, despite only limited contact with the interdependent contingency, par ticipants reported that the overall intervention was fair ( M = 85.9, SD = 14.2).

PAGE 30

30 Not all of the treatment components were rated quite as favorably as the vouchers. Participants rated the online peer support forum as the least favorable ( M = 54.3, SD = 24. 7) and least helpful ( M = 56.6, SD = 22.1) treatment component ( Table 2 3). According to responses to openended questions on the treatment acceptability questionnaire, the most common objection to the forum was a lack of participation by teammates. Althou gh most participants posted comments on the forum regularly, they did so relatively infrequently. The mean number of posts per participant was 9.8 ( SD = 5.7) over the course of the intervention (i.e., roughly one post every other day). As might be expected median number of forum posts), rated the forum as more favorable ( M = 66.5, SD = 17.6) and more helpful ( M = 66.9, SD = 18) than did others. Social e xchanges on the support forum were quite positive. In fact 65% of posts were rat ed as positive. This finding is of particular interest given the criticism that group contingencies have the potential to promote undesirable or negative behavior among participants (e.g., threats or aggression; Romeo, 1998). In the current study, however, only one instance of negative behavior was observedJ25 posted a negative comment on the support forum directed at his teammate, E33. Notably this post was unrelated to the interdependent contingency arrangement In other words, the negative post was not evoked by E33 s failure to meet the interdependent contingency requirement. Rather, E33s lack of forum participation ev oked the negative response ( Table 2 2) In fact E33 was demonstrating a period of continuous abstinence at the time J25 posted the negative comment.

PAGE 31

31 The results of Experiment 1 suggest that Internet based group CM is not only feasible and acceptable, but convenient as well. Although researchers were based at the University of Florida Smoking Laboratory and Clinic in Gainesville, Florida, several participants lived in surrounding North Central Florida communities and/or traveled in and outside the state while participating in the study. For example, C30 and K27 each lived 68 kilometers from the clinic (Table 2 1). During the study, both of these participants spent several days in Orlando, Florida (> 200 kilometers southeast of Gainesville), and S45 spent a week in Athens, Georgia (> 500 kilometers north of Ga inesville). However, because treatment was delivered via the Internet, smokers who lived considerable distances from the clinic were able to participate, and treatment was not interrupted by travel. One major limitation of Experiment 1 is that the results cannot be used to dissociate the effects of independent and interdependent group contingencies on smoking cessation The mixed contingency that was arranged by researchers in Experiment 1 is advantageous, because it combines the benefits of both independe nt and interdependent contingencies of reinforcement. That is, the independent group contingency ensures precise correspondence between abstinence and experimenter delivered consequences, while the interdependent group contingency may promote collateral social behavior This mixed contingency, however, does not permit us to identify the relative advantages of the independent and interdependent contingencies. Indeed, the outcomes observed in Experiment 1 may have been a function of the independent contingency alone. An independent group contingency is similar to an individual contingency of reinforcement, and Internet based CM programs that employ

PAGE 32

32 only individual contingencies have already been demonstrat ed efficacious (e.g., Dallery et al. 2007). Thus, one aim of Experiment 2 was to determine the effects of interdependent group contingencies alone on smoking cessation. Another aim of Experiment 2 was to determine the effects of social support on smoking cessation. Although t he positive social exchanges observed in Experiment 1 suggest that smokers are willing to use an online discussion forum to support one another during their quit attempts the effects of this support on smoking cessation remain unclear. Few relationships were observed between measures of social support and abstinence in Experiment 1. I t is possible that such relationships were not detected because the effects of the monetary contingencies masked the effects of other variables on smoking cessation Thus, social and monetary contingencies were isolated in Experiment 2.

PAGE 33

33 Table 2 1. Participant charact eristics. Team ID Sex Age Race/ethnicity Education Weekly income Cigs/ day CO FTND Kilometers from clinic 1 C30 F 50 White Some college $501 600 18 23 4 64 M39 M 49 White College graduate $501 600 28 23 9 8 K43 M 22 Asian Graduate school <$100 18 12 7 5 2 M48 M 21 Hispanic Some college $100 200 20 34 5 5 K59 F 20 White Some college $201 300 20 11 4 3 B60 M 29 White Graduate school $401 500 20 21 5 5 3 J25 M 37 White Some college <$100 12 20 6 5 K27 M 27 White Some college $100 200 10 19 3 64 E33 M 24 White Some college $301 400 12 19 2 5 4 D63 F 50 White Some college $501 600 10 14 3 6 E66 F 19 White Some college $100 200 20 13 7 3 5 T47 M 38 White GED <$100 40 45 5 38 S45 M 45 Black Some college $100 200 12 15 4 3 Note: ID = participant identification code. CO = breath carbon monoxide level at intake (ppm). FTND = score. Kilometers from clinic = distance from participants residence to University of Florida Smoking Laboratory and Clinic, Gainesville, FL.

PAGE 34

34 Table 2 2 Forum Posts. Rating Quantity % Total Samples Positive 95 65% K27 "J25, I see you are back on track so far keep it up!" M39 "Lets make some money!" M48 "Wow K59, you are doing really well!" Neutral 32 34% T47 "Hello all." E66 "Ive been doing a little better, not by much though, Ive got to get very motivated." Negative 1 1% J25 "Hey E33, thanks for sharing! You could join us or at least let us know whats working for you. We are supposed to be in this together, yet you remain an outsider, some teammate you are."

PAGE 35

35 Table 23. Treatment acceptability. Question Anchor = 0 Anchor = 100 M SD Overall intervention How easy to use was the internet program that you completed? not easy to use very easy to use 82.7 17.9 How helpful was the internet program in your quit attempt? not helpful very helpful 74.5 16.3 How convenient was the internet program that you completed? not convenient very convenient 77.9 14.5 How effective was the internet program that you completed? not effective very effective 76.2 21 How fair was the internet program that you completed? not at all fair very fair 85.9 14.2 CO monitor How much did you like using the CO meter to monitor your progress? not at all a great deal 76.9 19.7 Quantitative progress graph How much did you like seeing your progress on the graph? not at all a great deal 86.6 19.7 Vouchers How much did you like earning vouchers based on your teams performance? not at all a great deal 76.9 22 How much did you like earning vouchers based on only your performance? not at all a great deal 83.3 17.2 How helpful was earning vouchers based on your teams performance? not helpful very helpful 70.5 18.5 How helpful was earning vouchers based on only your performance? not helpful very helpful 79.2 18.4 Online support forum How easy to use was the discussion forum? not easy to use very easy to use 84.8 18.5 How much did you like using the discussion forum? not at all a great deal 54.3 24.7 How helpful was the discussion forum in your quit attempt? not helpful very helpful 56.6 22.1 Clearing the Air How much of the Clearing the Air guide to quitting smoking did you read? none of it all of it 69.5 29.9 How much did you like the Clearing the Air guide to quitting smoking? not at all a great deal 66.8 26.5 How helpful was the Clearing the Air guide that you used? not helpful very helpful 60.2 29.5 Note: M = mean, SD = standard deviation.

PAGE 36

36 Figure 21. Within subject breath CO level (ppm). Dashed vertical lines represent changes in experimental condition. Dashed horizontal lines represent the abstinence cri terion (4 ppm) Baseline duration increases across teams from left to right (i.e., Team 1 experienced a 2day baseline, Team 2 experienced a 3 day baseline, and so on). Note the different scale on the y axis for participant T47. 0 10 20 30 40 50 60 70 0 5 10 15 20 25 30 35 40 CO level T47 0 10 20 30 40 50 0 5 10 15 20 25 30 35 40 CO level S45 0 10 20 30 40 50 0 5 10 15 20 25 30 35 CO level 0 10 20 30 40 50 0 5 10 15 20 25 30 35 CO level D63 E66 Sample 0 10 20 30 40 50 0 5 10 15 20 25 30 35 CO Level 0 10 20 30 40 50 0 5 10 15 20 25 30 35 CO Level 0 10 20 30 40 50 0 5 10 15 20 25 30 35 CO Level J25 K27 E33 0 10 20 30 40 50 0 5 10 15 20 25 30 CO level 0 10 20 30 40 50 0 5 10 15 20 25 30 CO level 0 10 20 30 40 50 0 5 10 15 20 25 30 CO level M48 K59 B60 0 10 20 30 40 50 0 5 10 15 20 25 30 CO level 0 10 20 30 40 50 0 5 10 15 20 25 30 CO Level ( ppm ) 0 10 20 30 40 50 0 5 10 15 20 25 30 CO level C30 M39 K43 A B C A B C A B C A B C A B C Team 1 Team 2 Team 3 Team 4 Team 5 A = Baseline B = Tapering C = Abstinence Induction

PAGE 37

37 Figure 22. Percentage of samples negative for breath CO. Circles represent individual participant s percentages of negative breath CO ( i.e., B ar s represent the mean for all participants ( N = 13) during each condition. Baseline Tapering Abstinence Induction% Negative CO Samples

PAGE 38

38 CHAPTER 3 EXPERIMENT 2 Experiment 1 demonstrated the feasibility acceptability and preliminary efficacy of Internet based group CM to promote abstinence from cigarette smoking. The purpose of Experiment 2 was to dissociate the monetary and social contingencies of group CM to determine the effects of each of these treatment components on smoking cessation. The effects of monetary group contingencies on smoking cessation were examined within participants, and the ef fects of online peer support were examined between participants. Methods Participants Participants were 32 healthy smokers (14 Female) recruited from Gainesville, FL and surrounding communities through print media, radio announcements, television advertisements, and word of mouth. The same screening methods and inclusion criteria used in Experiment 1 were used in Experiment 2 (see Experiment 1 Participants ) Thus, participants smoke d 10 cigarettes per day, reported a minimum 2 yea r smoking history, and expressed a desi re to quit smoking In addition, participants completed the Need to Belong (NTB) scale during intake (Leary, Kelly, Cottrell, & Schreindorfer 2005 ; Mellor, Stokes, Firth, Hayashi, & Cummins, 2008) This 10item questionnaire with 5point Likert scale assessed participants need to belong to social groups and was collected prior to study participation so researchers could later evaluate whether the measure was predictive of smoking cessation forum use, or group cohesion. Participant charact eristics are displayed in Table 31. The University of Florida Institutional Review Board approved all study procedures.

PAGE 39

39 The purpose of this study was to isolate the effects of several treatment components on promoting only brief periods of abstinence. The refore, we did not perform an intention to treat analysis. Forty two participants were recruited. These p articipants were assigned to small teams ( n = 3) using the same methods as those used in the first experiment (see Experiment 1 Participants ) Two participants fro m different teams withdrew altering the experimenter arranged contingencies for two teams The loss of 1 or 2 participant s from a team consisting of only 3 participants represent s a substantial change in the response criterion for the group contingency arranged during the interdependent contingency condition (see Experiment 2 Within subject treatment conditions ) Thus, reduction s in team size were expected to impact the remaining team s performance during this condition (Shapiro & Goldberg, 1990) Therefore, data from 2 participants who withdrew from the study (and data from their respective teams ) were excluded from final data analyses. In addition, 4 participants (each from different teams) submitted less than 50% of scheduled sample s ubmissions. Due to these participants noncompliance with study procedures and irregular contact with experiment arranged contingencies their data were excluded from final data analyses. However data from these participants respective teams were included in analyses because the missing samples did not alter the experimenter arranged contingencies for the remaining teammates. Thus, data collected from 32 participants are analyzed in the Experiment 2 Results Materials Participants were loaned the same equipment used in the first experiment (see Experiment 1 Methods ).

PAGE 40

40 Set up Set up procedures were the same as those used in Experiment 1 (see Experiment 1 Set up). In addition, researchers collected a breath CO measure from each particip ant at this time point. T reatment conditions began on Mondays. Thus, r esearchers set up participants on Thursdays and Fridays of the preceding week Researchers informed participants on the Friday before the onset of the first condition which contingency arrangement they would experience during the first week of the study (see Experiment 2 Withinsubject treatment condition). Similarly, on subsequent Fridays during the intervention, participants were informed which withinsubject treatment condition they w ould experience the following week. TM and CO Monitoring P rocedure P articipants were instructed to submit video samples of breath CO measur ements twice daily (minimum 8 h inter sample interval). However, participants were only able to submit videos Monday through Friday. Participants had access to all features of the website during the weekend except the Post Video button (see Experiment 1 M TM and CO monitoring procedure), which was inactive on Saturdays and Sundays. Experimental Design We us ed a 2x3 factorial design. Access to a moderated online discussion forum was the betweensubject factor and contingency arrangement was the withinsubject factor.

PAGE 41

41 Between Subject Treatment C onditions Teams were randomly assigned to one of two groups. Six t eams ( n = 16 ; 7 Females ) were TM Group Support Forum Six t eams ( n = 16 ; 7 Females ) were n ot given access to this online discussion forum. Forum access Participants with forum access could click on a link located on their TM TM Group Support Forum (see Experiment 1 Online peer support forum for a description of this feature) Participants received the same guidelines for communicating via the online peer support forum as parti cipants received in Experiment 1. The forum moderator posted approximately five comments on the forum per within subject treatment condition (Monday through Friday). T wice per week these comments included informational support (Cohen, 2004) based on recomm endations provided by the authors of the Clearing the Air booklet (e.g., S tay away from places where smoking is allowed. ) The moderator also post ed emoti onal support (Cohen) when participants met treatment goals (e.g., Good job meeting your CO goal!). No forum access. Participants without forum access could not communicate with their teammates T hese participants received the same informational support received by participants with forum access However, participants without forum access received this support in TM homepages. These participants did not receive the experimenter delivered emotional support that participants with forum access re ceived.

PAGE 42

42 Within Subject Treatment C onditions Participants were exposed to three treatment conditions: (1) no vouchers (2) in dependent contingency, and (3) interdependent contingency. Each condition lasted 5 days ( Monday through Friday ) Participants could not post videos during the weekend. Thus, participants were exposed to 2 days with no monetary contingencies between each within subject treatment condition. The order in which participants were exposed to these conditions was counterbalanced across teams such that every possible sequence of conditions was used once among participants with forum access and once among participants without forum access. During every withinsubject condition, participants were instructed to quit smoking and meet the 4 ppm breath CO abstinence goal. In addition, during each condition, those participants with forum access could communicate with their teammates No vouchers No monetary contingency was arranged during this condition. H owever all participants had access to ot her features of the intervention (e.g., Internet based monitoring and the Clearing the Air booklet). In dependent contingency During the independent contingency condition, participants earned vouchers on an escalating schedule of reinforcement (Roll et al ., 1996) contingent on submission of sample). Each consecutive negative sample submission r esulted in a $.25 increase in voucher value. In addition, participants received a $5.00 bonus voucher contingent on three consecutive negative sample submissions. Thus, the first negative sample

PAGE 43

43 resulted in a $3.00 voucher, the second resulted in $3.25, the third resulted in $8.50 (i.e., $3.50 + $5.00), the fourth resulted in $3.75, and so on. A reset contingency (Roll & Higgins, 2000) was also arranged such that when a participant failed to submit a sample or submitted a positive sample, then that participant did not receive a voucher, and the value of the voucher contingent on the next negative sample was reset to the initial amount (i.e., $3.00). Following three consecutive negative sample submissions, the voucher magnitude then returned to the highest pr evious level. Participants could earn $56.25 in vouchers if they submitted all scheduled samples and were contin uously abstinent throughout the independent contingency condition. Interdependent c ontingency During the interdependent group contingency condit ion, vouchers were available on the same escalating schedule of reinforcem ent with reset contingency that was used in the independent contingency condition except for one major differencethe vouchers in this condition were contingent on group, rather than individual, performance. If every member on a team submitted a negative sample, they each received a voucher. If one teammate failed to submit a sample or submitted a positive sample, no one on the team received a voucher even if the other members of the team submitted negative samples. Participants could earn $56.25 in vouchers if they and their teammates submitted all scheduled samples and were continuously abstinent throughout the interdependent contingency condition. During th is condition participants also had access to their TM homepage. Thus, they were able to see when their teammates submitted positive and negative breath CO measures.

PAGE 44

44 Exit I nterview An exit interview was conducted with participants within 1 week following study completion (see Experiment 1 Exit interview for details ). Only participants with access to the TM Group Support Forum completed the GEQ. There were no reported instances of external communication between par ticipants. All p articipants were compensated with $50 in vouchers for completing the study Data A nalysis Participant characteristics MannWhitney U tests were used to compare characteristics between participants with access to the TM Group Support F orum and those without access to the forum. There were no significant differences in demographic measures or other participant characteristics between the two groups of participants Primary outcome measures Visual and statistical analyses reve a led no significant effect of the betweensubject factor, forum access, on breath CO measures nor any interactions between forum access and the withinsubject factor, contingency arrangement Thus, data from both groups of participants were combined, and one way r epeated measures ANOVA s were calculated on two primary outcome measures ( the p ercentage of negative CO samples and the most consecutive negative CO samples) with contingency arrangement (no vouchers, independent contingency, and interdependent contingency) as a factor. M issing samples were considered positive. Planned pairwise comparisons of the mean percentage of negative CO samples and consecutive negative CO samples were then made with the Bonferroni procedure between no vouchers and independent

PAGE 45

45 contingency conditions, no vouchers and interdependent contingency conditions, and independent and interdependent contingency conditions Pearson product moment correlations were calculated to detect correlations between breath CO measures and potential predictors of treatment success, including: age, income, FTND score, NTB score, breath CO level at intake, and average number of cigarettes smoked per day prior to intake. Correlations were also calculated to detect relationships between breath CO and GEQ score. In addition the data were analyzed for correlations between breath CO measures and quantitative and qualitative measures of support forum posts Secondary measures Pearson product moment c orrelations were calculated to detect relationships between GEQ score and NTB score, and between both of these measures and quantitative measures of TM Group Support Forum posts. Quantity of support forum posts created by participant s with forum access w ere compared between withinsubject treatment conditions using a Friedman repeated measures ANOVA on ranks Pairwise comparisons of the differences in ranks were then made with the Tukey procedure between no vouchers and independent contingency conditi ons, no vouchers and interdependent contingency conditions, and independent and interdependent contingency conditions. Su pport forum posts were also rated for quality (i.e., positive, negative, or neutral) by two independent observers (see Experiment 1 Dat a analysis for details) The percentage of posts rated as positive was compared between withinsubject treatment conditions using a oneway repeated measures ANOVA. In addition, the cost in vouchers for each participant was calculated and compared across i ndependent and interdependent contingency conditions using a Wilcoxon signed rank

PAGE 46

46 test Finally, w e used t tests to compare mean responses (range 0100 on a visual analog scale) to each treatment acceptability question across groups (i.e., participants with forum access and those without forum access) and one way repeated measures ANOVAs to compare responses by all participants to questions regarding independent and interdependent contingency acceptability. Results CO Da ta At Set up, the average breath CO l evel for all participants was 25 ppm ( SD = 13.4). At this time point, 3 4 days prior to study commencement, only 1 of 32 participants submitted a negative sample (i.e., 1% of samples were negative prior to the onset of experimental conditions ). During the 3week intervention, the average breath CO for all participants was 7 ppm ( SD = 6.8 ), and 4 8 % of samples were negative. Regardless of whether participants had access to the TM Group Support Forum, they submitted approximately the same percentage of negative CO samples ( Table 31) A two way repeated measures ANOVA revealed no difference in the mean percentage of negative samples submitted between participants with and without forum access ( F = 0, p = 1). Moreover, there was no significant interaction effects detected between forum access and the withinsubject factor, contingency arrangement, on the percentage of negative sample submissions ( F = .19 p = .82 ). Figure 31 shows the percentage of negative C O samples for all participants (those with and without forum access) as a function of contingency arrangement. Across within subject treatment conditions, p articipants submitted more negative samples when vouchers were available than when no vouchers were available. Data for all participants were combined and analyzed using a oneway repeated measures

PAGE 47

47 ANOVA, and comparisons between contingency arrangements revealed a significant difference between mean percentages of negative CO samples submitted during the no voucher s ( M = 34.7, SD = 38.9) and independent contingency conditions ( M = 55.6, SD = 41.5; t = 3.43, p = .003) and between the no voucher s and interdependent contingency conditions ( M = 52.8, SD = 39.4; t = 2.97, p = .01), but no difference between the independent and interdependent contingency conditions ( t = .46 p = 1). Figure 31 shows substantial variability in the percentages of negative samples submitted by participants. Visual analysis of the within subject CO data revealed several patterns o f responding across treatment conditions S eventeen participants submitted negative breath CO samples more reliably during one or both monetary contingency conditions relative to the no voucher s condition, 7 participants submitted few or no negative samples during any treatment condition, and 8 participants submitted negative samples regularly throughout all three treatment conditions. The 8 participants who submitted negative samples reliably during the no voucher s condition experienced this condition during the second or third week of the intervention. Figure 32 shows that all three within subject treatment conditions promoted abstinence among some participants during the second and third week s of the 3 week inter vention. That is, during all three treatment conditions, some participants submitted 50% or more negative samples during the second or third week of the intervention. Moreover, several participants submitted 50% or more negative samples during the first week of the intervention when the independent and interdependent contingency conditions were in effect However no participant who was exposed to the no vouchers condition first in the sequence of

PAGE 48

48 within subject treatment conditions submitted 50% or more negative samples during this condition. Figure 33 shows the highest number of consecutive negative samples submitted by each participant (those with and without forum access) during each treatment condition. P articipants submitted more consecutive negative samples when vouchers were available than when no vouchers were available. Twice as many participants were continuously abstinent for 3 days during the independent and interdependent contingency conditions relative to the no voucher s condition. A oneway repeated measures ANOVA revealed a significant effect of contingency arrangement on the most consecutive negative samples submitted by each participant ( F = 6.07, p = .004). Comparisons revealed a significant difference in the most consecutive negative sample submission s between the no voucher s condition ( M = 2.8, SD = 3.6) and independent contingency condition ( M = 4.9, SD = 4.2; t = 3.3, p = .005) and between the no voucher s condition and inter dependent contingency condition ( M = 4.5, SD = 4; t = 2.62, p = .03), but no difference between the independent and interdependent contingency conditions ( t = .68, p = 1) No significant correlations were detected between breath CO measures and the predictor variables we tested Contingent R einf orcement E arned Participants earned significantly more vouchers during the independent contingency condition ( M = $28.85, SD = 23.73) than they earned during the interdependent contingency condition ( M = $6.47, SD = 12.10; W = 334, p < .001) despite similar treatment outc omes during each condition.

PAGE 49

49 Support Forum D ata The 16 participants who had access to the TM Group Support Forum posted 119 comments during all three withinsubject treatment conditions ( M = 7.4, SD = 5.4). Eighty nine percent of the posts were rated as positive, 11% were rated as neutral, and no posts were rated as negative ( IOA = 90%). Participants made 33 posts (85% positive) during the no vouchers condition, 37 posts (86% positive) during the independent contingency condition, and 49 po sts (94% positive) during the interdependent contingency condition. The forum moderator made approximately the same number of posts per condition: 33 posts (97% positive; 1 post was rated as neutral) during the no vouchers condition, 35 posts (100% positiv e) during the independent contingency condition, and 34 posts (100% positive) during the inter dependent contingency condition. A Friedman repeated measures ANOVA on ranks revealed a significant difference in the number of participants support forum posts as a function of withinsubject treatment condition ( 2 = 7.56, p = 0.23). Comparisons indicated that participants posted significantly more comments during the interdependent contingency condition ( M = 3.1, SD = 2.6) relative to the no voucher s condition ( M = 2.1, SD = 2; q = 3.5, p < .05). In fact 12 out of 16 participants posted more comments during the interdependent contingency condition relative to the no vouchers condition. Only 7 participants posted more comments during the independent contingency condition ( M = 2.3, SD = 1.9) relative to the no voucher s condition, and the number of posts per participant w as not significantly different between these two conditions ( q = 2.5, p > .05). Although 10 participants posted more comments during the interdep endent contingency condition relative to the independent contingency condition, the number of posts per participant

PAGE 50

50 was not significantly higher during the interdependent contingency condition relative to the independent contingency condition ( q = 2.5, p > .05). The mean percentage of positive posts per participant w as not significantly different between treatment conditions ( F = .77, SD = .47). No significant correlations were detected between quantity or quality of support forum posts and breath CO measures. Treatment Acceptability D ata Participants with access to the TM Group Support Forum reported that they liked using the forum ( M = 80.8, SD = 20.1) and that it was helpful in their quit attempt ( M = 71, SD = 22.4). Participants reported that they liked earning vouchers based on individual performance ( M = 77.7, SD = 25.8) significantly more than they liked earning vouchers based on team performance ( M = 56.1, SD = 32.6; t = 3.02, p = .005). Participants also reported that earning vouchers based on individual performance was significantly more helpful ( M = 73.7, SD = 26.5) than earning vouchers based on team performance ( M = 50.5, SD = 33; t = 2.8, p = .009 ); moreover, this was the only acceptability measure that was significantly different between participants with forum access and those without forum access. Participants with forum access reported that the interdependent contingency was more helpful in their quit attempt ( M =64, SD = 25.3) than participants without forum access ( M = 36.9, S D = 35.3; t = 2.5, p = .018 ). GEQ and NTB M easures Mean GEQ score for participants with access to the TM Group Support Forum was 5.7 ( SD = 1.7), representing, on average, moderate group cohesion across teams. Mean NTB score for all participants was 2.6 ( SD = .6) representing, on average, low to moderate need to belong to social groups. NTB scores were similar among

PAGE 51

51 participants with forum access ( M = 2.7, SD = .7) and without forum access ( M = 2.5, SD = .6; t = 1.16, p = .255). No significant correlations were detected between NTB scores and GEQ scores or between either of these measures and breath CO measures, quantity or quality of support forum posts, or treatmen t acceptability measures. Discussion The results of Experiment 2 show that Internet based group CM can be used to promote brief abstinence from cigarette smoking Only one participant submitted a negative breath CO sample during Set up. Thus, 1% of samples were negative prior to treatment conditions T he percentage of negat ive samples increased to 48% during the intervention. Abstinencecontingent monetary incentives increase d negative sample submissions relative to a condition with no incentives but access to the TM Group Support Forum did not improve primary outcome measures. Thirty five percent of samples were negative during the no vouchers condition. This finding suggest s that, in the absence of incentives, goal setting and instructions to quit smoking combined with several other features of the Internet based int ervention (e.g., self monitoring and feedback) are enough to promote smoking cessation among some participants. Adding monetary incentives to these treatment components increased the percentage of negative sample submissions to 56% during the independent c ontingency condit ion and 53% during the interdependent contingency condition. Thus, interdependent contingencies alone can be used to promote smoking cessation. To our knowledge, this is the first study to demonstrate that interdependent group contingencies of reinforcement can be used to promote abstinence from any abused substance.

PAGE 52

52 The results also suggest that interdependent contingencies may promote collateral social behavior. Participants with forum access posted more comments on the forum during this condition than during any other withinsubject treatment condition. Moreover, the comments were remarkably positive during t his condition94% of the posts were rated as positive by independent observers. However, thi s emergent social behavior did not appear to improve primary treatment outcomes. Thus, future research is needed to investigate methods for enhancing the value of social incentives (e.g., by assigning participants from preexisting social networks to the s ame team ). Cost effectiveness is another potential advantage of interdependent group contingencies. Although, the percentage of negative samples submitted by participants was similar across independent and interdependent contingency arrangements the cost in vouchers was four times higher during the independent contingency condition ( M = $28.85, SD = 23.73) relative to the interdependent contingency condition ( M = $6.47, SD = 12.10). These results suggest that interdependent contingencies may be more affordable than independent contingencies. However, it remains unclear if the outcomes observed in the current study were a function of voucher magnitude, contingency arrangement, or both. I t is possible that lower magnitude vouchers comparable to the amount which was earned during the interdependent contingency condition could have promoted the same treatment outcomes if available on an independent schedule of reinforcement Thus, future research is needed to compare independent and interdependent contingency arrangements with incentives of var i ous magnitudes. Despite the potential practical advantages of interdependent group contingencies, treatment acceptability data indicate that these contingencies are much less preferred

PAGE 53

53 than independent contingencies P articipants liked earning vouchers based on individual performance much more than they liked earning vouchers based on team performance. Moreover, those participants without access to the TM Group Support Forum and, t herefore unable to communicate w ith their teammates, did not find the interdependent contingency helpful in their quit attempt. The results of Experiment 2 should be interpreted with caution. One major limitation of th is experiment is the small sample size. Only 32 smokers completed the study Moreover, only half ( n = 16) had access to the TM Group Support Forum. Thus, future stud ies should investigate whether findings from the current study generalize to larger samples of smokers. Another major limitation of Experiment 2 is one of the inclusion criterion used in recruitment Only smokers who reported a desire to quit smoking were invited to participate. Although this sample of smokers represents a clinically relevant population (i.e ., treatmentseeking smokers ; Perkins et al., 2006) confounding motivating factors may have attributed to treatment outcomes (e.g., some smokers may have had a stronger desire to quit than others) Indeed, such factors may be responsible for the variabili ty in breath CO measures observed between participants. Although none of the potential predictor variables we examined correlated with treatment outcomes (e.g., FTND score, NTB score, breath CO at intake), it is possible that motivation to quit may have contributed to treatment success. Thus, to get a clearer picture of the effects of the independent variables we examined on smoking cessation, future studies should recruit smokers who report no desire to quit smoking.

PAGE 54

54 Table 3 1. Participant characteristi cs. No Forum ( n = 16) Forum ( n = 16) M SD M SD Sex (% Male) 56.3 56.3 Age 39.6 14 37.5 13.6 Race (% White) 86.7 81.3 Education (Median) some college some college Weekly Income (Median) $301400 $201300 Cigarettes per day 19.6 10.3 17 5.5 CO (ppm) at Intake 27.1 15 27.8 18.2 NTB score 2.5 0 .6 2.7 0.7 FTND score 5.3 2 4.7 2.1 Table 32. P ercentage of negative samples. No Forum ( n =16) Forum ( n =16) M SD M SD No Vouchers 36 44 33 32 Independent Contingency 56 43 55 39 Interdependent Contingency 51 41 55 40

PAGE 55

55 Figure 31 Pe rcentage of negative samples across conditions. Percentage of samples negative for breath CO (i.e., CO ) submitted by all participants ( N = 32) with and without forum access presented as a function of withinsubject treatment condition. Circles represent percentages for each participant. Bars represent mean percentages for all participants Figure 32 Pe rcentage of negative samples acr oss week s in treatment Percentage of negative samples submitted by all participants ( N = 32) presented as a function of time in treatment. Each circle represents the percentage of negative samples for one participant. Each panel represents a different wit hin subject treatment condition. Thus, in the No Vouchers panel, the data above Week 1 represent the percentage of negative samples submitted during the no voucher s condition for each participant who experienced this condition during the first week of the 3week intervention. % Negative CO Samples 0 20 40 60 80 100 No Vouchers Independent Interdependent Interdependent Contingency % Negative CO Samples 0 20 40 60 80 100 Independent Contingency % Negative CO Samples 0 20 40 60 80 100 No Vouchers % Negative CO Samples 0 20 40 60 80 100 Week 1 Week 2 Week 3 Week 1 Week 2 Week 3 Week 1 Week 2 Week 3

PAGE 56

56 Figure 33 Consecutive negative samples. The most consecutive negative samples submitted by all participants ( N = 32) across within subject treatment condition. Circles represent the highest number of consecutive negative samples by each participant during (maximum of 10 samples or 5 days of continuous abstinence). Bars represent mean percentages for all participants. Any data point falling on or above the dashed horizontal line indicates that the participant was continuously abstinent for 3 or more days. Most Consecutive Negative CO Samples 0 2 4 6 8 10 No Vouchers Independent Interdependent

PAGE 57

57 CHAPTER 4 GENERAL DISCUSSION To our knowledge, the current study is the first to use group CM to promote abstinence from ci garette smoking. Although the findings are preliminary, they are nonetheless encouraging. They suggest that Internet based group CM is a feasible and acceptable smoking intervention. Moreover, the intervention may provide researchers with a n advantageous t reatment model for investigating the effects of social support on drug abstinence. Previous research suggests that social support may promote smoking cessation (Baha & Le Faou, 2010; Chen, White, & Pandina, 2001; Christakis & Fowler, 2008; Cohen & Lichtenstein, 1990; Hennrikus et al., 2010; Ji et al., 2005; Mermelstein, Cohen, Lichtenstein, Baer, & Kamarck, 1983; Mlle r, Pedersen, Villebro, & N rgaard, 2003; Westmaas, Wild, & Ferrence, 2002). Thus, understanding what dimensions of social support are necess ary to influence behavior change would allow researchers and practitioners to apply this knowledge to the treatment of drug dependence. The moderated online support forum is ideal for initial investigations into the influence of social support on behavior change because it affords researchers the ability to investigate social interactions while minimizing or eliminating undesirable behavior among participants, preserv ing their anonymity, and protecting their confidentiality The Internet based intervention also allows all social interactions to be recorded for descriptive analyses In many previous studies in which the effects of group contingencies on behavior change were investigated, researchers were only able to collect data on emergent social behavior via self report (e.g., Williamson et al. 1992) or during a brief window when participants were in the presence of trained observers, tape

PAGE 58

58 recorders, or video recorder s (e.g., Speltz et al. 1982). In the current study however, a complete record of all social exchanges was obtained. Thus, we were able to find that Internet based group CM promotes social support. Moreover, a descriptive analysis revealed that this collateral behavior was remarkably positive. However, we were unable to determine the function of the support forum posts. In other words, the current study did not evaluate whether tips and advice from successful quitters functioned as pro mpts to help others qui t smoking or whether abstinencecontingent praise functioned as reinforcers for smoking cessation. In future studies however an online forum could permit researchers or confederates to experimentally manipulate quality and quantity of social interactio ns to identify functional relationships between social behavior and abstinence and to learn which dimensions of social support promote target behavior change. Empirical investigations such as these are needed to advance researchers understanding of the ro le social support plays in drug abstinence. I t is unclear which variables contributed to infrequent forum participation in the current study Participant s responses to open ended questions on the treatment acceptability questionnaire indicated that anonymity may have decreased the value of social incentives. For example, one participant from Experiment 2 V461, noted that his least favorite part of the intervention was that he was given no chance to put a face to the name of [his] teammates. Other participants suggested that having more teammates or allowing real time communication via chat rooms would improve the social component of the intervention. Fu ture studies should therefore investigate ways to facilitate communication, perhaps by allowing teammates to meet one another; enlarging team size; stratifying teams based on common characteristics; providing

PAGE 59

59 incentives contingent on forum participation; o r u sing a forum moderator who is also an ex smoker, group therapist, or counselor. This latter method would allow researchers to integrate psychosocial therapy into the online peer support forum. Although participants did not use the forum frequently, several reported that it was their favorite feature of the intervention. Indeed, partici pants in Experiment 2 rated this feature much more highly than participants in Experiment 1 ( M = 81, SD = 20 versus M = 54, SD = 25, respectively). The difference in accept ability ratings between participants in each experiment did not appear to be related to group cohesion. Participants in Experiment 2 had the same average GEQ score as participants in Experiment 1 ( M = 5.7, SD = 1.7 versus M = 5.7, SD = 1.8, respectively). However, the different acceptability ratings may have been due to differences observed in the quality of support forum posts. Although the majority of posts were rated as po sitive in Experiment 1 (65%), even more were rated as positive in Experiment 2 (89%). The increase in the percentage of positive posts across experiments may have been related to the increase in the quantity and quality of moder ator posts in Experiment 2. That is, the moderator s behavior m ay have served as a model which was imitated by participants Thus, f uture research is needed to examine the influence of moderator behavior on participants social behavior. The results of this study suggest that group CM may represent a more cost effective alternative to traditional CM In Experi ment 2, similar treatment effects were observed across independent and interdependent contingency arrangements However, the amount of vouchers awarded to participants was significantly lower during the interdependent contingency condition than during the inde pendent contingency

PAGE 60

60 condition. Strict i nterdependent contingencies like the one used in Experiment 2 are likely inappropriate for clinical application. As the acceptability data collected in Experiment 2 indicate, the response requirement is likely to frustrate some patients when they meet their treatment goals and their teammates do not. However, a mixed contingency arrangement like the one used in Experiment 1 may be more acceptable to patients and practitioners while still promoting social support Presumably, a mixed contingency such as this would be more affordable than individual contingencies of reinforcement. Participants in Experiment 1 earned relatively few of the interdependent vouchers; yet, many still abstained from smoking. Future studies should compare mixed group contingency arrangements with individual or independent contingencies to determine whether group contingencies can help lower costs or enhance traditional CM treatment outcomes. The value of social and monetary group contingencies may even be enhanced if researchers preserve participants access to peer support after financial incentives are withdrawn M aintaining this social component as well as other features of the Internet based intervention while transitioning to interdepende nt contingency arrangements over the course of an intervention or gradually thinning out monetary incentives may result in a low cost method to increase treatment duration and long term maintenance of treatment gains. As the results of Experiment 2 suggest self monitoring, feedback, goal setting, and other features of the Internet based group CM intervention may not be enough to initiate smoking cessation, but these treatment components may be sufficient for sustaining abstinence once it is established with incentives

PAGE 61

61 In sum, Internet based group CM represents a promising strategy for treating cigarette smoking Moreover, it is an ideal treatment model for systematically investigating the effects of social contingencies on behavior change Future investigations of the effects of this intervention on smoking cessation will allow researchers to learn more about the role social support plays in promoting drug abstinence.

PAGE 62

62 LIST OF REFERENCES Alessi, S. M., Badger, G. J., & Higgins, S. T. (2004). An experimental examination of the initial weeks of abstinence in cigarette smokers. Experimental and Clinical Psychopharmacology, 12 (4), 276 287. Alessi, S. M., Hanson, T., Wieners, M., & Petry, N. M. (2007). Low cost contingency management in community clinics: delivering incentives partially in group therapy. Experimental and Clinical Psychopharmacology, 15 (3), 293 300. Baha, M., & Le Faou, A. L. (2010). Smokers reasons for quitting in an anti smoking social context. Public Health, 124 (4), 225 231. Barlow, D. H., Nock, M. K., & Hersen, M. (2008). Single Case Experimental Designs: Strategies for Studying Behavior Change (3rd ed.). Boston: Allyn & Bacon. Benishek, L.A., Kirby, K.C., Dugosh, K.L. & Padovano, A. (2010) Beliefs about the empirical support of drug abuse treatment interv entions: A survey of outpatient t reatment providers. Drug and Alcohol Dependence, 107, 202 208. Benowitz N L Jacob, P ., III Ahijevych, K., Jarvis, M. J., Hall, S., LeHouezec, J. et al. (2002) Biochemical verification of tobacco use and cessation Nicotine & Tobacco Research, 4, 149 1 5 9 Bigelow, G. E., & Silverman, K. (1999). In Higgins S. T. & Silverman K. (Eds.), Motivating behavior change among illicit drug abusers: Research on contingency management interventions (pp. 15 31). Washington, DC: American Psychological Association. Bride, B. E., Abraham, A. J., & Roman, P. M. (2010). Diffusion of contingency management and attitudes regarding its effectiveness and acceptability. Substance Abuse, 31 (3), 127 135. Chen, P. H., White, H. R., & Pandina, R. J. (2001). Predictors of smoking cessation from adolescence into young adulthood. Addictive Behaviors, 26 (4), 517 529. Christakis, N. A., & Fowler, J. H. (2008). The collective dynamics of smoki ng in a large social network. The New England Journal of Medicine, 358 (21), 2249 2258. Cohen, S., & Lichtenstein, E. (1990). Partner behaviors that support quitting smoking. Journal of Consulting and Clinical Psychology, 58, 304 309. Cohen, S. (2004). Social relationships and health. American Psychologist, 59 (8), 676 684. Cooper, T. E., Heron, W.L. & Heward J. O. (2007). Applied Behavior Analysis (2nd ed.). Upper Saddle River, NJ: Pearson.

PAGE 63

63 Dallery, J., & Glenn, I. M. (2005). Effects of an Internet based voucher reinforcement program for smoking abstinence: a feasibility study. Journal of Applied Behavior Analysis, 38 (3), 349 357. Dallery, J., Glenn, I. M., & Raiff, B. R. (2007). An Internetbased abstinence reinforcement treatment for cigarette smoking. Drug and Alcohol Dependence, 86, 230 238. Dallery, J., Meredith, S., & Glenn, I. M. (2008). A deposit contract method to deliver abstinence reinforcement for cigarette smoking. Journal of Applied Behavior Analysis, 41 (4), 609 615. Deller, A., Stenz, R., Forstner, K., & Konrad, F. (1992). The elimination of carboxyhemoglobin--gender specific and circadian effects. Transfusion Medicine and Hemotherapy 19 (3), 121 126. Dunn, K. E., Sigmon, S. C., Thomas, C. S., Heil, S. H., & Higgins, S. T. (2008). Voucher based contingent reinforcement of smoking abstinence among methadonemaintained patients: a pilot study. Journal of Applied Behavior Analysis, 41 (4), 527 538. Dutra, L., Stathopoulou, G., Basden, S. L., Leyro, T. M., Powers, M. B., & Otto, M. W. (2008). A metaanalytic review of psychosocial interventions for substance use disorders. American Journal of Psychiatry, 165, 179 187. Estabrooks, P. A., & Carron, A. V. (1999). Group cohesion in older adult exercisers: prediction and intervent ion effects. Journal of Behavioral Medicine, 22 (6), 575 588. Fagerstrom, K. O., & Schneider, N. G. (1989). Measuring nicotine dependence: a review of the Fagerstrom Tolerance Questionnaire. Journal of Behavioral Medicine, 12 (2), 159 182. Fiore M C Ja en, C R Baker T B Bailey, W. C., Benowitz, N. L., Curry, S. J., et al. (2008). Treating tobacco use and dependence: 2008 update. Rockville, MD: US Department of Health and Human Services, Public Health Service. Gresham, F. M., & Gresham, G. N. (1982). Interdependent, dependent, and independent group contingencies for controlling disruptive behavior. Journal of Special Education, 16 (1), 101110. Griffiths, R.R., Bigelow, G.E., & Henningfield, J.E. (1980). In N.K. Mello (Ed.), Adv ances in Substance Abuse (pp. 1 90). Greenwich, CT: JAI Press, Inc Hartzler B Lash S J & Roll, J M. (2012). Contingency management in substance abuse treatment: A structured review of the evidence for its transportability. Drug and Alcohol Dependence, 122 1 10.

PAGE 64

64 Hennrikus D., Phyllis, P., Hellerstedt, W., Lando, H. A., Steele, J., & Dunn, C. ( 2010). Increasing support for smoking cessation during pregnancy and postpartum: Results of a randomized controlled pilot study. Preventive Medicine, 50, 134137. Higgins, S.T., Budney, A.J. & Bickel, W.K. (199 4 ). Applying behavioral concepts and principles to the treatment of cocaine dependence. D rug and Alcohol Dependence, 34, 8797. Higgins, S. T., Heil, S. H., Solomon, L. J., Bernstein, I. M., Lussier, J. P., Abel, R. L., et al. (2004). A pilot study on voucher based incentives to promote abstinence from cigarette smoking during pregnancy and postpartum. Nicotine & Tobacco Research, 6 (6), 1015 1020. Higgins, S. T., Silverman, K., & Heil, S. H. (2008). Contingency Management in Substance Abuse Treatment New York: The Guilford Press. Hursh, S. R. (1984). Behavioral economics. Journal of the Experimental Analysis of Behavior, 42 435 4 52. Javors, M. A., Hatch, J. P., & Lamb, R. J. (2005). Cutoff levels for breath carbon monoxide as a marker for cigarette smoking. Addiction, 100 (2), 159 167. Ji, M., Hofstetter, C. R., Hovell, M., Irvin, V., Song, Y. J., Lee, J., Park, H., et al. (2005) Smoking cessation patterns and predictors among adult Californians of Korean descent. Nicotine & Tobacco Research, 7 (1), 59 69. Kirby, K. C., Benishek, L. A., Dugosh, K. L., & Kerwin, M. E. (2006). Substance abuse treatment providers beliefs and objec tions regarding contingency management: implications for dissemination. Drug and Alcohol Dependence, 85 (1), 19 27. Kirby, K. C., Kerwin, M. E., Carpenedo, C. M., Rosenwasser, B. J., & Gardner, R. S. (2008). Interdependent group contingency management for cocainedependent methadone maintenance patients. Journal of Applied Behavior Analysis, 41 (4), 579 595. Joumard, R., Chiron, M., Vidon, R., Maurin, M., & Rouzioux, J. M. (1981). Mathematical models of the uptake of carbon monoxide on hemoglobin at low carbon monoxide levels. Environmental Health Perspectives, 41, 277 289. Leary, M. R., Kelly K. M., Cottrell C. A., & Schreindorfer L. S. (2005). Individual differences in the need to belong: Mapping the nomological network. Unpublished manuscript, Wake Forest University. Ledgerwood, D. M., Alessi, S. M., Hanson, T., Godley, M. D., & Petry, N. M. (2008). Contingency management for attendance to group substance abuse treatment administered by clinicians in community clinics. Journal of Applied Behavior Analysis, 41 ,517 526.

PAGE 65

65 Litow, L. & Pumroy, D. K., (1975). A brief review of classroom group oriented contingencies. Journal of Applied Behavior Analysis, 8, 341347. Lussier J. P., Heil S. H., Mongeon J. A., Badger G. J., & Higgins S. T., 2006. A meta analysis of voucher based reinforcement therapy for substance use disorders. Addiction, 101 (2), 192 203. Mazur, J.E. ( 1987) An adjusting procedure for studying delayed reinforcement. In:Commons, M.L., Mazur, J.E., Nevin, J.A., & Rachlin, H. (Eds.), Quantitative Analyses of Behavior ( pp. 55 73). L awrence Earlbaum, Hillsdale, NJ McGovern, M. P., & Carroll, K. M. (2003). Evidencebased practices for substance use disorders. The Psychiatric Clinics of North America, 26 (4), 991 1010. McGovern, M. P., Fo x, T. S., Xie, H., & Drake, R. E. (2004). A survey of clinical practices and readiness to adopt evidencebased practices: Dissemination research in an addiction treatment system. Journal of Substance Abuse Treatment, 26 (4), 305 312. Mellor, D., St okes, M. Firth, L., Hayashi, Y., & Cummins R. (2008). Need for Belonging,Relationship Satisfaction, Loneliness, and Life Satisfaction. Personality and I ndividual Differences 45 213 218. Mermelstein, R., Cohen, S., Lichtenstein, E., Baer, J. S., & Kamarck, T. (1986). Social support and smoking cessation and maintenance. Journal of Consulting and Clinical Psychology, 54 (4), 447 453. Mller, A. M., Pedersen, T., Villebro, N., & Nrgaard, P. (2003). Impact of lifestyle on perioperative smoking cessat ion and postoperative complication rate. Preventive Medicine, 36 (6), 704 709. Perkins, K. A., Stitzer, M., & Lerman, C. (2006). Medication screening for smoking cessation: a proposal for new methodologies. Psychoparmacology, 184, 628 636. Petry, N. M., We instock, J.M., & Alessi, S.M. (2011). A randomized trial of contingency management delivered in the context of group counseling. Journal of Consulting and Clinical Psychology, 79 (5), 686 696. Petry, N. M., Weinstock, J., Alessi, S. M., Lewis, M. W., & Die ckhaus, K. (2010). Groupbased randomized trial of contingencies for health and abstinence in HIV patients. Journal of Consulting and Clinical Psychology, 78 (1), 89 97. Prendergast, M., Podus, D., Finney, J., Greenwell, L., & Roll, J. (2006). Contingency management for treatment of substance use disorders: A metaanalysis. Addiction, 101, 1546 1560.

PAGE 66

66 Reynolds, B., Dallery, J., Shroff, P., Patak, M., & Leraas, K. (2008). A web based contingency management program with adolescent smokers. Journal of Applied B ehavior Analysis, 41 (4), 597 601. Roll, J M, & Higgins, S. T. (2000). A within subject comparison of three different schedules of reinforcement of drug abstinence using cigarette smoking as an exemplar. Drug and Alcohol Dependence, 58 103 109. Roll, J. M ., Higgins, S. T., & Badger, G. J. (1996). An experimental comparison of three different schedules of reinforcement of drug abstinence using cigarette smoking as an exemplar. Journal of Applied Behavior Analysis, 29 (4), 495 504. Roll, J. M., Madden, G. J., Rawson, R., & Petry, N. M. (2009). Facilitating the Adoption of Contingency Management for the Treatment of Substance Use Disorders. Behavior Analysis in Practice, 2 (1), 4 13. Romeo, F. F. (1998). The negative effects of using a group contingency system Journal of Instructional Psychology, 25 (2), 130. Schuster, C. R., & Thompson, T. (1969). Self administration of and behavioral dependence on drugs. Annual Review of Pharmacology, 9, 483 502. Schwartz, J. L. (1992). Methods of smoking cessation. Medical Clinics of North America, 76 (2), 451 476. Shapiro, E. S., & Goldberg, R. (1990). In vivo rating of treatment acceptability by children: Group size effects in group contingencies to improve spelling performance. Journal of School Psychology, 28, 233 250. Sigmon S .C, Lamb R.J, & Dallery J. (2008). In Higgins S.T ., Silverman, K., & Heil, S.H. (Eds.). Contingency management in substance abuse treatment ( pp. 99 119 ) New York: Guilford. Silverman, K., Chutuape, M. A., Bigelow, G. E., & Stitzer, M. L. (1999). Voucher based reinforcement of cocaine abstinence in treatment resistant methadone patients: effects of reinforcement magnitude. Psychopharmacology, 146 (2), 128 138. Skinner, B. F. (1938). The B ehavior of Organisms: An Experimental Analysis New York: AppletonCentury Crofts. Skinner, B.F. (1953). Science and Human Behavior New York: Macmillan Skinner, B.F. (1957). Verbal Behavior New York: AppletonCentury Crofts Speltz, M. L., Shimamura, J. W., & McReynolds, W. T. (1982). Procedural variations in group contingencies: effects on childrens academic and social behaviors. Journal of Applied Behavior Analysis, 15 (4), 533 544.

PAGE 67

67 Stitzer, M.L. ( 1999) Combined behavioral and pharmacological treatments f or smoking cessation. Nicotine & Tobacco Research, 1 (Suppl 2) S181 S187. Stitzer, M. (2006). Contingency management and the addictions. Addiction, 101 (11), 1536 1537. Stoops, W. W., Dallery, J., Fields, N. M., Nuzzo, P. A., Schoenberg, N. E., Martin, C. A., et al. (2009). An internet based abstinence reinforcement smoking cessation intervention in rural smokers. Drug and Alcohol Dependence, 105, 56 62. Tidey, J. W., ONeill, S. C., & Higgins, S. T. (2002). Contingent monetary reinforcement of smoking re ductions, with and without transdermal nicotine, in outpatients with schizophrenia. Experimental and Clinical Psychopharmacology, 10 (3), 241 247. US Department of Health and Human Services (2004) The health consequences of smoking: a report of the Surgeon General Atlanta, GA: US Department of Heal th and Human Services, CDC Westmaas, J. L., Wild, T. C., & Ferrence, R. (2002). Effects of gender in social control of smoking cessation. Health Psychology: Official Journal of the Division of Health Psychology, American Psychological Association, 21 (4), 368 376. Williamson, D. A., Williamson, S. H., Watkins, P. C., & Hughes, H. H. (1992). Increasing Cooperation among Children Using Dependent GroupOriented Reinforcement Contingencies. Behavior Modification, 16 (3), 414 425.

PAGE 68

68 BIOGRAPHICAL SKETCH Steven Meredith graduated as a valedictorian from the University of Florida in 2005 with a B.S. in Psychology. Following graduation, he continued his education at the University of F lorida Department of Psychology with a concentration in Behavior A nalysis. As a graduate student he conducted basic behavioral pharmacology research and earned an M.S. in Psychology in 2009. He subsequently focused his research efforts on applied behavioral pharmacology. He earned several academic and research awards as a graduate student, including the American Psychological Assoc iation Dissertation Research Award, the E.F. Malagodi Jr. Memorial Scholarship, the Society for the Advancement of Behavior Analysis Doctoral Dissertation Grant and the B.F. Skinner Foundation Research Award. He earned his Ph.D. in August 201 2, after whic h he continue d to conduct research in behavior analysis and behavioral pharmacology as a National Institute of Health postdoctoral fellow at the Johns Hopkins University School of Medicine.