Contingency Management Smoking Cessation in Appalachia

Description

According to the University of Kentucky, research results as recent as 2021 continue to find that the Appalachian population has the highest rates of smoking and smoking-related diseases in the nation. Specific to pregnancy, studies continue to document that, in Appalachia, higher numbers of pregnant women are likely to smoke, with a 2025 Eastern Economic Journal article showing percentages in West Virginia slightly over 25%, the rest of Appalachia at 20% — compared to about 13% in the rest of the United States. Additionally, the impacts of prenatal smoking on infant and child health are well-documented.

There are several smoking cessation program options for pregnant women, although fewer studied specifically for rural women. In 2009, University of Kentucky Associate Professor of Behavioral Sciences Brady Reynolds started working with a web-based contingency management (CM) smoking cessation program that addressed the isolation or travel issues of pregnant adult and adolescent women in Appalachian regions of Kentucky and Ohio.

Reynolds used the web-based program Motiv8 as a server for the project. Like other CM curricula, the smoking cessation program offered rewards to achieve results. Participants were given monetary incentives in the form of vouchers that were then used for online purchases. Program directors bought the items for participants in order to make sure purchases were appropriate.

Two to three times a day during each study phase, participants would submit video recordings of themselves giving breath samples using a handheld breath carbon monoxide (CO) reader known as a Smokerlyzer. Similar to a breathalyzer for alcohol, a person breathes into the device and within seconds results show participants how much CO is in their lungs and bloodstream. A higher CO level indicates recent smoking from the participant.

While abstinence was the goal for every participant, goals for reducing smoking were individualized and based on the participant's initial smoking rate. Goals and CO levels were mapped so participants could track their improvements in real time.

The web-based CM smoking cessation program was funded by a grant from the National Cancer Institute.

Services offered

The CM program lasted 6 weeks and consisted of five phases. Each phase had monetary incentives that increased with each accomplished goal. Total potential earnings from all phases combined could total approximately $830.

• Baseline (7 days) – Participants become accustomed to submitting CO breath samples and determine their baseline average CO level.
• Shaping (4 days) – Participants receive reinforcements for gradual decreases in CO level.
• Abstinence (21 days) – The goal of this phase was to promote continued abstinence. Abstinence from smoking was defined as 4 parts per million (ppm) carbon CO or less.
• Thinning (5 days) – The purpose of the thinning phase was for participants to gradually transition from the high incentives for abstinence. In this phase, participants were still required to submit the same amount of breath samples at the same ppm.
• Return to Baseline (5 days) – Incentives were removed and participants were evaluated to see if they would return to smoking.

Results

In a pilot study of 7 pregnant women:

• Participants provided an average of 68% of their required twice daily breath samples
• Participants who quit or reduced smoking in this program provided 71.4% of their required breath samples
• At peak abstinence, 30% (2 of 7) of participants were able to quit smoking
• Continuing smokers reduced smoking by 50% on average

In a study of 62 adolescent smokers, teens were split between an active group that required breath CO reduction and a control group where no requirements were implemented. However, both had access to the same potential monetary incentives.

• Both groups significantly reduced their breath CO
• Active group participants reduced their average CO from baseline to return-to-baseline phase by 4.4 ppm compared to 1.7 ppm reduction by the control group
• Only participants from the active group maintained all reductions until 6-week post treatment
• On average, active group participants earned $147.90 compared to $345.26 earned on average from members of the control group

Research and publications relating to smoking cessation program:

Harris, M., Reynolds, B. (2015). A pilot study of home-based smoking cessation programs for rural, Appalachian, pregnant smokers. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 44(2), 236-245.

Reynolds, B., Harris, M., Slone, S.A., Shelton, B.J., Dallery, J., Stoops, W. and Lewis, R. (2015). A feasibility study of home-based contingency management with adolescent smokers of rural Appalachia. Experimental and Clinical Psychopharmacology, 23(6), 486-493.

Challenges

A lack of Internet service and computer equipment were the principal barriers of this program since many living in Appalachia have limited or no broadband access. Used loaner equipment was a necessity and was reused as much as possible. Roughly 95% of smoking cessation participants required loaner equipment.

At the time of the original study, CM cost was approximately $296 per participant for program financial incentives. Additionally, there were ongoing costs for loaner equipment (e.g., laptop, web camera, CO monitor) and Internet access that would further increase the expense of implementing CM. These costs could make this program difficult to use widely without grant funding.

Replication

In general, providing smoking cessation treatment to rural smokers is often difficult due to travel, economic, and cultural barriers. This makes web-based programs attractive to project creators. However, determining equipment and broadband service needs should be a main priority when constructing a rural, web-based, cessation program.

Dr. Reynolds and collaborators found that a similar phone-based model used for pregnant smokers also showed success. While tracking CO levels of participants would require creative thinking, a phone-based program could be a replication alternative to deal with broadband and equipment barriers.