This study evaluated the efficacy of a contingency management (CM) procedure that provided opportunities to win prizes as reinforcers. At intake to outpatient treatment, 42 alcohol-dependent veterans were randomly assigned to receive standard treatment or standard treatment plus CM, in which they earned the chance to win prizes for submitting negative Breathalyzer samples and completing steps toward treatment goals. Eighty-four percent of the CM participants were retained in treatment for an 8-week period compared with 22% of the standard treatment participants (p < .001). By the end of the treatment period, 69% of those receiving CM were still abstinent, but 61% of those receiving standard treatment had used alcohol (p < .05). These results support the efficacy of this CM procedure. Participants earned an average of $200 in prizes. This CM procedure may be suitable for use in standard treatment settings because prizes can be solicited from the community. Contingency management techniques are effective for improving retention in substance abuse treatment programs and reducing drug use. For treating substance abusers, there are four central tenets of contingency management (e.g., Budney & Higgins, 1998; Higgins, Budney, & Bickel, 1994). First, the clinician arranges the environment such that substance use is readily detected. Second, tangible reinforcers are provided when abstinence is demonstrated. Third, incentives are withheld when drug use is uncovered. Finally, reinforcement from alternative sources (e.g., employment, family, or social) is increased to compete with reinforcement derived from drug use. Methadone programs sometimes use incentives such as take-home doses or increases in dose to reinforce abstinence. In settings that do not use substitution drugs, contingency management programs provide money (Shaner, Roberts, Eckman, & Tucker, 1997) or vouchers, exchangeable for retail goads, an submission of drug-free urine samples (Higgins, Budney, & Bickel, 1994; Higgins et al., 1993).

Background: Many smokers remain refractory to current therapies, which only partially address weight gain after smoking cessation. Thus, this study evaluated whether naltrexone hydrochloride augmentation of nicotine patch therapy improves smoking abstinence and reduces postcessation weight gain more than nicotine patch therapy alone and at what dose. Methods: Six-week double-blind placebo-controlled trial with follow-up in an outpatient research center. Four hundred individuals who smoked 20 or more cigarettes daily were randomly assigned to treatment for 6 weeks with a 21-mg nicotine patch and oral naltrexone hydrochloride (0, 25, 50, or 100 mg/d) after equal random treatment assignment and followed up for 1 year after randomization. The a priori specified primary end points were prolonged 4-week cigarette abstinence after a 2-week grace period in the intent-to-treat sample and weight gain in these abstainers. Results: We found no significant differences in prolonged 4-week abstinence (P = .49) or 6-week continuous abstinence after the quit date (P=.12) during treatment in the intent-to-treat analysis. Among 295 treatment completers, the 100-mg dose was associated with higher continuous abstinence rates (71.6%) compared with placebo (48%) (odds ratio, 2.73; 95% confidence interval, 1.39-5.39; PϽ.01). Among continuous abstainers, the 25-mg naltrexone hydrochloride group gained significantly less weight (mean±SEM, 0.7±0.31 kg) than the placebo group (mean±SEM, 1.9±0.33 kg; PϽ.01). Similar naltrexone dose effects on weight were found for those with prolonged abstinence and treatment completers, irrespective of abstinence. Conclusions: The 100-mg dose of naltrexone hydrochloride appears the most promising for augmenting the efficacy of the nicotine patch on smoking cessation outcomes but requires further study. The significant weight reduction with low-dose naltrexone therapy suggests that it may be useful as a second-line treatment for weightconcerned smokers.

Prospect theory suggests that because smoking cessation is a prevention behavior with a fairly certain outcome, gain-framed messages will be more persuasive than loss-framed messages when attempting to encourage smoking cessation. To test this hypothesis, the authors randomly assigned participants (N = 258) in a clinical trial to either a gain-or loss-framed condition, in which they received factually equivalent video and printed messages encouraging smoking cessation that emphasized either the benefits of quitting (gains) or the costs of continuing to smoke (losses), respectively. All participants received open label sustained-release bupropion (300 mg/day) for 7 weeks. In the intent-to-treat analysis, the difference between the experimental groups by either point prevalence or continuous abstinence was not statistically significant. Among 170 treatment completers, however, a significantly higher proportion of participants were continuously abstinent in the gain-framed condition as compared with the loss-framed condition. These data suggest that gain-framed messages may be more persuasive than loss-framed messages in promoting early success in smoking cessation for participants who are engaged in treatment.Keywords message framing; smoking cessation; bupropion Prospect theory describes the nonlinear relationship between objective outcomes (in terms of gains and losses from some reference point) and one's subjective reactions to them (Tversky & Kahneman, 1981). The framing implications of prospect theory suggest that individuals respond differently to factually equivalent messages depending on whether they are framed so as to emphasize benefits (gain-framed) or costs (loss-framed). This idea is applicable to messages intended to promote health (Rothman & Salovey, 1997). For example, with respect to sunscreen use, a gain-framed message is "Don't expose yourself to the sun, and you won't risk becoming sick," and a loss-framed message is "Don't protect yourself from the sun, and you won't help yourself stay healthy." Regarding smoking cessation, "You will live longer if Correspondence concerning this article should be addressed to Benjamin A. Toll, Yale University School of Medicine, Department of Psychiatry, 1 Long Wharf Drive, Box 18, New Haven, CT 06511. E-mail: benjamin.toll@yale.edu. NIH Public Access Author ManuscriptPsychol Addict Behav. Author manuscript; available in PMC 2008 December 1. NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript you quit smoking" is a gain-framed message, and "You will die sooner if you do not quit smoking" is a loss-framed message. Prospect theory suggests that if gains are made salient, people are averse to risk, and when losses are made prominent, individuals are risk-seeking. Even though the messages may be equivalent factually, the framing of the message can influence an individual's willingness to incur risk either to encourage a desirable outcome or avoid an outcome that is unwanted (Tversky & Kahneman, 1981).A review of the literature on mes...

Alcohol-tobacco interactions and relapse precipitants were examined among alcohol-dependent smokers in a trial of concurrent alcohol and tobacco treatment. After discharge from treatment, participants completed 14 days of electronic diary (ED) assessments of mood, self-efficacy, urges to drink or smoke, and drinking and smoking behavior. ED data revealed an increase in frequency of alcohol urges after smoking episodes. Drinking relapse episodes were predicted by prior ED ratings of low self-efficacy to resist drinking and high urge to smoke. Smoking relapse episodes were predicted by high urge to smoke and high negative, high arousal mood. Results support a cross-substance cue reactivity model of multiple substance use and a limited-strength model, but not a cross-substance coping model.

Little is known about the impact of alcohol involvement on smoking cessation relapse or possible mechanisms for these associations. We addressed these issues using data from a randomized clinical trial of 2 types of framed messages (gain vs. loss) in conjunction with open label sustained-release (SR) bupropion (Toll et al., 2007) (N = 249). Participants were categorized according to whether or not they were diagnosed with a lifetime alcohol use disorder (AUD; i.e., current or past alcohol abuse or past alcohol dependence) and according to 3 levels of alcohol use: abstinence, moderate or hazardous use. Alcohol use categories were established for drinking at baseline, during the 6-week treatment period and through 12 weeks post-quit. There were few significant differences by baseline alcohol use level or AUD history for a series of predictors of smoking cessation failure (e.g., depressive symptoms). During treatment and follow-up, the probability of any smoking on heavy drinking days was significantly higher than the probability of smoking on moderate drinking or abstinent days. AUD history did not predict smoking cessation relapse in any analysis, nor were any alcohol use × AUD history interactions significant. Moderate alcohol users and to a lesser extent, abstainers from alcohol at baseline were less likely than hazardous drinkers to have relapsed at 12 weeks post-quit. Based on these findings, it appears that risk of any smoking and of relapse was associated primarily with heavy drinking days and a hazardous pattern of use respectively, rather than with moderate drinking.