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Opioid use disorder (OUD) is a major public health issue and recovery is a long-term and complex process. Opioid Agonist Treatment (OAT) including medications such as methadone and buprenorphine, is the first-line medical intervention for OUD, however clinical responses among sub-populations differ and concurrent heroin use among individuals in OAT is reported. Contingency management (CM) is a behavioural intervention involving the application of positive reinforcement (e.g., monetary incentives) contingent upon evidence of positive behaviour change. CM is based on the theoretical principles of operant conditioning and is among the most efficacious psychosocial intervention in promoting substance use-related behaviours, including abstinence from smoking, alcohol and illicit drugs, medication adherence, vaccination uptake and attendance. Technology can be leveraged to expand the reach and accessibility of these interventions, automating key components of intervention delivery, including objective behaviour monitoring and immediate reward delivery. Currently, there are no fully remote CM interventions specifically targeting heroin use among individuals undergoing treatment for OUD, highlighting a critical need for innovation in addressing this complex aspect of substance use. Developing and delivering a fully digitalised app-based CM intervention for reducing heroin use among individuals in treatment for OUD holds considerable potential. This paper provides a protocol for a feasibility study that aims to determine the acceptability and feasibility of conducting a future randomised controlled trial of the clinical effectiveness of app-based CM to encourage heroin abstinence among clients receiving OAT in UK drug treatment services. Forty OAT service users in UK drug treatment services who continue to use heroin will be randomly assigned to either (1) OAT plus a smartphone app providing abstinence incentives or (2) standard OAT alone. Participants in the intervention arm will receive financial incentives contingent on heroin-negative toxicology results. Over a 12-week period, participants will receive thrice-weekly push notifications via the smartphone app when an oral saliva test is due. Participants will receive feedback upon submission and verified heroin-negative tests will result in notification of earnings. The primary outcome of this feasibility trial is the number of eligible service users recruited over the 6-month recruitment period. Other feasibility outcomes include intervention adherence, drug screening completion and follow-up rates. Acceptability will be explored among both clinicians and service users. Progression to a larger confirmatory trial will be evaluated based on the pre-specified progression criteria. Research on CM has grown exponentially over the last decade, with remote technologies being leveraged more than ever to expand the reach and scope of these interventions. This study will evaluate the feasibility of a mCM app to support heroin abstinence among OAT recipients. By integrating CM with mobile technology, this approach could enhance treatment accessibility and effectiveness, potentially improving outcomes for a high-risk population.

Limited information exist on tobacco and e-cigarette use patterns in cancer survivors. The purpose of this study is to report on use patterns in cancer survivors compared with non-cancer participants from the Population Assessment of Tobacco and Health (PATH) Study. Sociodemographic data and tobacco product use were analyzed for 32,244 adult participants from the PATH Study in 2013-2014 by cancer status and age. Logistic regression examined the patterns of and factors associated with tobacco use by cancer status. Overall, cancer survivors represented 7.1% (n = 1,527) of participants, were older, and had a higher proportion of females and non-Hispanic whites than non-cancer participants. In cancer survivors, current and former cigarette smoking was reported in 12.7% and 32.9% respectively, compared with 18.5% and 19.0% in non-cancer adults. Current e-cigarette use was reported by 3.8% of survivors compared with 5.7% of non-cancer participants. Dual tobacco use was reported by 25.0% and poly use by 6.9% of cancer survivors who currently smoked. All other forms of current tobacco use were individually reported by <5% of survivors. Young adult cancer survivors (aged 18-44) reported the highest rates of current cigarette smoking (27.9%) and current e-cigarette use (11.8%). The effects of age, sex, race/ethnicity, education, and income on tobacco use status were comparable for cancer survivors and non-cancer participants. Cancer survivors who were younger, male, of lower educational attainment, and those diagnosed with a tobacco-related cancer were more likely to report current tobacco use. Among cancer survivors, cigarette smoking remains the predominant form of tobacco use, although other tobacco/nicotine use and dual/poly use are common. The PATH Study provides detailed tobacco product use patterns in survivors, including their adoption of emerging alternative tobacco products.

Technology-based interventions to promote health are expanding rapidly. Assessing the preliminary efficacy of these interventions can be achieved by employing single-case experiments (sometimes referred to as n-of-1 studies). Although single-case experiments are often misunderstood, they offer excellent solutions to address the challenges associated with testing new technology-based interventions. This paper provides an introduction to single-case techniques and highlights advances in developing and evaluating single-case experiments, which help ensure that treatment outcomes are reliable, replicable, and generalizable. These advances include quality control standards, heuristics to guide visual analysis of time-series data, effect size calculations, and statistical analyses. They also include experimental designs to isolate the active elements in a treatment package and to assess the mechanisms of behavior change. The paper concludes with a discussion of issues related to the generality of findings derived from single-case research and how generality can be established through replication and through analysis of behavioral mechanisms.

Although tobacco use has significantly declined in the general population, traditional tobacco use treatment uptake and success rates remain disproportionately low among people who identify as African American/Black, Hispanic/Latina/o, and American Indian/Alaska Native. Technology-based interventions (TBIs) for tobacco use are promising alternatives to traditional tobacco use treatments. This scoping review aims to investigate the extent to which the use of digital TBIs in tobacco use treatment research promotes health equity among people who identify as African American/Black, Hispanic/Latina/o, and American Indian/Alaska Native. This scoping review identifies US-based studies (between January 2000 and March 2021) that enlist TBIs for tobacco use treatment and include people who identify as African American/Black, Hispanic/Latina/o, and American Indian/Alaska Native at ≥50% of the sample when combined; features studies that are also race and ethnicity conscious; and highlights health equity-promoting insights from included studies. In 85% (22/26) of the studies, the largest proportion of the sample was African American/Black, most participants had low socioeconomic status, and recruitment was most commonly from medical settings. In total, 58% (15/26) of the studies were race and ethnicity conscious, and 67% (10/15) of these studies sought to partner with potential end users. An array of TBIs were represented; however, SMS text messaging was most prevalent. Most TBIs were combined with other evidence-based intervention components (eg, nicotine replacement therapy). Approximately one-third of the studies (8/26, 31%) required participants to have their own device or internet access. The majority were underpowered to detect substantial differences. The modest number of studies, particularly for persons who identify as Hispanic/Latina/o and American Indian/Alaska Native, demonstrates the limited application of TBIs for tobacco use and that additional research is needed to determine the extent to which TBIs for tobacco use promote health equity among these populations. RR2-10.2196/34508.

Higher rates of delay discounting, or impulsive choice, may be related to relapse during abstinence reinforcement interventions for cigarette smoking, and a transdermal nicotine patch may attenuate delay discounting. The objectives of this study are to assess the relation between delay discounting and smoking after nicotine deprivation in a laboratory model of abstinence reinforcement and the effects of a transdermal nicotine patch on discounting and smoking. Smokers with no self-reported intention to quit were randomly assigned to an active (14 mg) or placebo patch group (n = 15 per group). In each of three sessions, after a 3-h deprivation period, participants completed a delay discounting task, mood, and craving measures and finally engaged in a laboratory model of abstinence reinforcement. Three abstinence reinforcement conditions were presented in counterbalanced order across the three sessions. During the control session, monetary consequences were delivered every 30 s regardless of smoking. During the low (5.00 dollars available) and high (20.00 dollars available) sessions, participants could earn a progressively increasing amount of money for each 30 s period of abstinence. The low and high conditions significantly increased the latency to smoke relative to control and significantly decreased the amount of smoking. The nicotine patch decreased negative affect, but it did not significantly affect delay discounting or smoking. Individuals who smoked during the low and high conditions showed higher rates of discounting. The patch did not attenuate delay discounting or smoking after a period of deprivation, but contingencies for abstinence significantly decreased smoking. Higher rates of delay discounting were related to smoking in a model of abstinence reinforcement treatment.

Problematic internet use (PIU) is of increasing concern to society and is correlated with negative behavioral and health issues. Human laboratory procedures to assess economic demand for internet use may be useful in translational efforts to better understand PIU and to assess potential treatments. One such procedure involves hypothetical purchases of access to internet use. Little is known about how such hypothetical purchases relate to actual behavior. In the current study, we assessed the correlation between measures of demand via an internet purchase task (IPT) and breakpoints on a progressive ratio (PR) schedule (n = 52). Participants responded on a computer-based task on an escalating work requirement that resulted in 30-s of access to their internet-enabled smartphone. We found a statistically significant correlation between demand intensity (Qo) and total responses (r(29) = .83, p < .001), and between Omax (maximum response expenditure) and total responses (r(29) = .34, p = .03) on the PR schedule. We did not find a relationship between measures of demand elasticity and measures of PR behavior. Because Omax is reflective of both demand and elasticity and Q0 is primarily influenced by demand alone, the results of this study indicate that demand intensity of internet use may be a better predictor of real-world behavior than other measures of demand. These results suggest that demand intensity for internet access may be a valuable proxy for behavior-based measures in the assessment and treatment of PIU.

Smoking is the leading cause of preventable death in the United States and imposes a substantial economic cost. Despite the well-established potential harm, relapse rates remain high during quit attempts. In the realm of applied behavior analysis, functional assessment has long been recognized as a reliable method to increase effectiveness of treatments for a variety of problem behaviors. Functional assessment may aid in designating targeted treatment for smokers based on the maintaining function(s) of the behavior. The current study (N = 414) sought to assess the reliability and validity of the Functional Assessment of Smoking for Treatment Recommendations (FASTR) and provide preliminary evidence towards a hypothesized factor structure. The full FASTR included five subscales derived from the field of functional behavior assessment: 1) Automatic Positive Reinforcement, 2) Social Positive Reinforcement, 3) Automatic Negative Reinforcement, 4) Social Negative Reinforcement, and 5) Antecedent Stimuli. The full battery of subscales was found to be adequately reliable and valid, with overall sample reliability coefficients ranging from α = 0.69 to α = 0.90. Confirmatory factor analysis of the five-factor model produced acceptable fit indices (CFI = 0.908, TLI = 0.896, RMSEA = 0.059, SRMR = 0.071). A five-factor model performed favorably across several fit indices, providing preliminary validity for the FASTR. Further research should aim to replicate the observed factor structure in other samples and establish the clinical utility of the FASTR.

Background: Opioid maintenance treatment (OMT) is the standard for treatment of opioid use disorder, but some individuals on OMT experience disrupted sleep, heightened sensitivity to pain, and continued relapse to non-medical opioid use. An adjunctive treatment that has potential to address these shortcomings of OMT is aerobic exercise. Objective: The aim of the present review was to identify and evaluate components of aerobic exercise interventions targeting OMT patients. Methods: For this PROSPERO-registered review (ID CRD42020139626), studies were identified via electronic bibliographic databases, funded research (NIH RePORTER) and clinical trials databases (ClinicalTrials.gov), and reference sections of relevant manuscripts. Studies that evaluated the effects of an aerobic exercise intervention using a comparison condition or pretest-posttest design in adult OMT patients were included. Results: Of 2971 unique records, three primary studies and one supplemental manuscript comprised the final sample. All studies were randomized trials involving supervised exercise interventions enrolling small samples of middle-aged OMT patients. Exercise interventions included a variety of aerobic and non-aerobic activities (e.g. flexibility exercises), and none controlled the dose of aerobic exercise. Few studies used objective measures of physical activity or cardiorespiratory fitness and there were no significant effects of adjunctive exercise on substance use outcomes, but tests of the latter were likely underpowered. Conclusions: Though early in the accumulation of evidence, interventions targeting aerobic exercise for OMT patients appear feasible, acceptable to patients, and beneficial. Longer-term studies that employ larger samples, include assessments of behavioral and biological mechanisms of change, more rigorous measurement of physical activity, and controlled doses of aerobic activity are warranted.

Smoking, obesity, and insufficient physical activity are modifiable health risk behaviors. Self-regulation is one fundamental behavior change mechanism often incorporated within digital therapeutics as it varies momentarily across time and contexts and may play a causal role in improving these health behaviors. However, the role of momentary self-regulation in achieving behavior change has been infrequently examined. Using a novel momentary self-regulation scale, this study examined how targeting self-regulation through a digital therapeutic impacts adherence to the therapeutic and two different health risk behavioral outcomes. This prospective interventional study included momentary data for 28 days from 50 participants with obesity and binge eating disorder and 50 participants who smoked regularly. An evidence-based digital therapeutic, called Laddr™, provided self-regulation behavior change tools. Participants reported on their momentary self-regulation via ecological momentary assessments and health risk behaviors were measured as steps taken from a physical activity tracker and breathalyzed carbon monoxide. Medical regimen adherence was assessed as daily Laddr usage. Bayesian dynamic mediation models were used to examine moment-to-moment mediation effects between momentary self-regulation subscales, medical regimen adherence, and behavioral outcomes. In the binge eating disorder sample, the perseverance [  = 0.17, 95% CI = (0.06, 0.45)] and emotion regulation [  = 0.12, 95% CI = (0.03, 0.27)] targets of momentary self-regulation positively predicted Laddr adherence on the following day, and higher Laddr adherence was subsequently a positive predictor of steps taken the same day for both perseverance [  = 0.335, 95% CI = (0.030, 0.717)] and emotion regulation [  = 0.389, 95% CI = (0.080, 0.738)]. In the smoking sample, the perseverance target of momentary self-regulation positively predicted Laddr adherence on the following day [  = 0.91, 95% CI = (0.60, 1.24)]. However, higher Laddr adherence was not a predictor of CO values on the same day [  = -0.09, 95% CI = (-0.24, 0.09)]. This study provides evidence that a digital therapeutic targeting self-regulation can modify the relationships between momentary self-regulation, medical regimen adherence, and behavioral health outcomes. Together, this work demonstrated the ability to digitally assess the transdiagnostic mediating effect of momentary self-regulation on medical regimen adherence and pro-health behavioral outcomes. ClinicalTrials.gov, identifier (NCT03774433).

Self-regulation has been implicated in health risk behaviors and is a target of many health behavior interventions. Despite most prior research focusing on self-regulation as an individual-level trait, we hypothesize that self-regulation is a time-varying mechanism of health and risk behavior that may be influenced by momentary contexts to a substantial degree. Because most health behaviors (e.g., eating, drinking, smoking) occur in the context of everyday activities, digital technologies may help us better understand and influence these behaviors in real time. Using a momentary self-regulation measure, the current study (which was part of a larger multi-year research project on the science of behavior change) used ecological momentary assessment (EMA) to assess if self-regulation can be engaged and manipulated on a momentary basis in naturalistic, non-laboratory settings. This one-arm, open-label exploratory study prospectively collected momentary data for 14 days from 104 participants who smoked regularly and 81 participants who were overweight and had binge-eating disorder. Four times per day, participants were queried about momentary self-regulation, emotional state, and social and environmental context; recent smoking and exposure to smoking cues (smoking sample only); and recent eating, binge eating, and exposure to binge-eating cues (binge-eating sample only). This study used a novel, momentary self-regulation measure comprised of four subscales: momentary perseverance, momentary sensation seeking, momentary self-judgment, and momentary mindfulness. Participants were also instructed to engage with Laddr, a mobile application that provides evidence-based health behavior change tools an integrated platform. The association between momentary context and momentary self-regulation was explored mixed-effects models. Exploratory assessments of whether recent Laddr use (defined as use within 12 h of momentary responses) modified the association between momentary context and momentary self-regulation were performed mixed-effects models. Participants (mean age 35.2; 78% female) in the smoking and binge-eating samples contributed a total of 3,233 and 3,481 momentary questionnaires, respectively. Momentary self-regulation subscales were associated with several momentary contexts, in the combined as well as smoking and binge-eating samples. For example, in the combined sample momentary perseverance was associated with location, positively associated with positive affect, and negatively associated with negative affect, stress, and tiredness. In the smoking sample, momentary perseverance was positively associated with momentary difficulty in accessing cigarettes, caffeine intake, and momentary restraint in smoking, and negatively associated with temptation and urge to smoke. In the binge-eating sample, momentary perseverance was positively associated with difficulty in accessing food and restraint in eating, and negatively associated with urge to binge eat. While recent Laddr use was not associated directly with momentary self-regulation subscales, it did modify several of the contextual associations, including challenging contexts. Overall, this study provides preliminary evidence that momentary self-regulation may vary in response to differing momentary contexts in samples from two exemplar populations with risk behaviors. In addition, the Laddr application may modify some of these relationships. These findings demonstrate the possibility of measuring momentary self-regulation in a trans-diagnostic way and assessing the effects of momentary, mobile interventions in context. Health behavior change interventions may consider measuring and targeting momentary self-regulation in addition to trait-level self-regulation to better understand and improve health risk behaviors. This work will be used to inform a later stage of research focused on assessing the transdiagnostic mediating effect of momentary self-regulation on medical regimen adherence and health outcomes. ClinicalTrials.gov, Identifier: NCT03352713.