A Case Series of a Behavioral Activation−Enhanced Smoking Cessation Program for Inpatient Substance Users With Elevated Depressive Symptoms

Abstract

Smoking is the leading preventable cause of death and disease in the world and represents a critical public health problem. Smokers with substance use disorders and depressive symptoms have particular difficulties quitting smoking and represent an underserved population. The current study utilized a novel behavioral activation (BA)−enhanced smoking cessation treatment with three clients in residential substance use treatment who had elevated depressive symptoms. We present detailed descriptions of the treatment they received and the challenges they faced. Our clients, who received five individual BA-enhanced smoking cessation sessions and two follow-up booster sessions, benefited significantly from the BA treatment. Over an 8-week follow-up period, they did not relapse to smoking and experienced significant decreases in depressive symptoms. This suggests BA may be a beneficial treatment strategy for this particularly challenging population.

Keywords

smoking cessation substance users behavioral activation depressive symptoms

1 Theoretical and Research Basis for Treatment

Tobacco use is the leading non-infectious cause of death and disease worldwide; half of people who smoke will die from smoking-related causes (World Health Organization, 2013). In the United States, 20% of deaths, or about 450,000 deaths annually, are related to smoking, which is more than the number of deaths caused by motor vehicle injuries, suicide, HIV, drug and alcohol use, and murder combined (Centers for Disease Control and Prevention, [CDC] 2008). Population-based studies suggest 50% of cigarettes consumed are purchased by individuals with psychiatric or substance use disorders (SUDs; Schroeder & Morris, 2010), who have higher rates of nicotine dependence (Prochaska, Delucchi, & Hall, 2004; Ziedonis et al., 2008) and who have significant difficulties quitting smoking (e.g., Weinberger, Mazure, Morlett, & McKee, 2013; Weinberger, Pilver, Desai, Mazure, & McKee, 2013; Weinberger, Pilver, Hoff, Mazure, & McKee, 2013). Importantly, tobacco smoking, not drug or alcohol use, is the largest contributor to mortality among substance users (Hser, McCarthy, & Anglin, 1994; Hurt et al., 1996), demonstrating the overwhelming significance of tobacco use in this population. Because of these disparities, it is critical to develop effective smoking cessation programs targeting combined mood and substance use vulnerabilities.

Despite these known health risks, clinicians treating individuals with SUDs and depression typically do not advise their clients to quit smoking, nor do they provide treatments to support cessation efforts (Guydish et al., 2011; Prochaska, 2010). These practices may be due in part to assumptions that smoking cessation increases clients’ likelihood of relapsing to substances, causes exacerbation of psychiatric symptoms (Fuller et al., 2007; Prochaska, Fromont, Louie, Jacobs, & Hall, 2006), or is not as immediate a priority as abstinence from other substance use (Prochaska, 2010). However, there have been multiple studies demonstrating smoking cessation does not interfere with treatments for depression (e.g., Lawn & Pols, 2005; Prochaska et al., 2008) or SUDs (Prochaska et al., 2004; Tsoh, Chi, Mertens, & Weisner, 2011). Unfortunately, despite clear negative health-related consequences associated with smoking, few clinicians advise their clients to quit smoking because of these concerns. In addition, low cessation rates observed in these groups may discourage clinicians from even suggesting cessation. Overall, this lack of attention to smoking not only indicates the need for better dissemination efforts but also suggests the importance of developing effective treatments clinicians can easily implement.

The available research suggests individuals with comorbid SUDs and depressive symptoms represent an important population to target in smoking cessation programs because of their combined mood and substance-related vulnerabilities and because of the challenges they face when attempting to quit smoking. Among these smokers, the benefits of recommended cessation treatments such as nicotine replacement therapy (NRT) and cognitive behavioral therapy (CBT) for smoking cessation are less robust than they are among the general population (e.g., Kinnunen, Korhonen, & Garvey, 2008; Prochaska et al., 2004; Weinberger, Mazure, et al., 2013), although see more recent stage-based work by Prochaska and colleagues (e.g., Hall & Prochaska, 2009; Prochaska, Hall, Delucchi, & Hall, 2013). Thus, individuals with SUDs and depressive symptoms who wish to quit smoking may require targeted treatment techniques to support their quit attempts.

Treatments specifically targeting smoking cessation among individuals with SUDs have utilized NRT, CBT, and contingency management (Okoli et al., 2010); behavioral therapy (Joseph, Willenbring, Nugent, & Nelson, 2004); content focused on depressive symptoms (Baca & Yahne, 2009); and group counseling (Reid et al., 2008). However, despite utilizing the best available practices to target cessation within this population, abstinence rates are still particularly low. For example, only 5% to 6% of individuals with SUDs who received NRT + nine CBT sessions were abstinent from cigarettes at a 13-week follow-up visit, as compared with 0% of individuals who did not receive treatment (Reid et al., 2008). Similarly, a smoking cessation treatment that included NRT and four 1-hr individual behavioral therapy sessions for individuals with alcohol use disorders had abstinence rates of 13% at an 18-month follow-up (Joseph et al., 2004). Because of this, tailored treatments based on individual client needs have been suggested as an important alternative (e.g., Cohen & McChargue, 2006; Cooper, Hanson, Burke, & Hunt, 2008). Overall, smoking cessation programs aimed at individuals with SUDs have produced mixed outcomes because of the challenges individuals with SUDs bring to treatment.

Similarly, a number of cessation programs have been developed for smokers with elevated depressive symptoms, including those targeting motivation using stage-based treatment models (Hall et al., 2006) and mood management and depression via CBT (Batra et al., 2010; Brown et al., 2007). However, despite significant advances in smoking cessation therapies for individuals with depressive symptoms, low cessation rates continue to be observed (e.g., Weinberger, Mazure, et al., 2013). Interestingly, meta-analytic work suggests that targeting improvements in clients’ moods benefits cessation outcomes (Gierisch, Bastian, Calhoun, McDuffie, & Williams, 2012), implying it is essential to focus on mood improvements during cessation attempts.

Based on these prior challenges, there have been attempts to develop unique treatment strategies to address the needs of individuals with depressive symptoms and SUDs. Recently, researchers have targeted both reductions in negative moods and increases in positive affect via behavioral activation (BA), with the intent of increasing abstinence from cigarettes and drugs. BA focuses on helping individuals to become involved in meaningful, enjoyable activities that resonate with their values across a variety of life areas (Hopko, Lejuez, Ruggiero, & Eifert, 2003). Engagement in positive rewarding activities through BA has been shown to reduce depressive symptoms (Lejuez, Hopko, Acierno, Daughters, & Pagoto, 2011; Lejuez, Hopko, LePage, Hopko, & McNeil, 2001; Martell, Addis, & Jacobson, 2001) and has recently been integrated into smoking cessation treatment (MacPherson et al., 2010) and substance use treatment (Daughters et al., 2008). Within smoking cessation, MacPherson and colleagues (2010) compared standard smoking cessation treatment with a BA-enhanced smoking cessation treatment (BATS) and found smokers receiving BATS had significantly improved smoking and depressive symptom outcomes, as compared with those receiving smoking cessation treatment. Similarly, BA has been successfully used to target depressive symptoms and reduce dropouts from residential substance use treatment among individuals with SUDs (Daughters et al., 2008). Taken together, these findings suggest BA may help to address the unique needs of substance users with elevated depressive symptoms.

We developed a novel BA-enhanced smoking cessation intervention, as a part of a larger ongoing randomized control trial (RCT), and administered it to three smokers with elevated depressive symptoms in an urban residential substance use treatment center in the mid-Atlantic. The Behavioral Activation for Drug Abusing Smokers (BA-DAS) treatment protocol was developed in an iterative fashion using strategies tested among community smokers with elevated depressive symptoms (MacPherson et al., 2010) and substance users with elevated depressive symptoms (Daughters et al., 2008). As compared with MacPherson and colleagues’ (2010) protocol, the BA-DAS treatment included simplified consolidated monitoring forms, treatment manual text compatible with a fifth grade reading level, and five sessions of individualized treatment over 2½ weeks (as opposed to weekly group-based sessions), with two 15-min booster sessions. Client and therapist feedback during initial sessions informed different iterations of the treatment manual over time. Clients described here all received treatment using the finalized manual. The treatment included key elements of psychosocial treatment for smoking cessation (Fiore et al., 2008), NRT (Fiore, Jorenby, Baker, & Kenford, 1992), and elements of BA to target elevated depressive symptoms and support cessation attempts (Lejuez et al., 2011; MacPherson et al., 2010). Our goal was to reduce clients’ chances of relapsing by increasing positive affect and reducing negative affect, through the use of BA. Because even low-level depressive symptoms negatively affect cessation (Weinberger, Pilver, Desai, et al., 2013), we expected directly targeting symptoms would increase cessation.

Treatment was delivered across five 60- to 90-min individual therapy sessions over 2½ weeks. Clinical psychology doctoral students, who trained extensively in smoking cessation and BA techniques, provided treatment. Therapists received weekly supervision with the treatment developer (L.M.). Therapy was audiotaped and reviewed to ensure treatment compliance. Clients’ quit dates were scheduled to occur on the day of the third treatment session. Two 15-min follow-up sessions occurred 2 and 4 weeks post quit. We hypothesized our clients (a) would not relapse to smoking, (b) would evidence significant reductions in depressive symptoms, and (c) would not relapse to substance use. All outcomes were assessed pre-treatment, on quit day, at the final treatment session, at booster treatment sessions 2 and 4 weeks post quit, and at an 8-week follow-up. Although a longer-term follow-up would have been ideal, within the constraints of this pilot, follow-ups beyond 8 weeks were not feasible.

2 Case Introduction

The three clients included in this case series were inpatients at a substance use treatment center in the mid-Atlantic, who participated in the open-label pilot phase of a larger ongoing RCT. The majority of clients at this treatment center are low-income, African Americans who are court-mandated to treatment. We recruited our clients within their first 7 to 10 days post admission to the treatment center. Our clients met the following inclusion criteria: (a) had a Beck Depression Inventory−II (BDI-II; Beck, Brown, & Steer, 1996) score of 7+, in line with MacPherson and colleagues (2010); (b) endorsed 5+ on a scale from 1 to 10 for motivation to quit smoking; and (c) smoked 5+ cigarettes/day for at least the past year. We excluded clients from this case series who (a) had psychotic symptoms, (b) used non-combustible tobacco products, (c) had physical concerns preventing NRT usage, or (d) began taking psychotropic medications within the prior 3 months.

Case 1: “George” was a heterosexual African American male in his 40s who was court-mandated to attend residential substance use treatment.

Case 2: “Thomas” was a heterosexual African American male in his early 50s who voluntarily admitted himself to residential substance use treatment.

Case 3: “Larissa” was a heterosexual African American female in her late 20s who voluntarily admitted herself to residential substance use treatment.

3 Presenting Complaints

Case 1

Prior to entering our treatment, George smoked 8 to 10 cigarettes daily, for “stress relief.” In line with the BA-DAS treatment rationale, he noted he particularly craved cigarettes when feeling down, irritable, or anxious, and when using drugs. He reported difficulties finding work as a major stressor, which affected his ability to financially support himself and his children; he and his daughters lived with his mother. Securing employment was a major post-treatment goal for George. He wanted to quit smoking for health reasons (an aunt died of cancer), to be a better role model to his daughters, and to save money.

Case 2

Prior to entering our treatment, Thomas smoked 14 to 20 cigarettes daily. He attributed his failure to quit permanently to feeling irritable when not smoking and to often being around smokers. He strongly associated cigarettes with drinking and drug use; his relapse to cigarettes usually occurred when using substances. His main reason for wanting to quit smoking was health related. He stated, “Cigarettes are why my mother died.” He also wanted to save money; he and his therapist estimated he spent $2,920 annually on cigarettes. Finally, he stated, “Smoking has to go in order for me to stay sober and off drugs.” Difficulties finding employment and a stable housing situation were major stressors for him.

Case 3

Prior to entering our treatment, Larissa smoked 7 to 9 cigarettes daily. She wanted to quit smoking to be “a better role model” for her children and to be physically healthier. Larissa reported frequently smoking when feeling depressed or irritable and noted her mood was often linked to the types of activities she completed daily. Lack of employment was a major stressor for Larissa, as she had been suspended from her job because of her substance use.

4 History

Case 1

George began drinking and using marijuana when he was 17 years old and smoking crack cocaine when he was 21 years old. He first smoked cigarettes at age 13. He quit smoking for 18 months while incarcerated, but immediately resumed smoking on release. He reported having a supportive family he would be living with post substance use treatment.

Case 2

Thomas first drank alcohol at age 9, began drinking heavily at 17, and began smoking crack/cocaine when he was 29. He first started smoking cigarettes when he was 9 years old. He reported quitting smoking several times in the past, with his most recent quit attempt lasting 5 weeks in 2010. Thomas reported being homeless prior to entering treatment.

Case 3

Larissa began using phencyclidine (PCP) when she was 18 years old and used marijuana from ages 13 to 17. She began smoking cigarettes when she was 14 years old. She was employed full-time prior to attending treatment, but was temporarily suspended from her job after receiving several Driving Under the Influence (DUI) charges. She quit smoking during her three pregnancies, but resumed smoking post birth because “the baby was no longer at risk.” Larissa reported her family was supportive and that she would be living with her parents and children, in a home she owned, post treatment.

5 Assessment

There were a number of parameters in place to increase clients’ willingness to provide accurate information during assessments. We informed clients at every assessment session that the information they provided would be kept confidential to minimize their fears that this information would be relayed to treatment center staff or to probation/parole officers.

Smoking and Substance Use Measures

During our baseline interview, clients provided information about their daily cigarette and substance use during the prior 90 days on the Time Line Follow Back (TLFB; Sobell & Sobell, 1978, 1996). They completed the TLFB at the third session; fifth session; and at 2-, 4-, and 8-week follow-ups. As is standard, relapse was defined as smoking one cigarette/day for 7 days in a row, or smoking five cigarettes/day for 3 days in a row (Shiffman, et al., 2006). Expired carbon monoxide (CO; 10ppm cutoff) via a Vitalograph Breathco was used to verify self-reported cigarette abstinence, whereas urinalysis tests verified drug abstinence. Nicotine dependence was assessed via the Fagerstrom Test for Nicotine Dependence (FTND; Heatherton, Kozlowski, Frecker, & Fagerström, 1991).

Diagnoses and Depressive Symptoms

The Structured Clinical Interview for DSM-IV (SCID-IV (First, Spitzer, Gibbon, & Williams, 1995) assessed for Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV; American Psychiatric Association [APA], 1994) Axis I and II disorders. The BDI-II (Beck, Brown, & Steer, 1996) assessed clients’ depressive symptoms. A score of 0 to 13 on the BDI-II indicates low-level depressive symptoms (Beck et al., 1996) that negatively affect cessation rates (Berlin & Covey, 2006; Weinberger, Pilver, Desai, et al., 2013).

Case 1

George had a 12th-grade reading level and met DSM-IV diagnostic criteria for cannabis, cocaine, and alcohol dependence. He did not meet diagnostic criteria for other Axis I diagnoses, although he had depressive symptoms (his BDI score was 26, indicating moderate depressive symptoms). His FTND score was 7, indicating moderate nicotine dependence. George reported previously being prescribed psychiatric medications, but stopped taking them because he did not like how they made him feel; he could not recall which medications he tried.

Case 2

Thomas had a 12th-grade reading level and met DSM-IV criteria for cocaine dependence, alcohol dependence, and major depressive disorder. His BDI score was 32 (which indicates severe depressive symptoms). He reported past depressive episodes and sexual abuse. His FTND score was 4, indicating low to moderate nicotine dependence. Thomas was prescribed Seroquel and Elavil in 2011, but had been unmedicated for the past 2 years.

Case 3

Larissa had an 11th-grade reading level and met DSM-IV diagnostic criteria for PCP dependence, major depressive disorder, and generalized anxiety disorder. Her BDI score was 14 (indicating mild depression). She also met diagnostic criteria for past cannabis dependence. Her FTND score was 5, indicating moderate nicotine dependence. Larissa reported taking Seroquel for sleep problems and Trazodone for her mood.

6 Case Conceptualization

BA strategies focused on helping clients develop rewarding, smoke-free lifestyles. Based on research demonstrating a relationship between low-level depressive symptoms and poor cessation rates (Berlin & Covey, 2006; Weinberger, Pilver, Desai, et al., 2013), we targeted increases in positive affect and decreases in negative affect, to increase cessation in line with these mood changes. BA components (see Lejuez et al., 2011) included (a) daily completion of an activity and smoking log; (b) identification of important life areas (i.e., Relationships, Career/Education, Free Time, and Wellness) and values (things individuals cared about and prioritized within these life areas); (c) selection of activities enabling clients to live their lives according to these values; (d) formulation of a schedule to determine when activities would be performed; (e) assessment of activity completion and modification of activities when necessary; and (f) enlistment of social support through behavioral contracts (Table 1).

Table 1.

BA-DAS Session Content.

Session 1: Discussion of reasons for quitting and provision of treatment rationale

Provide clients with the treatment rationale linking low mood to difficulties quitting smoking

Introduce daily activity, smoking, and mood monitoring form (completed hourly)^a

Review previous quit attempts and prior strategies used

Discuss high-risk situations for smoking

Discuss financial, health, hygiene, and substance use related motives for quitting

Set quit date

Discuss importance of social support and environmental modifications

Session 2: Determination of values and scheduling of activities

Review daily activity, smoking, and mood monitoring form^a

Reflect on importance and enjoyment associated with activities completed^a

Connect importance/enjoyment of activities completed with mood and cigarettes smoked^a

Identify clients’ values and activities they can do to live life according to their values

Schedule activities, based on the prior exercise, to be completed before the following session^a

Discuss “avoid, alter, substitute” strategies^a

Introduce the NRT patch, including the application, side effects, and dose

Session 3: Quit day

Discuss the client’s quit attempt and problem solve if the client had challenges^a

Review activity completion^a

Discuss the abstinence violation effect

Discuss the benefits and/or challenges associated with the NRT patch^a

Session 4: Discussion of quit attempt and creation of contracts

Create in-treatment contracts to support activity completion

Session 5: Post-treatment planning

Review the in-treatment contract

Identify post-treatment activities in line with clients’ values

Create post-treatment contracts to support post-treatment activity completion

Discuss benefits experienced related to quitting

Sessions 6 and 7:

Discuss post-treatment abstinence challenges

Discuss post-treatment activity monitoring and planning

Discuss “avoid, alter, substitute” strategies

Note. BA-DAS = Behavioral Activation for Drug Abusing Smokers; NRT = nicotine replacement therapy.

Treatment components that are repeated through Session 5.

Details from three cases will be presented to illustrate how different clients responded to the BA-DAS intervention. Examples of client values and activities will be given to demonstrate how clients engaged in the treatment and how the treatment was personalized to individual clients’ needs. For each case, only a few examples of individual values and related activities will be presented, rather than presenting all of the values and activities reported by clients.

7 Course of Treatment and Assessment of Progress

Case 1

George easily grasped the treatment rationale and resonated strongly with the connections made between negative affect and smoking. Within the context of daily activity monitoring, he noticed many of the activities he was completing were not particularly enjoyable or important. He drew connections between these activities and his low mood. Following this, he and the therapist discussed his desire to smoke when feeling irritable, bored, or down. This provided the basis for discussing the importance of adding enjoyable and important activities to his daily schedule to improve his mood and support his quit attempt.

George identified his values and related activities within the BA framework. Within the life area Relationships, he particularly valued being a good role model to his daughters and being dependable. The therapist and George explored a variety of activities he could complete to live his life according to these values. While in treatment, he chose to make at least one comment daily in his treatment groups, which he reported to his daughters in his letters. By engaging more actively in his treatment groups and regularly writing letters to his daughters, he believed he was being a good role model and demonstrating his ability to be dependable to them, which were important values to him. Post-treatment family activities included attending church, studying the Bible, going to the movies, and having family dinners.

A briefer description of values and activities related to Career, Wellness, and Free Time will be provided to give a general sense of George’s priorities within these areas. Within the life area Career, he valued having an enjoyable and reliable job. Related activities included seeking résumé help, getting information about job training, contacting his case manager about jobs, and practicing answering questions about his incarceration history. Within the life area Wellness, he valued being physically healthy, having a personal relationship with God, and developing coping skills. Related activities included playing basketball, eating vegetables, attending church, discussing his faith, and attending therapy. Within the life area Free Time, he valued being active and relaxed. Related activities included taking walks, going to museums, playing sports, reading magazines, and watching movies/television. The corresponding mood improvements after completing these activities was important in supporting George’s quit attempt.

George regularly completed scheduled activities across multiple life areas between Sessions 3 and 5. Because clients’ schedules at the treatment center included little free time, activity completion required George to be creative. Frequently, he scheduled activities when other clients were taking smoke breaks, or before bed. The therapist encouraged George to select activities he could schedule for 5- to 30-min blocks to increase the likelihood of activity completion, as well as his sense of accomplishment. For example, to write a letter to his daughters, he separately scheduled finding a stamp and envelope, writing the letter, and mailing it.

During the following sessions, George and his therapist focused on activity completion and how his mood and smoking were affected by it. The therapist regularly reinforced the connections between activity completion, mood improvements, and reduced urges to smoke. On George’s quit day, he did not smoke any cigarettes, had completed his scheduled activities, and was wearing his NRT patch. Although he wanted to go outside during the four smoke breaks scheduled at the treatment center during the day, he decided to pray, read, and exercise instead. He did not report experiencing any negative affect but rather reported feeling proud because of his success. He reported he not only was completing alternative activities during scheduled smoke breaks but also was engaging in enjoyable and important activities that positively affected his mood throughout the day. The fifth session with George focused on the progress he had made and on post-treatment planning. The therapist and George scheduled activities to complete during the post-treatment week and discussed high-risk situations he would encounter.

Case 2

Thomas easily grasped the treatment rationale because his failed quit attempts were largely due to feelings of boredom and irritability. He agreed building a new lifestyle, including activities he valued, would be important to his quit attempt. Wellness was his most important life area. Within this area, he valued having a close relationship with God and sharing his faith. Related activities included talking about spirituality, directing the church choir, performing in the church play, and praying. Other Wellness values included being physically and emotionally healthy. Related activities included walking, eating vegetables, taking medications, attending therapy, spending time with supportive people, and reading self-help books.

More briefly, within the life area Relationships, he valued being a good parent and re-establishing contact with his youngest daughter, whom he had not seen in 13 years. Related activities included writing a letter to his daughter and offering to babysit his grandchildren. Another value was to establish and maintain sober friendships. Related activities included introducing himself to others in the center with similar goals and attending Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings. Within the life area Career, he valued having a stable career in the food service industry. Related activities included enrolling in culinary school, obtaining his food handler’s license, and contacting former colleagues. With his therapist, he discussed how to break larger activities such as “getting culinary arts training” into smaller steps such as “obtain and fill out an application for classes.” Within the life area Free Time, he valued helping others and enjoying life. Related activities included ministering, shooting pool, reading, visiting hospitals, working with the elderly, going to the movies, and swimming.

Thomas was very active during treatment and did not smoke any cigarettes post quit. He scheduled and completed many activities in the center across multiple life areas. However, many of the activities he scheduled were important but not enjoyable. For example, writing a letter to his daughter was important but emotionally draining; his enjoyment ratings for this activity were low. The therapist discussed the importance of not only including important activities but also selecting enjoyable activities to combat his irritable mood, especially because irritability was a main trigger for smoking. Thomas added more activities in the life area Free Time, such as shooting pool and reading for pleasure to boost his mood.

Thomas and his therapist spent his fifth session formulating a post-treatment plan. Post-treatment activities Thomas scheduled included attending AA/NA meetings, attending mental health appointments, volunteering at church, applying for food service classes, reporting to his parole officer, and contacting a temp agency for work. Thomas and his therapist also discussed high-risk situations he might encounter post treatment and how to cope with them. Specifically, smelling smoke was his “number one trigger,” which he planned to avoid by staying where smoking was prohibited, or avoiding smokers when outside. He left treatment feeling positive about his progress and the new lifestyle he was building. He had not smoked since quit day and had handled high-risk situations by planning alternative activities and using coping strategies.

Case 3

In line with the treatment rationale, Larissa reported frequently smoking when feeling depressed or irritable and noted her mood was often linked to the types of activities she completed daily. She recognized she was completing few enjoyable activities at the treatment center, which affected her mood negatively and increased her desire to smoke. She quickly determined her values across multiple life areas and easily translated her values into activities.

Within the life area Career, she valued having job security and being a reliable employee. Post treatment, she intended to re-apply for the job she lost prior to treatment because it was a well-paying position with the potential for advancement. Importantly, being re-hired was contingent on successfully completing substance use treatment. In turn, staying sober was critical to her value of being a more reliable employee and having job security. Related activities included finding an NA sponsor, talking on the phone/meeting weekly with this sponsor, and practicing waking up early while in treatment to maintain that schedule outside of treatment. These activities not only would increase her reliability but also would increase the likelihood she would be able to resume working at her prior employer post treatment.

A briefer description of values and activities related to Relationships, Wellness, and Free Time is provided below to give a general sense of Larissa’s priorities within these areas. Within the life area Relationships, she valued being someone her children could trust and being a supportive mother. Related activities included attending NA meetings, going to church with her children, and taking them to the park. Church and NA meeting attendance were relevant because lessons learned would help her become a more trustworthy and supportive mother. Within the life area Wellness, she valued having a healthy mind and body. Related activities included getting a gym membership, using a stationary bike, drinking eight glasses of water daily, eating three servings of vegetables daily, attending therapy, and reading self-help books. Within the life area Free Time, she valued being able to let her “brain rest.” Related activities included taking baths, watching television and movies, taking walks, and talking with close friends. She believed completing these activities would increase her sense of enjoyment and accomplishment, thereby improving her mood and supporting her quit attempt.

On Larissa’s quit day, she had not smoked any cigarettes, had completed her scheduled activities, and was wearing her NRT patch. She reported feeling proud and was excited to tell her children she had quit. She reported craving a cigarette in the morning but choosing to clean the cafeteria to “keep busy” and avoid going outside. During her quit day therapy session, the therapist and Larissa planned several rewarding activities she could complete to boost her mood and support her quit attempt. The therapist and Larissa also discussed potential high-risk situations for smoking and discussed strategies Larissa could use to avoid smoking.

Larissa did not complete her scheduled activities prior to Session 4. She initially was less talkative during this session, and it was more challenging than usual to engage her in the session content. She mentioned her mother was in the hospital and that she had been unable to obtain updates regarding her mother’s health. She reported having a slip prior to Session 4 when she received news of her mother’s hospitalization. Despite this setback, her mother’s poor health reminded her of her commitment to her own health. Because of this, the therapist and Larissa focused primarily on completing relaxing activities and activities that would help her feel more in control of her life to support her quit attempt. Therefore, she scheduled writing a letter to her mother, using the exercise bike daily, and praying every morning.

During the fifth session, the therapist and Larissa focused on her post-treatment plan. She reported she had not smoked since the prior meeting, and the therapist and Larissa discussed how she could maintain abstinence both by planning activities that would boost her mood using BA as well as with avoid, alter, substitute strategies. She made plans to join a gym, cook dinner four times weekly, call her fiancé daily (he was incarcerated), attend four NA meetings weekly, and pick her children up from school daily. The therapist and Larissa discussed multiple strategies she could use to request others avoid smoking in her presence. They also explored strategies she could use if they did smoke. She reported this would be particularly challenging because her parents lived in her home and smoked regularly.

8 Complicating Factors

There are a number of environmental factors that can help explain why substance users in particular have difficulties quitting smoking. First, substance users’ peers and family members are more likely to smoke (Burling, Ramsey, Seidner, & Kondo, 1997), the majority of substance users live with smokers (Orleans & Hutchinson, 1993), and the majority of substance users’ peers in substance use treatment smoke (Prochaska et al., 2004). All of these factors presented challenges to clients in this case series. This group is particularly vulnerable, as they are regularly exposed to smoking cues that compromise their ability to maintain abstinence. One challenge within the treatment center where our study was conducted concerned a policy requiring clients to go outside during smoking breaks, even if they wished to stay inside to avoid smoking cues. Similarly, it was often difficult for clients to engage in alternative activities, such as reading books or writing letters, because of rules prohibiting them from carrying books or loose paper. Despite these challenges, our clients did not relapse during the study period, or during follow-ups.

An additional challenge in this group is previous research has demonstrated smokers with depression, as compared with non-psychiatric smokers, choose smoking as a preferred activity more often and ascribe more benefits to smoking (Spring, Pingitore, & McChargue, 2003). For these individuals, cigarettes are more appealing than alternative rewards and the benefits of smoking outweigh the costs; non-psychiatric smokers perceive the pros and cons to be equivalent (Spring et al., 2003). Thus, our clients may already have had difficulties finding other activities to be rewarding because of their elevated depressive symptoms, which were then compounded by constraints in scheduling potentially rewarding activities. Despite these challenges, our clients were willing to actively schedule alternative activities, which may have afforded them more opportunities to come into contact with potential sources of reward beyond smoking.

As one specific example of challenges faced, client Thomas experienced several highly stressful events post treatment and used both crack cocaine and cigarettes. He was evicted from his apartment, lost most of his possessions (including his treatment manual), was living in a homeless shelter, and learned his uncle had died. All of these events affected his mood and led him to use to cope with difficult feelings; he reported smoking crack cocaine and a couple of cigarettes on the day of his uncle’s death. To help Thomas cope with these challenges, the therapist and Thomas discussed how he could deal with feelings of stress, grief, and frustration. The therapist also provided him copies of the forms from the treatment manual, and together they planned activities for the following week to target improvements in his mood. The therapist reminded Thomas that a slip did not mean he had to go back to using or that he was a “smoker” again. She praised him for being committed to continuing with his quit, despite these challenges.

9 Access and Barriers to Care

Prior work suggests the importance of increasing participation and engagement in smoking cessation treatment. For example, in one study, only 40% of clients dually diagnosed with psychiatric and SUDs, who enrolled in smoking cessation (weekly group therapy, NRT, and bupropion), attended the first four treatment sessions, with only 15% attending at least eight sessions (Saxon et al., 2003). Low attendance may be due to a variety of factors but is likely to negatively affect cessation rates. Because of the cooperative relationship we developed with the drug treatment center where we saw our clients, we were able to schedule appointments with clients while they received residential treatment. In addition, we used a variety of strategies to increase retention for follow-ups, including frequent reminder phone calls, obtaining the contact information of clients’ friends and family members (to contact clients if their phones were disconnected), and meeting with clients in creative, accessible locations (we often met for follow-ups at libraries or fast food chains close to clients’ homes). Because of these strategies, we had 100% session and assessment attendance.

10 Follow-Up

Case 1

During George’s follow-ups, the therapist and George discussed his progress. On discharge from the treatment center, he lived with his mother and daughters. At the first follow-up session, he reported having smoked two “puffs” of a cigarette after having an argument with his girlfriend. The therapist and George brainstormed different strategies for coping with this particular high-risk situation, including noticing when he was feeling angry and leaving the situation before it escalated or running while listening to music to calm down. The therapist and George discussed additional enjoyable and important activities he could schedule to improve his mood and make him less susceptible to smoking when in stressful situations.

At both follow-up sessions, George reported he had been completing activities in concordance with his values across a variety of life areas. He reported attending church with his daughters, completing paperwork at a job-training site, playing basketball with friends, going to the movies with his girlfriend, and cooking a healthy dinner on several occasions. Overall, he was pleased with the progress he had made in treatment in terms of his mood and smoking and reported already noticing health benefits, such as being able to breathe more easily while playing basketball. During the second follow-up, he reported he had not smoked since the previous meeting and had continued engaging in enjoyable and important activities.

From entry into BA-DAS, through the 8-week follow-up, George evidenced decreases in cigarette consumption (Table 2) and BDI-II depressive symptoms (Figure 1). Moreover, his urinalysis results indicated continued abstinence from cannabis and cocaine. At the 8-week follow-up, he had not relapsed to smoking or to drug use.

Table 2.

Weekly Cigarette Consumption Over Treatment and Follow-Ups.

	Baseline week	Quit week	2 weeks post quit	4 weeks post quit	8 weeks post quit
George	70	0	1	0	1
Larissa	30	3	1	2	3
Thomas	28	0	2	6	5

Figure 1.

Beck Depression Inventory−II symptom scores across treatment and follow-ups.

Case 2

Thomas’ challenges post treatment were discussed above, so a briefer summary is provided here regarding his follow-ups. He had not relapsed to smoking at the 8-week follow-up (Table 2). In addition, his urinalysis results indicated he had not used drugs. Finally, his BDI-II score indicated his depressive symptoms had decreased (Figure 1). Thus, despite Thomas’ setback at the 4-week follow-up, he had not resumed using drugs or cigarettes.

Case 3

At the first follow-up session, Larissa did not bring her treatment manual, so the therapist and Larissa reviewed her activity completion based on her memory. She reported completing activities in all life areas and noticing improvements in her mood and decreased cigarette cravings. She reported one slip, where she took one puff of a cigarette while smoking marijuana at a party. The therapist and Larissa discussed different strategies for coping in this type of situation in the future, including not attending high-risk parties for the short term, avoiding drinking at them, avoiding smokers there, dancing with friends instead of going outside to smoke, or drinking non-alcoholic beverages to reduce cigarette cravings. In addition, the therapist and Larissa discussed and scheduled several enjoyable activities she could complete to maintain her positive mood more broadly prior to the second follow-up.

At the second follow-up, she reported that she had continued engaging in enjoyable activities across a number of life areas. However, she had smoked two cigarettes after getting in a fight on the phone with her fiancé. The therapist and Larissa discussed activities she could do to cope with these feelings of anger and sadness, including calling a friend to vent, taking a kick boxing class, and watching a video to improve her mood. She noted continued improvements in her mood and that breathing while exercising was easier. She was excited to continue with her life as a non-smoker and to add new activities to her schedule to maintain her positive mood.

Although her BDI-II scores decreased across treatment (Figure 1) and at the initial follow-ups, it was elevated during the 8-week follow-up. However, despite this, she had not relapsed to smoking, nor did her urinalysis results indicate drug use (Table 2).

11 Treatment Implications of the Case

The smoking cessation difficulties individuals with substance use and depressive disorders face are well documented (Weinberger, Mazure, et al., 2013; Weinberger, Pilver, Desai, et al., 2013; Weinberger, Pilver, Hoff, et al., 2013). Although clients in our study did not maintain continuous abstinence through the 8-week follow-up, none fully relapsed (1+ cigarettes/day for 7+ days in a row, or 5+ cigarettes/day for 3+ days in a row; Shiffman et al., 2006) during that time. As continuous abstinence from cigarettes, without lapses during cessation attempts, is rare (e.g., Okoli et al., 2010), relapse rates are better able to reveal patterns of cessation (Shiffman et al., 2006). Importantly, BA-DAS benefited clients when they were most vulnerable to relapse, that is, within the first few weeks post quit (Shiffman et al., 2006). Because of this, BA-DAS shows promise for some of the most difficult-to-treat clients. As a next step, it will be necessary to determine whether BA-DAS not only prevents relapse but also enhances longer-term abstinence in comparison with existing treatments. Overall, BA-DAS holds strong promise as a cessation program able to prevent relapse during the early post-quit period.

The BA-DAS treatment also shows promise in reducing depressive symptoms during the quit attempt and 8 weeks post quit. Despite facing a number of difficult life circumstances post quit and after leaving residential drug treatment, our clients experienced substantive reductions in depressive symptoms over time. These findings are consistent with prior BA studies conducted in similar populations (Daughters et al., 2008; MacPherson et al., 2010). As this is a case series, we cannot determine whether the effects of BA-DAS on depressive symptoms are causal or are moderated by gender. However, the potential role of gender will be important to examine in future larger-scale studies, as epidemiological work has demonstrated higher rates of depression in women than in men (Kessler, Chiu, Demler, & Walters, 2005), which is consistent with the pattern of depressive symptoms reported by Larissa at the 8-week follow-up. Overall, our results suggest the BA-DAS treatment may contribute to reductions in depressive symptoms that are maintained in the weeks subsequent to smoking cessation.

Finally, prior work demonstrates substance users who attempt to quit smoking cigarettes in the context of substance use treatment are more likely to remain abstinent from drugs and alcohol (Prochaska et al., 2004). Although two of our clients reported using substances during the follow-ups, rates of use were quite low, with each only using drugs one to two times during the 8-week follow-up period and exhibiting clean urines at the 8-week follow-up. Because this is a case series, we cannot make broad assumptions about these findings; however, they do suggest substance use outcomes were not negatively affected by cessation.

12 Recommendations to Clinicians and Students

It has frequently been assumed that individuals with complex diagnostic profile do not wish to nor are capable of making quit attempts. However, the literature typically does not bear out these assumptions, nor does our work with this population. Generally, among individuals receiving treatment for SUDs, 40% to 80% express an interest in smoking cessation (e.g., Clarke, Stein, McGarry, & Gogineni, 2001) with more than 50% engaging in cessation attempts over a 6-month period (Unrod, Cook, Myers, & Brown, 2004). This suggests there is a substantive group of clients who are interested in receiving treatment supporting cessation. Anecdotally, we have found this to be the case at the center where this work was conducted; clients frequently asked our staff whether they could enroll in our cessation program. This suggests individuals with complex diagnostic profiles are ready and willing to receive targeted smoking cessation programs.

Although our findings suggest strong benefits of BA-DAS, there are a number of limitations that must be considered by individuals implementing this treatment. First, it is necessary to test this intervention in a larger sample, with a contact-time matched control condition, within a randomized control trial, and with longer follow-up periods to determine whether BA-DAS is more effective than existing interventions. To understand the effects of BA-DAS on long-term cessation rates, much longer follow-ups are necessary. Second, it will be important to determine the quality and/or quantity of activities clients need to schedule to improve their mood and decrease the reward potential of cigarettes. Third, it will be interesting to explore whether the duration of a rewarding activity (5 min vs. 30 min) is of particular importance, or whether the overall enjoyment and importance associated with an activity is most critical. Finally, it will be necessary to examine how to maximize activity completion at follow-ups when clients are in potentially new or conversely, previously high-risk, environments. Despite these limitations, there are a number of strengths of this study, including cessation benefits within this particularly difficult-to-treat population, high treatment satisfaction, and substantive decreases in depressive symptoms over treatment. These case descriptions provide an important basis for future work to examine BA-enhanced smoking cessation treatments in difficult-to-treat samples.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by grants from American Cancer Society (ACS) 120511-RSGT-11-011-01-CPPB (Principal Investigator: MacPherson) and the National Institute of Drug Abuse F31 DA035033 (Principal Investigator: Banducci).

Author Biographies

Anne N. Banducci is a graduate student in clinical psychology who is interested in exploring the etiology and treatment of comorbid internalizing and substance use disorders. Specifically, she focuses on exploring factors like genetics and childhood trauma in the development of psychopathology and applying that knowledge within treatment.

Katherine E. Long is a graduate student in clinical psychology. She is broadly interested in factors that contribute to the development of conduct problems and substance use. She has specifically focused on the role of psychopathic traits in aggressive behavior and substance use.

Laura MacPherson is a professor within clinical psychology. Her clinical and research interests include a developmentally informed examination of the progression and cessation of addictive behaviors among adolescents and young adults to improve youth-tailored interventions, as well as developing behavioral treatments for adult smokers with psychiatric comorbidities.

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