Researcher tackles smoking with largest ACT study ever: Jonathan Bricker interview

In this interview, Bricker discusses ACT and smoking, how ACBS members can help, as well as exciting plans for the ACBS World Conference in Sydney. Jonathan Bricker, PhD, is founder and leader of the Tobacco & Health Behavior Science Group in the Division of Public Health Sciences at the Fred Hutchinson Cancer Research Center. A licensed clinical psychologist, he is also an Associate Professor in the Department of Psychology at the University of Washington. 

Doug: Congratulations on your new grant! What can you tell us about the research you will be conducting?

Jonathan: Thanks Doug. Certainly happy to tell you about it. Quit smoking programs delivered by the web generally don’t work well. Over 90% of people who try them do not quit smoking. That is sad. That is sad because over 4 million people in the United States, and millions more worldwide, go the web seeking help for quitting smoking so it’s a huge missed opportunity to offer effective help. And it is sad because it so discouraging to the people who try these websites. And it sad because quitting smoking is the number one way to prevent premature death, disease, and human suffering.

I believe that ACT might help to solve this problem. So our research team has been incredibly fortunate to receive over 3.2 million US dollars from the National Cancer Institute (an institute within the National Institutes of Health) to conduct arguably the largest randomized trial of ACT to date. Our planned sample size for this five year study is over 2500. We are going to randomize US residents who want to quit smoking to either ACT or a current standard website. Then we are going to follow them for a year to learn about whether our ACT program changed core processes of acceptance and commitment. Most importantly, we are going to learn whether ACT has higher quit rates than the control group.

If ACT works better, we will have an incredible opportunity to disseminate ACT around the world as a new model for helping people quit smoking. Right at their computer. The potential impact of the ACT website could be enormous.

Doug: What attracted you to ACT as an approach to smoking cessation?

Jonathan: That is a very personal story that I plan to share in Sydney at the ACBS World Conference. I will just say for now that it’s an ACT story of finding my core passions while living past obstacles both real and imagined. For my work life, I learned to jump.

Doug: I understand that your work uses very brief ACT interventions over the phone and the internet. Did you face any difficulty in adapting ACT to these formats? Are people still able to connect with the material?

Jonathan: Yes, as I will talk about in Sydney, we have now come full circle on “treatment delivery wheel.” Going around each spoke of the wheel, we have now developed ACT quit smoking protocols being tested in trials for delivery by in person one-on-one, in groups, by phone, by web, and most recently, by smartphone.

About the phone, in the quit smoking world, the phone is a fairly common way to deliver treatment. Reaches over half a million people a year in the US alone. Every state in the US and most developed countries have quit smoking hotlines. Quitlines are really an unsung hero of delivering behavioral treatments on a broad scale. Most of what we do in therapy is face-to-face—myself included. So quitlines are a great model for how we can expand the reach of therapy beyond our offices and clinics.

Regarding phone adaptation, back in late 2007, I pretended I was blind as a first guide for how to see the world of voice from an ACT point of view. And I discovered, as many people who are blind can attest, is that you can hear much better that way. You hear subtleties in language. You hear the music inside a person’s story. And once I was able to live inside that world, the possibilities for adaptation opened up to me. Pragmatic issues and ways of addressing them became clearer. And we are planning a symposium for Sydney where we will share how well it went for folks who enrolled in our latest phone trial.

As for the web adaptation, an inspiration was the testimonial. We video-recorded testimonials from actual former smokers who talked about how quitting smoking changed their lives in deep and meaningful ways. So without ever using the word “values,” we showed web viewers intuitively what values were and how people just like them were living them now in a smokefree life. So the invitation was to take a cue from the testimonials to consider how viewers might put to words what quitting smoking is all about for them. Did it work? Well, I can certainly say that our pilot randomized trial (which we presented in World Con Washington DC last year), showed that the ACT website folks had over double the quit rate (23%) than the quit rate for the Smokefree.gov website folks (10%). These results were a key impetus for our new trial of web-delivered ACT for quitting smoking.

Doug: Your lab has looked at smoking both with longitudinal studies and intervention studies. How have these different lines of research influenced each other? Do your longitudinal findings inform your ideas for interventions?

Jonathan: For me, both study designs inform the basic research. For example, we were thinking that young adults (i.e., age 18) who avoid their emotions might be at risk for taking up smoking. They may use smoking as one way to avoid noticing aversive thoughts, emotions, and sensations, in a manner that leads to a continuous feedback loop: aversive emotional state→smoking in order to avoid aversive emotional state→paradoxical increase in aversive emotional state→smoking in order to avoid aversive emotional state. Indeed, we found in a recent study of 3300 youth that the avoiders, who at baseline never smoked, were over two and half times more likely to become daily smokers a mere two years later. These kinds of findings are basic science that stimulates our search for treatments that target avoidance. ACT is really ideal in that regard.

We can complete the picture by showing how much the ACT interventions actually change avoidance by increasing acceptance. In all of our randomized trials, we examine the extent to which our ACT interventions increase willingness to experience cues to smoke, and in turn, how much willingness impacts quitting smoking. That is example of how our treatment trials have basic science embedded within them.

So whether basic research takes the form of a longitudinal study or a randomized trial, both provide opportunities to inform our fundamental understanding of what makes people smoke and how to help them quit.

Doug: What do you feel are the biggest challenges for smoking cessation research? And, how could the ACBS community help to address these – either with research or clinical work?

Jonathan: There are huge challenges for smoking cessation—both the clinical and the research side. On the clinical side, about 60% of therapists do not even ask their clients if they smoke. So every single clinician in ACBS can help by simply asking their clients if they smoke. Without doing any ACT intervention, merely informing clients that quitting is the single most powerful action they can take for preventing premature death and suffering can speak volumes. As clinicians, we often have deep and meaningful relationships with our clients. Just the mere fact that we see our clients far more often than our counterparts in medicine makes our relationships so important to our clients. So hearing that message from us can spark change within our clients and stimulate them to act—now.

On the research side, dissemination is a big challenge. Treatments that work rarely get out further than the journal articles they are reported in. So if our ACT protocols do work, we certainly will want to disseminate them. And the ACBS community can be a big help in spreading the word, putting the protocols into action. Until then, we are all having to impatiently wait until these big trials make their way through the rigorous processes. I often say that science moves at iceberg speed.

Doug: Any plans for the ACBS World Conference in Sydney this summer?

Jonathan: We have exciting plans for ACBS World Conference. I will share my personal story of how I became an ACT researcher. Broadly, the message will be about using ACT to find meaning in work.

And our research team members will present a symposium on several of our ACT for quit smoking studies. Currently, we are planning to present results from our pilot randomized telephone trial and share two new developments fresh the lab: a prototype of the very first ACT smartphone intervention for quitting smoking and our in-person protocol for ACT for bipolar disorder smoking cessation. Lots to share.

Doug: Is there anything else you’d like to share with the ACBS community?

Jonathan: I am so grateful for this worldwide community for its support, enthusiasm, creativity, value of rigorous science, and willingness to take risks.

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Interview by Douglas Long