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. Author manuscript; available in PMC: 2022 Jan 1.
Published in final edited form as: J Subst Use. 2020 Sep 28;26(6):669–676. doi: 10.1080/14659891.2021.1879295

Readiness to Quit Smoking among Smokers in Substance Use Treatment: Associations with Stress, Substance Use Severity, Relapse Concerns and Gender

Siwen Xie 1, Haruka Minami 1, Danusha Selva Kumar 1, Jacki Hecht 2, Erika Litvin Bloom 3, Christopher Kahler 4, Ana Abrantes 5, Lawrence H Price 5, Steven Ondersma 6, Richard A Brown 2
PMCID: PMC8659404  NIHMSID: NIHMS1667295  PMID: 34899051

Abstract

Smoking prevalence among individuals in substance use treatment remains higher than in the general population. Given that many smokers in substance use treatment are reluctant to quit smoking, it is important to understand the factors that impede smokers’ readiness to quit. The current study used baseline data from a randomized controlled trial involving 60 adult smokers receiving substance use treatment to investigate relations between the severity of substance use problems (SSUP), perceived stress (PS), concerns about relapse (i.e., concerns that quitting smoking would hurt one’s recovery process (CR)), and readiness to quit smoking. This study also investigated moderating roles of concerns about relapse and gender. Regression analyses showed a significant main effect of concerns about relapse on readiness to quit in the next 30 days, but no effect for either severity of substance use problems, perceived stress, or the SSUPxCR interaction. There were significant interaction effects between PS and both gender and CR. Among men and those with lower concerns about relapse, higher perceived stress was significantly associated with lower readiness to quit. Findings suggest that psychoeducation to alleviate concerns that quitting smoking could limit substance use recovery could be beneficial. Stress management interventions may be especially beneficial to men.

Keywords: readiness to quit, perceived stress, severity of substance use problems, concerns about relapse

Introduction

Smoking is the largest preventable cause of premature death in the U.S., and is responsible for 480,000 annual deaths through cancers, cardiovascular and respiratory diseases (Centers for Disease Control and Prevention, 2019a). While smoking prevalence in the general population has declined from 20.9% in 2005 (Substance Abuse and Mental Health Services Administration, 2011) to 13.7% in 2018 (Centers for Disease Control and Prevention, 2019b), the rate of smoking is approximately 75% among individuals in substance use treatment (Campell et al., 2016; Guydish et al., 2011; Substance Abuse and Mental Health Services Administration, 2011). Those with SUDs continue to face higher smoking-related morbidity and mortality than the general population (Bandiera et al., 2015; Hser et al., 1994).

Although consumers and treatment professionals sometimes worry that attempting to quit smoking could interfere with treatment (Prochaska, 2010; Richter et al., 2002), current evidence suggests the opposite: that quitting smoking improves abstinence outcomes in substance use treatment (Friend and Pagano, 2005; Gulliver et al., 2006; Lemon et al., 2003; McKelvey et al., 2017; Prochaska et al., 2004). For example, Friend and Pogano (2005) found that among smokers receiving outpatient or aftercare SUD treatment, quitting smoking was associated with greater alcohol abstinence days and reduced alcohol consumption. Moreover, a meta-analysis indicated that quitting smoking is associated with a longer duration of abstinence from substances (McKelvey et al., 2017). These findings highlight the beneficial effects of quitting smoking on substance use treatment outcomes.

Research shows that approximately 80% of smokers in substance use treatment are interested in quitting smoking (Clarke et al., 2001; Richter et al., 2001). However, many are not ready to quit (Baca and Yahne, 2009; McClure et al., 2014; Pagano et al., 2016; Stotts et al., 2003; Substance Abuse and Mental Health Services Administration, 2011), and readiness to quit smoking, but not interest in quitting, predicts actual quit attempts (Martínez et al., 2015; Teater and Hammond, 2010). Identifying the factors associated with readiness to quit smoking may facilitate the development of effective interventions for this population. In the limited research in this area, several factors have shown potential.

Severity of Substance Use Problems

The severity of substance use problems (i.e., the degree of maladaptive substance-seeking and substance-using behaviors) is a possible factor associated with readiness to quit smoking (Conway et al., 2010). Severity of substance use problems has been associated with greater perceived barriers to quit smoking among smokers receiving residential SUD treatment (Martin et al., 2016), which in turn, is associated with lower readiness to quit smoking (McHugh et al., 2017). Additionally, higher levels of nicotine dependence, evident among those with more severe substance use (Harrell et al., 2011; John et al., 2003), has been associated with reduced readiness to quit smoking among smokers in substance use treatment (Ramo et al., 2010). However, the direct relationship between the severity of substance use problems and readiness to quit smoking as well as potential moderating factors on this relationship have not been examined.

Perceived Stress

Perceived stress is defined as the degree to which life events are experienced as stressful and elicit negative emotional responses (Garey et al., 2016). In the general population, those with higher perceived stress tend to smoke more cigarettes and have higher nicotine dependence (Garey et al., 2016; Todd, 2004; Ludman et al., 2002). While many smokers report that they smoke to cope with stress (Baker et al., 2004; McKee et al., 2011; Villanti, et al., 2016), no studies to date have examined the associations between perceived stress and readiness to quit. Additionally, research among adolescent smokers has found that the relationship between perceived stress and tobacco use is stronger in females (Leventhal et al., 2017). However, the moderating role of gender on the impact of perceived stress on readiness to quit among adult smokers has not been explored.

Concerns about Relapse

Research shows that 50 to 69% of smokers in inpatient substance use treatments have concerns about substance use relapse if they quit smoking concurrently (Martin et al., 2016; McHugh et al., 2017). Thus, the concerns that quitting smoking might cause substance relapse may impact smokers’ readiness to quit smoking (Hendricks et al., 2014). However, the direct relationship between concerns about relapse and readiness to quit smoking has yet to be examined in the context of substance use treatment. Furthermore, concerns about relapse may moderate the relationship between severity of substance use problems, perceived stress and readiness to quit smoking. It is possible that current substance-related problems and perceived stress may be more potent barriers to quit among those with greater concerns about relapse. However, these moderating effects have not been explored.

The current study investigated the main effects of the severity of substance use problems, perceived stress, and concerns about relapse on readiness to quit smoking in the next 30 days among smokers receiving substance use treatment through a partial hospital program. We hypothesized that: 1) greater severity of substance use problems is associated with reduced readiness to quit smoking, 2) higher perceived stress levels are associated with reduced readiness to quit smoking, and 3) greater concerns that quitting smoking would hurt the recovery process are associated with lower readiness to quit smoking. Next, we tested the moderating role of the level of concerns about relapse, predicting that the relationship between 4) the severity of substance use problems and readiness to quit smoking and 5) perceived stress and readiness to quit smoking are stronger among those with greater concerns that smoking cessation could hurt recovery. Lastly, we explored whether gender moderated the relationships between the severity of substance use problems/perceived stress and readiness to quit.

Method

Participants

This study used baseline data from a randomized controlled trial of brief computer-based intervention to motivate Tobacco Quitline use among smokers receiving substance use treatment. (Brown et al., 2016). A total of 60 participants from a substance use day treatment partial hospital program in Rhode Island were enrolled. The inclusion and exclusion criteria are presented in Table 1.

Table 1.

Inclusion and Exclusion Criteria.

Inclusion Exclusion
Ages between 18 – 70 History of psychotic disorder or current psychotic symptoms
Currently smoking at least 10 cigarettes a day Current suicidal or homicidal ideations
Current diagnosis of drug or alcohol abuse or dependence Cognitive impairment that impeded terms in informed consent or study participation
Have reliable access to phone
Rhode Island or Massachusetts resident
 Untreated visual impairment or bilateral hearing loss
Current use of nicotine replacement or pharmaceutical therapies to quit smoking
Use of any other tobacco product
Non-English speaker
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Measures

Demographic data.

Information on participants’ age, gender, race/ethnicity, education attainment, marital status and number of cigarettes smoked per day was collected.

Nicotine dependence.

The 6-item Fagerström Test for Cigarette Dependence (FTCD) (Heatherton et al., 1991) was used to assess nicotine dependence. The score ranges from 0 to 10, with a larger score indicating greater nicotine dependence. The measure has demonstrated high test-retest reliability and validity (Buckley et al., 2005).

Severity of substance use problems.

The Short Inventory of Problems - Alcohol and Drugs (SIP-AD), a 15-item measure, was administered to assess the severity of substance use problems in the past three months (i.e., physical, psychological, interpersonal and social consequences of substances use). The score ranges from 0 to 45, with a higher score indicating greater negative consequences of alcohol and drugs (Blanchard et al., 2003). The measure has shown excellent test-retest reliability and validity (Alterman et al., 2009; Blanchard et al., 2003).

Perceived stress.

The Perceived Stress Scale (PSS) is a 4-item global measure for perceived stress in the past month (Cohen et al., 1983). The total score ranges from 0 to 16, with a higher score indicating greater perceived stress. The PSS has demonstrated acceptable test-retest reliability and internal validity, having been utilized as a brief measure of current (during the past month) stress (Karam et al., 2012; Mitchell et al., 2008).

Concerns about relapse.

Concerns that quitting smoking would hurt SUD recovery were assessed using one single-item question, asking participants “How much do you think quitting smoking will hurt your ability to stay clean and sober?”, with 0 indicating “Not at all” and 100 indicating “Very much.”

Readiness to quit smoking.

The Readiness Ruler method was used to assess readiness to quit smoking within the next 30 days, on a scale of 1 to 10. A score of 1 indicated “Not at all ready to quit smoking within the next 30 days”, and 10 indicated “Actively quitting smoking within the next 30 days.” The Readiness Ruler has demonstrated good test-retest reliability and validity (Hesse, 2006; Maisto et al., 2011).

Data Analysis

First, we computed a correlation matrix of all predictor variables to assess correlations between the predictors. Next, we used R (R Core Team, 2016) for a series of linear and logistic regressions to test the effects of severity of substance use problems, perceived stress, and concerns about relapse on readiness to quit smoking in the next 30 days. In order to test the main effects of the above three factors on readiness to quit, we ran separate linear regression models controlling for gender and nicotine dependence (FTCD). We also ran the combined analyses, entering these three variables into the same linear regression model. Since there were no differences in the significance or direction of the findings between separate or combined analyses, we report the findings of the combined model. Next, to examine the moderating effects of concerns about relapse and gender, we entered the following interactions separately into the main effect model: 1) the Severity of Substance Use Problems X Concerns about Relapse, 2) Perceived Stress X Concerns about Relapse, 3) the Severity of Substance Use Problems X Gender, and 4) Perceived Stress X Gender. The concerns about relapse score was median centered to facilitate the interpretation of interaction effects. When interaction effects were significant, marginal effects plots were created to visualize how the effects of the predictor on the outcome (i.e., the coefficient estimate and its 95% confidence intervals) changes depending on the value of the moderating variable.

Results

Participants

Participant characteristics are presented in Table 2. Of the 60 participants, 51.7% were female, 11.7% were ethnic minorities (5% Hispanic), and 36.7% had a high school diploma or less.

Table 2.

Demographic and baseline characteristics (N = 60).

N (%)
Female 31 (51.67%)
Hispanic or Latino 3 (5.00%)
Race/Ethnic group
White 53 (88.33%)
Native Hawaiian 1 (1.67%)
Asian 1 (1.67%)
Black or African American 5 (8.33%)
Education
AA or higher 13 (21.67%)
Some College 25 (41.67%)
HS Diploma 15 (25.00%)
Some HS 6 (10.00%)
Less than HS 1 (1.67%)
Marital Status
Married 7 (11.67%)
Engaged 3 (5.00%)
Living Together 2 (3.33%)
Never Married 29 (48.33%)
Divorced 14 (23.33%)
Separated 2 (3.33%)
Widowed 2(3.33%)
Readiness to Quit in the Next 30 Days (Yes) 19 (31.67%)
Mean (SD)
Age 36.45 (12.96)
Cigarettes Per Day 15.13 (5.49)
Nicotine Dependence (FTCD) 4.94 (1.89)
Severity of Substance Use Problems (1–45) 29.35 (11.18)
Perceive Stress (1–16) 10.17 (2.79)
Concerns about Relapse (1–100) 49.70 (35.01)
Readiness to Quit in the Next 30 Days (1–10) 2.91 (2.32)
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Note. FTCD: Fagerström Test for Cigarette Dependence

The Severity of Substance Use Problems: Short Inventory of Problems - Alcohol and Drug (SIP-AD)

Concern about Relapse: Concerns that quitting smoking would hurt the recovery process

Readiness to Quit

Main effects.

Contrary to our hypotheses, a linear regression model revealed no significant relationship between readiness to quit and either severity of substance use problems (β = −0.01, 95% CI = −0.05, 0.03, p = ns) or perceived stress (β = −0.08, 95% CI = −0.26, 0.10, p = ns). In contrast, concerns about relapse was significantly associated with readiness to quit smoking (β = −0.04, 95% CI = −0.06, −0.02, p < .001). Those who had greater concerns that quitting smoking would lead to relapse reported lower readiness to quit smoking in the next 30 days, supporting our hypothesis (Table 4a).

Table 4a.

Main effects of the severity of substance use problems, perceived stress, and concerns about relapse on readiness to quit smoking.

β 95% CI p
Intercept 6.22 [3.73, 8.70] 0.001**
Female −0.35 [−1.39, 0.69] 0.506
Nicotine Dependence (FTCD) −0.02 [−0.27, 0.23] 0.873
Severity of Substance Use problems (SIP-AD) −0.01 [−0.05, 0.03] 0.795
Concerns about Relapse −0.04 [−0.06, −0.02] 0.000**
Perceive Stress −0.08 [−0.26, 0.10] 0.373
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Note. FTCD: Fagerström Test for Cigarette Dependence

SIP-AD: Short Inventory of Problems - Alcohol and Drug

*

p < 0.05.

**

p < 0.01.

Interaction effects.

A linear regression model showed that the interaction between Severity of Substance Use Problems and Concerns about Relapse was not associated with readiness to quit smoking (β = 0.00, 95% CI = 0.00, 0.00, p = ns) (Table 4b). However, there was a significant effect of the interaction between Perceived Stress and Concerns about Relapse on readiness to quit (β = 0.01, 95% CI = 0.01, 0.01, p < .05) (Table 4c). Greater perceived stress was significantly associated with lower readiness to quit smoking, but only among those who reported low concerns about relapse (i.e., Score ≤ 25) (Figure 1a), the opposite direction of our prediction. Finally, although the interaction model did not find a significant Severity of Substance Use Problems X Gender interaction (β = −0.04, 95% CI = −0.16, 0.08, p = ns) (Table 4d), a linear regression revealed a significant Perceived Stress X Gender interaction effect on readiness to quit (β = 0.50, 95% CI = 0.07, 0.93, p < .05). That is, higher perceived stress was significantly associated with lower readiness to quit only among men (β = −0.41, 95% CI = −0.74, −0.08, p < .05) (Table 5a, Figure 2), but not in women (β = 0.09, 95% CI = −0.18., 0.36, p = ns) (Table 5b).

Table 4b.

Interaction effect (the Severity of Substance Use Problems × Concerns about Relapse) on readiness to quit smoking.

β 95% CI p
Intercept 3.47 [1.59, 5.37] 0.001**
Female −0.45 [−1.51, 0.61] 0.413
Nicotine Dependence (FTCD) −0.04 [−1.59, 1.51] 0.789
Severity of Substance Use Problemsa −0.01 [−0.05, 0.03] 0.832
Concerns about Relapse −0.05 [−0.09, −0,01] 0.020*
Severity of Substance Use Problems x Concerns about Relapse 0.00 [0.00, 0.00] 0.498
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Note. FTCD: Fagerström Test for Cigarette Dependence

*

p < 0.05.

**

p < 0.01.

a

Given the interaction term in this model, this coefficient indicates the relationship between the severity of substance use problems and readiness to quit smoking when Concerns about Relapse is at its median (centered around its median).

Table 4c.

Interaction effect (Perceived stress × Concerns about Relapse) on readiness to quit smoking.

β 95% CI p
Intercept 3.92 [1.71, 6.11] 0.001**
Female −0.39 [−1.39, 0.61] 0.444
Nicotine Dependence (FTCD) 0.02 [−0.23, 0.27] 0.857
Perceived Stressa −0.09 [−0.27, 0.09] 0.302
Concerns about Relapse −0.09 [−0.15, −0.03] 0.001**
Perceived Stress x Concerns about Relapse 0.01 [0.01, 0.01] 0.043*
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Note. FTCD: Fagerström Test for Cigarette Dependence

*

p < 0.05.

**

p < 0.01.

a

Given the interaction term in this model, this coefficient indicates the relationship between perceived stress and readiness to quit smoking when Concerns about Relapse is at its median (centered around its median).

Figure 1b.

Figure 1b.

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(a & b) depicts the estimated coefficient of (a) perceived stress, (b) self-efficacy on being ready to quit smoking by concerns about relapse. The estimated coefficient and 95% confidence interval (shaded in grey) were extracted from the logistic regression models. Where the confidence interval does not include zero indicates statistical significance of the coefficient (p < .05).

Estimated coefficient of self-efficacy on readiness to quit smoking in the next 30 days by concerns about relapse.

Table 4d.

Interaction effect (the Severity of Substance Use Problems × Gender) on readiness to quit smoking.

β 95% CI p
Intercept 3.61 [0.49, 6.73] 0.028**
Female −0.06 [−3.74, 3.62] 0.976
Nicotine Dependence (FTCD) −0.02 [−0.33, 0.29] 0.889
Severity of Substance Use Problemsa 0.00 [−0.10, 0.10] 0.946
Severity of Substance Use problems x Female −0.04 [−0.16, 0.08] 0.498
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Note. FTCD: Fagerström Test for Cigarette Dependence

*

p < 0.05.

**

p < 0.01.

a

Given the interaction term in this model, this coefficient indicates the relationship between the severity of substance use problems and readiness to quit smoking among men.

Table 5a.

Interaction effect (Perceived Stress × Gender) on readiness to quit smoking.

β 95% CI p
Intercept 7.90 [4.22, 11.59] 0.000**
Female −6.33 [−10.84, −1.82] 0.008**
Nicotine Dependence (FTCD) −0.04 [−0.33, 0.25] 0.775
Perceived Stressa −0.41 [−0.74, −0.08] 0.019*
Perceived Stress x Female 0.50 [0.07, 0.93] 0.027*
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Note. FTCD: Fagerström Test for Cigarette Dependence

*

p < 0.05.

**

p < 0.01.

a

Given this interaction term in this model, this estimated coefficient indicates the relationship between perceived stress and readiness to quit among men.

Figure 2.

Figure 2.

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Estimated coefficient of perceived stress on readiness to quit smoking in the next 30 days by gender.

Table 5b.

Interaction effect (Perceived Stress x Gender) on readiness to quit smoking.

β 95% CI p
Intercept 1.57 [−1.59, 4.73] 0.332
(Female = 0)a −6.33 [−10.84, −1.82] 0.008**
Nicotine Dependence (FTCD) −0.04 [−0.33, 0.25] 0.775
Perceived Stressb 0.09 [−0.18, 0.36] 0.512
Perceived Stress x (Female = 0)a −0.50 [−0.93. −0.07] 0.027*
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Note. FTCD: Fagerström Test for Cigarette Dependence

*

p < 0.05.

**

p < 0.01.

a

To examine the relationship between perceived stress and readiness to quit among women, we recoded the gender variable so that 1 indicated male and 0 indicated female in the model.

b

Given the interaction term in this model, this coefficient explains the relationship between perceived stress and readiness to quit smoking among women.

Follow-up Analyses.

Perceived stress did not differ across gender (r = 0.03, p = ns). Women (M = 61.74, SD = 32.04) were significantly more likely to report greater concerns about relapse than men (M = 36.83, SD = 33.92) (r = 0.36, p < .05).

Discussion

The current study examined the associations between the severity of substance use problems, perceived stress, concerns about relapse, gender, and readiness to quit smoking among smokers receiving substance use treatment. As predicted, smokers who had higher concerns about relapse (i.e., concerns that quitting smoking would hurt recovery process) were less likely to be ready to quit smoking. This finding suggests that concerns about relapse was a barrier to quit smoking among smokers receiving substance use treatment, consistent with previous research (McHugh et al., 2017; Martin et al., 2016). Psychoeducation regarding the benefits of smoking cessation in substance use treatment outcomes (Gulliver et al., 2006; McKelvey et al., 2017; Prochaska et al., 2004) may be important for smokers in substance use recovery.

However, the severity of substance use problems did not predict readiness to quit smoking in this sample. Past studies have linked severe substance use problems with more barriers to quit smoking (Martin et al., 2016), and associated more barriers to quit smoking with lower readiness to quit (McHugh et al., 2017). However, in a previous study, there was no correlation between substance use severity and intention to quit smoking among adolescent smokers in inpatient or outpatient substance use treatments (Ramo et al., 2010). This suggests that substance use problems may not affect smokers’ readiness to quit smoking, and smoking cessation treatment should be offered regardless of the severity of substance use problems.

Similarly, perceived stress was also not associated with readiness to quit smoking in the next 30 days. This finding is inconsistent with previous findings that people smoke to cope with stress (Baker et al., 2004; McKee et al., 2011; Villanti et al., 2016), and reflects the greater stress level among smokers in substance use treatment compared to the general population. Participants in our study reported a mean stress level score of 10.17 (SD = 2.79), compared to a mean score of 5.43 (SD = 2.95) in the U.S. general population (Vallejo et al., 2018). It is possible that overall elevated stress levels in this sample made it difficult to differentiate readiness to quit smoking based on perceived stress level.

We found a significant moderating effect of concerns about relapse on the relationship between perceived stress and readiness to quit smoking in the next 30 days while concerns about relapse did not impact the relationship between severity of substance use problems and readiness to quit. A marginal effect plot (Figure 1) showed that higher perceived stress was associated with lower readiness to quit smoking only among those with minimal concerns about relapse (i.e., score of below 25). This finding suggests that perceived stress was a notable barrier to quit attempts only when concerns about relapse was low. Thus, it is possible that the impacts of concerns about relapse on readiness to quit overshadow the effects of perceived stress given the strong relationship between concerns about relapse and readiness to quit smoking. In fact, previous research showed that concerns about relapse were among the strongest barriers to quitting smoking (Martin et al., 2006).

Figure 1a.

Figure 1a.

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(a & b) depicts the estimated coefficient of (a) perceived stress, (b) self-efficacy on being ready to quit smoking by concerns about relapse. The estimated coefficient and 95% confidence interval (shaded in grey) were extracted from the logistic regression models. Where the confidence interval does not include zero indicates statistical significance of the coefficient (p < .05).

Estimated coefficient of perceived stress on readiness to quit smoking in the next 30 days by concerns about relapse.

Furthermore, we found a significant moderating effect of gender on the relationship between perceived stress on readiness to quit smoking, such that higher perceived stress was associated with lower readiness to quit smoking only among men. Thus, the factors predicting readiness to quit in substance use treatment may differ across gender. For example, depressive or anxiety symptoms have been shown to be more prominent barriers impeding readiness to quit among women (Dahne et al., 2015), highlighting that there are gender differences in the predictors of readiness to quit smoking. Follow-up analyses showed that while there was no gender difference in perceived stress, women were significantly more likely to report greater concerns about relapse than men. Additionally, men were significantly more likely to report greater readiness to quit smoking in the next 30 days than women. The greater standard deviation on readiness to quit among men (2.65 vs. 1.83 in women) may have impacted the association between perceived stress and readiness to quit smoking. Additionally, even though we controlled for gender in our analyses, it is possible that the moderating effects of concerns about relapse on the perceived stress - readiness to quit relationship may have at least partly been attributable to the gender differences in concerns about relapse. These findings suggest that concerns about relapse and gender may affect relationships between perceived stress and readiness to quit. Improving stress management skills may be especially effective in facilitating quit attempts among men.

Limitations

This study had a limitation in its sample, which consisted primarily of White participants with an under-representation of Black or African American, Asian and Latino individuals. Additionally, all 60 participants in this study were recruited from a single substance use program. Thus, the generalization of our findings to a broader population of smokers in substance use treatment is limited. Since this study was cross-sectional, we cannot infer any causal relationships. Moreover, we are unable to conclude that higher readiness to quit smoking would lead to quit attempts or successful cessation. This study was also retrospective, using data that were not originally collected for this purpose.

Conclusion

The current study examined the relationships between severity of substance use problems, perceived stress, concerns about relapse, gender, and readiness to quit smoking among smokers in substance use treatment. Results demonstrated that concerns about relapse were associated with lower readiness to quit smoking. Higher perceived stress was associated with lower readiness to quit only among smokers with low concerns about relapse, and among men. The findings suggest that providing psychoeducation debunking smokers’ misconception about quitting smoking and the substance recovery process may help increase readiness to quit smoking while receiving substance use treatment. Furthermore, intervention targeting stress management among male smokers in substance use treatment may be especially effective to promote quit attempts. Future studies designed to investigate the causal relationships between these factors and readiness to quit smoking among smokers in substance use treatment are needed.

Table 3.

Correlations between gender, nicotine dependence, the severity of substance use problems, perceived stress, and concerns about relapse

1. 2. 3. 4.
1. Female -
2. Nicotine Dependence (FTCD) −0.03
3. Severity of Substance Use Problems 0.04 0.15
4. Perceived Stress 0.03 0.08 0.18
5. Concerns about Relapse 0.36** 0.14 0.13 0.06
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Note. FTCD: Fagerström Test for Cigarette Dependence

*

p < 0.05.

**

p < 0.01

Acknowledgements

The authors thank the staff of the Addictions Research Group and the Alcohol and Drug Day Treatment Program at Butler Hospital who assisted with this research.

Financial Support

This work was supported by the National Institute on Drug Abuse, under Grant # R34DA034312 to Richard A. Brown.

Footnotes

Conflict of Interest

Dr. Richard A. Brown has equity ownership in Health Behavior Solutions, Inc., which is developing products for tobacco cessation that are not related to this study. The terms of this arrangement have been reviewed and approved by the University of Texas at Austin in accordance with its policy on objectivity in research.

Dr. Steven Ondersma is part owner of a company that licenses e-intervention authoring software to investigators, and which was used to develop the intervention in the parent trial from which these data were taken.

Dr. Lawrence H. Price has received royalties from OCDScales; received grant support from NIH; served as a consultant to Wiley, Springer, University of Texas (Austin), and Fordham University; and served as a data safety monitoring board member for Baylor University, Cleveland Clinic, Clexio Biosciences, and Worldwide Clinical Trials.

Ethical Standards

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

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