CHOICE Lab Publications

Tomlinson, D. C., Wilkins, C., Bayrakdarian, N., Dolecki, F., Jr, Bonar, E. E., Fernandez, A., Tzilos Wernette, G., & Coughlin, L. N. (2025). Michigan tobacco cessation champions: A rapid qualitative analysis. Preventive Medicine Reports, 49(102945), 102945. https://doi.org/10.1016/j.pmedr.2024.102945

Abstract:

• Background: Smoking is the leading cause of preventable death in the United States. We interviewed Tobacco Cessation Champions, multi-sector decision makers, across the state of Michigan to assess and identify barriers and facilitators of smoking cessation and the current smoking cessation landscape.

• Methods: Twenty Tobacco Cessation Champion interviews (n = 20) were completed with multi-sector decision makers to assess implementation barriers and facilitators from May 2022 to September 2023. We used rapid qualitative analysis to identify common themes across the Tobacco Cessation Champion interviews.

• Results: Three key themes were identified across the Tobacco Cessation Champion interviews: 1) Facilitators and Barriers of Smoking Cessation Efforts; 2) Smoking Cessation Efforts: Underfunded, Underutilized, Not Marketable or Accessible, and 3) Need for more inclusive, person-centered smoking cessation interventions.

• Conclusion: Across the themes identified in the present report, champions identified myriad areas for improvement in the tobacco cessation landscape, including: Appeal, accessibility, and the functionality of current systems. The community should strive to improve trust and relationships between providers and patients, as the trust established between these parties is imperative for promoting tobacco cessation. Lastly, cessation efforts should aim to address and improve attitudes and stigma toward smoking and tobacco cessation.

Bayrakdarian, N. D., Bonar, E. E., Duguid, I., Hellman, L., Salino, S., Wilkins, C., Jannausch, M., McKay, J. R., Staton, M., Dollard, K., Nahum-Shani, I., Walton, M. A., Blow, F. C., & Coughlin, L. N. (2024). Acceptability and feasibility of a mobile behavioral economic health intervention to reduce alcohol use in adults in rural areas. Drug and alcohol dependence reports, 11, 100225. https://doi.org/10.1016/j.dadr.2024.100225

Abstract:

• Background: At-risk alcohol use is associated with increased adverse health consequences, yet is undertreated in healthcare settings. People residing in rural areas need improved access to services; however, few interventions are designed to meet the needs of rural populations. Mobile interventions can provide feasible, low-cost, and scalable means for reaching this population and improving health, and behavioral economic approaches are promising. 

• Methods: We conducted a pilot randomized controlled trial focused on acceptability and feasibility of a mobile behavioral economic intervention for 75 rural-residing adults with at-risk alcohol use. We recruited participants from a large healthcare system and randomized them to one of four virtually-delivered conditions reflecting behavioral economic approaches: episodic future thinking (EFT), volitional choice (VC), both EFT and VC, or enhanced usual care control (EUC). The intervention included a telephone-delivered induction session followed by two weeks of condition-consistent ecological momentary interventions (EMIs; 2x/day) and ecological momentary assessments (EMAs; 1x/day). Participants completed assessments at baseline, post-intervention, and two-month follow-up, and provided intervention feedback. 

• Results: All participants completed the telephone-delivered session and elected to receive EMI messages. Average completion rate of EMAs across conditions was 92.9%. Among participants in active intervention conditions, 89.3% reported the induction session was helpful and 80.0% reported it influenced their future drinking. We also report initial alcohol use outcomes. Discussion: The behavioral economic intervention components and trial procedures evaluated here appear to be feasible and acceptable. Next steps include determination of their efficacy to reduce alcohol use and public health harms. (PsycInfo Database Record (c) 2025 APA, all rights reserved)

Coughlin, L.N., Campbell, M., Wheeler, T., Rodriguez, C., Florimbio, A.R., Ghosh, S., Guo, Y., Hung, P., Newman, M.W., Pan, H., Zhang, K.W., Zimmerman, L., Bonar, E., Walton, M., Murphy, S., Nahum-Shani, I. A mobile health intervention for emerging adults with regular cannabis use: A micro-randomized pilot trial design protocol. Contemporary Clinical Trials. (In Press)

Abstract

• Background: Emerging adult (EA) cannabis use is associated with increased risk for health consequences. Just-in-time adaptive interventions (JITAIs) provide potential for preventing the escalation and consequences of cannabis use. Powered by mobile devices, JITAIs use decision rules that take the person's state and context as input, and output a recommended intervention (e.g., alternative activities, coping strategies). The mHealth literature on JITAIs is nascent, with additional research needed to identify what intervention content to deliver when and to whom.

• Methods: Herein we describe the protocol for a pilot study testing the feasibility and acceptability of a micro-randomized trial for optimizing MiWaves mobile intervention app for EAs (ages 18-25; target N = 120) with regular cannabis use (≥3 times per week). Micro-randomizations will be determined by a reinforcement learning algorithm that continually learns and improves the decision rules as participants experience the intervention. MiWaves will prompt participants to complete an in-app twice-daily survey over 30 days and participants will be micro-randomized twice daily to either: no message or a message [1 of 6 types varying in length (short, long) and interaction type (acknowledge message, acknowledge message + click additional resources, acknowledge message + fill in the blank/select an option)]. Participants recruited via social media will download the MiWaves app, and complete screening, baseline, weekly, post-intervention, and 2-month follow-up assessments. Primary outcomes include feasibility and acceptability, with additional exploratory behavioral outcomes.

• Conclusion: This study represents a critical first step in developing an effective mHealth intervention for reducing cannabis use and associated harms in EAs.

Coughlin, L.N., Bonar, E.E., Wieringa, J., Zhang, L., Augustiniak, A.N., Goodman, G.J. & Lin, L.A. Pilot trial of a telehealth-delivered behavioral economic intervention promoting cannabis-free activities among non-treatment seeking adults with cannabis use disorder. Journal of Psychiatric Research, (2023); 163: 202-210. PMID: 37224772

Abstract

• Background: Cannabis is increasingly consumed and increasingly perceived as harmless. Among those whose use develops into a cannabis use disorder (CUD), <5% initiate and engage in treatment. Thus, novel options for low-barrier, appealing treatments are needed to foster engagement in care.

• Methods: We conducted an open trial of a telehealth-delivered multicomponent behavioral economic intervention for non-treatment-engaged adults with CUD. Participants with CUD were recruited from a health system and screened for eligibility. Participants completed behavioral economic indices (cannabis demand, proportionate cannabis-free reinforcement), measures of cannabis use and mental health symptoms, and provided open-ended feedback on the intervention experience.

• Results: Of the 20 participants who enrolled and engaged in the initial intervention session, 70% (14 out of 20) completed all intervention components. All participants were satisfied/very satisfied with the intervention and 85.7% reported the telehealth delivery made it at least slightly easier/more likely for them to receive substance use care. Baseline to immediate post-treatment, behavioral economic cannabis demand decreased (intensity: Hedges' g = 0.14, maximum total expenditure: Hedges' g = 0.53, maximum expenditure for a single hit: Hedges' g = 0.10) and proportionate cannabis-free reinforcement (Hedges' g = 0.12) increased. Past-month total cannabis use decreased by 8.9% from baseline to post-treatment (Hedges' g = 0.39), along with decreases in recent depression (Hedges' g = 0.50) and anxiety symptoms (Hedges' g = 0.29).

• Discussion: These preliminary findings suggest that this behavioral economic intervention was highly acceptable and feasible for adults with untreated CUD. Changes in potential mechanisms of behavior change (cannabis demand, proportionate cannabis-free reinforcement) were consistent with reduced frequency of cannabis use and improved mental health outcomes.

Coughlin, L.N., Jennings, C.J., Hellman, L., Florimbio, A.R., Jannausch, M. & Bonar, E.E. Development and pilot testing of an  experimental cannabis marketplace: Toward evaluating the impact of cannabis policy on consumer choices. Cannabis and Cannabinoid Research. (2023);  Online ahead of print. PMID: 37347989

Abstract

• Introduction: The legal landscape of recreational cannabis production and consumption is rapidly expanding, driving a need to inform empirically supported cannabis regulatory policy. A behavioral economic framework integrating economic constructs (e.g., price, substitutability) with psychology and decision-making sciences, has previously been applied to tobacco regulatory sciences through the use of experimental marketplaces. However, experimental marketplaces have not yet been applied to understand cannabis choice behaviors or study ways to minimize risks from use. Herein, we describe the development and initial feasibility testing of an Experimental Cannabis Marketplace (ECM). The ECM can serve as an experimental platform relevant to evaluating the impact of regulatory policies on cannabis choices and use behavior. 

• Methods: The ECM was designed to resemble an online cannabis dispensary. Adults aged 21 and older with past month cannabis use and past month purchase from a recreational dispensary were recruited online. To test the feasibility and acceptability of the ECM, 62 people completed the ECM shopping task and provided feedback on the ECM prototype. Participants also reported about their typical purchases from real-world dispensaries. 

• Results: Nearly all participants rated the ECM as very (80.65%) or somewhat (16.13%) easy to navigate, and rated task instructions as at least mostly clear (100%). The majority (75.81%) said cannabis products available in the ECM were mostly the same or exactly the same as at their typical dispensary. Participant purchase choices in actual dispensary purchases closely matched ECM purchases, with 88% of product choices in typical real-world cannabis dispensaries matching the ECM products purchased. 

• Discussion: Initial testing of the ECM indicates it is an acceptable and feasible tool for understanding cannabis purchasing and choice behavior. These preliminary findings suggest that the ECM mimics cannabis dispensary settings with people making similar choices to those made in the real world.

Coughlin, L. N., Salino, S., Jennings, C., Lacek, M., Townsend, W., Koffarnus, M. N., & Bonar, E. E. (2023). A systematic review of remotely delivered contingency management treatment for substance use. Journal of Substance Use and Addiction Treatment, 208977.

Abstract

• Background: Substance use and related consequences (e.g., impaired driving, injuries, disease transmission) continue to be major public health concerns. Contingency management (CM) is a highly effective treatment for substance use disorders. Yet CM remains vastly underutilized, in large part due to implementation barriers to in-person delivery. If feasible and effective, remote delivery of CM may reduce barriers at both the clinic- and patient-level, thus increasing reach and access to effective care. Here, we summarize data from a systematic review of studies reporting remote delivery of CM for substance use treatment.

• Methods: We conducted a systematic review, reported according to PRISMA guidelines. The study team identified a total of 4358 articles after deduplication. Following title and abstract screening, full-text screening, and reference tracking, 39 studies met the eligibility criteria. We evaluated the methodological quality of the included studies using the Effective Public Health Practice Project Quality tool.

• Results: Of 39 articles included in the review, most (n = 26) targeted cigarette smoking, with others focusing on alcohol (n = 9) or other substance use or targeting multiple substances (n = 4). Most remotely delivered CM studies focused on abstinence (n = 29), with others targeting substance use reduction (n = 2), intervention engagement (n = 5), and both abstinence and intervention engagement (n = 3). CM was associated with better outcomes (either abstinence, use reduction, or engagement), with increasingly more remotely delivered CM studies published in more recent years. Studies ranged from moderate to strong quality, with the majority (57.5 %) of studies being strong quality.

• Conclusions: Consistent with in-person CM, remotely delivered CM focusing on abstinence or use reduction from substances or engagement in substance use treatment services improves outcomes at the end of treatment compared to control conditions. Moreover, remotely delivered CM is feasible across a variety of digital delivery platforms (e.g., web, mobile, and wearable), with acceptability and reduced clinic and patient burden as technological advancements streamline monitoring and reinforcer delivery.

Coughlin, L. N., Bonar, E. E., Walton, M. A., Fernandez, A. C., Duguid, I., & Nahum-Shani, I. (2022). New Directions for Motivational Incentive Interventions for Smoking Cessation. Frontiers in digital health, 4, 803301. https://doi.org/10.3389/fdgth.2022.803301

Abstract:

• Background: Motivational incentive interventions are highly effective for smoking cessation. Yet, these interventions are not widely available to people who want to quit smoking, in part, due to barriers such as administrative burden, concern about the use of extrinsic reinforcement (i.e., incentives) to improve cessation outcomes, suboptimal intervention engagement, individual burden, and up-front costs.

• Purpose: Technological advancements can mitigate some of these barriers. For example, mobile abstinence monitoring and digital, automated incentive delivery have the potential to lower the clinic burden associated with monitoring abstinence and administering incentives while also reducing the frequency of clinic visits. However, to fully realize the potential of digital technologies to deliver motivational incentives it is critical to develop strategies to mitigate longstanding concerns that reliance on extrinsic monetary reinforcement may hamper internal motivation for cessation, improve individual engagement with the intervention, and address scalability limitations due to the up-front cost of monetary incentives. Herein, we describe the state of digitally-delivered motivational incentives. We then build on existing principles for creating just-in-time adaptive interventions to highlight new directions in leveraging digital technology to improve the effectiveness and scalability of motivational incentive interventions.

• Conclusions: Technological advancement in abstinence monitoring coupled with digital delivery of reinforcers has made the use of motivational incentives for smoking cessation increasingly feasible. We propose future directions for a new era of motivational incentive interventions that leverage technology to integrate monetary and non-monetary incentives in a way that addresses the changing needs of individuals as they unfold in real-time.