Clinical or Environmental Factor Revisions to specific intervention components
Stress: Increased emphasis is placed on stress management. Stress management is introduced earlier in treatment, and discussed during every treatment session. The management of particular stressors associated with restriction of resources and /or of being of minority status are explicitly explored.
  1. Stress management is introduced and given greater emphasis as a primary component of treatment.
  2. Stress is more explicitly discussed as a precursor to relapse.
  3. Cognitive restructuring is used to
    1. a. facilitate understanding of a cognitive-behavioral conceptualization of stress and stress management earlier in treatment
      b. frame the relationship between stress and locus of control
      c. frame the relationship between stress and negative affect
      d. explicitly introduce negative affect as a powerful cue for smoking.
  4. Relaxation training is introduced in the first session instead of the third session, normalized, modeled, rehearsed in every session.
  5. Relaxation is practiced in session at the beginning of sessions 2-6 instead of the end of sessions 4-6.
  6. Relaxation homework is assigned for sessions 1-6 instead of 3-6.
  7. Goal setting includes more directive relation training practice goals and reviews of daily practice.
  8. Self-reinforcement is discussed as a stress management strategy, discussed in the third instead of the fifth session, and emphasized by repeating the concept in sessions 3-6 in a directive manner. 
  9. Everyday discrimination and micro-aggressions are explicitly discussed as stressors
  10. Financial stress  is explicitly discussed
  11. Strategies for managing interpersonal conflict are more concise and directive
  12. Strategies for maintain good health (nutrition, exercise, sleep) are explicitly linked to stress management and delivered in a more concise manner
  13. The belief that smoking alleviates stress is explicitly countered
Negative affect: Proactive emphasis on recognizing and managing negative affect.
  1. Managing negative affect is introduced as a primary component of treatment in first session instead of the third session and linked to stress and stress management in every session.
  2. Cognitive restructuring is used to
    1. a. frame the relationship between stress and negative affect
      b. frame stress management as a method of managing negative affect
      c. frame negative affect as affected by the environment and changeable by the individual
  3. Self-reinforcement is discussed as a strategy for managing negative affect.
  4. Moderate exercise is discussed as a method to manage negative affect
  5. Strategies for maintain good health (nutrition, exercise, sleep) are linked to managing negative affect and delivered in a more concise manner
Smoking in response to negative affect: Proactive, explicit emphasis on recognizing and managing negative affect as a cue to smoke and a risk for relapse.
  1. Cognitive restructuring is used to frame negative affect as a cue to smoke.
  2. Negative affect is explicitly discussed as a precursor to relapse.
  3. Negative affect is normalized as a cue to smoke.
  4. Participants are encouraged to manage negative affect as they would any other cue to smoke.
Discounting the value of delayed rewards: New explicit emphasis placed on recognizing and choosing long-term versus immediate rewards.
  1. Shifting one’s focus to long-term rewards is introduced as a primary component of treatment.
  2. Immediate challenges are reframed to place them in the context of long-term relapse prevention.
  3. Situations in which one can wait for a larger reward later are identified.
  4. Foregoing selected short-term rewards for larger rewards later are encouraged. 
  5. Behavioral rehearsal is used to practice waiting for a larger reward.
  6. Self-reinforcement strategies without long-term consequences are encouraged.
  7. Specific goals are developed for waiting for larger rewards.
  8. Problem-solving and conflict management are framed to decrease delay discounting.
  9. Future thinking is encouraged by incorporating an episodic future thinking goal-setting exercise.
Locus of control: New proactive emphasis placed on supporting perceived personal control.
  1. Shifting perceptions of control from an external to internal focus is introduced as a primary component of treatment.
  2. The discussion of willpower is framed to shift perception of control from an external to an internal focus.
  3. Locus of control is linked to stress and stress management.
  4. Wording throughout manual was revised to more strongly encourage an internal locus of control.
  5. Perceived personal control is incorporated into framing of stress management, problem-solving, impulsivity, negative affect, and smoking in response to negative affect.
  6. Locus of control is discussed in the context of faith-based beliefs in a new exercise discussing a common parable, “Getting into the boat.”
Impulsiveness: New explicit emphasis placed on identifying and addressing impulsive decision-making.
  1. Impulsive decision-making is introduced as a primary component of treatment in first session.
  2. Impulsive decision-making is linked to stress and stress management.
  3. The cue-urge-response cycle is framed as sometimes being automatic and impulsive.
  4. The management of situations where impulsive decision-making might occur are explicitly discussed.
  5. Behavioral rehearsal is used to help anticipate and practice alternative responses to situations that elicit impulsive decision-making.
  6. Specific goals are developed for self-monitoring of impulsive decision-making.
  7. Problem-solving and conflict management are framed to decrease impulsive decision-making.
  8. Self-reinforcement strategies are encouraged as a means of countering impulsive decision-making.
Smoking policies in the home: New explicit emphasis placed on developing smoking policies in the home.
  1. Managing smokers in one’s environment introduced in first session as a primary component of treatment in the first session.
  2. Increased emphasis on managing smokers in one’s environment.
  3. New content on benefits of smoke-free policies in the home.
  4. Barriers to establishing smoke-free policies in the home are explicitly discussed.
  5. Rights as a non-smoker are discussed in the fourth instead of the fifth session. 
Treatment utilization: New emphasis placed on increasing the positive valance of treatment.
  1. Treatment participation is introduced as a primary component of treatment in the first session.
  2. Increased emphasis is placed on
    1. increasing the positive valence of treatment by
      1. a. focusing on participant attachment to the group,
        b. reinforcing attendance,
        c. reinforcing personal responsibility for others in group before every session,
        d. ensuring participants receive positive feedback from group members through a structured exercise at the beginning of each session, and
        e. sending “we missed you” postcards signed by all participants to participants who miss sessions;
    2. in-session behavioral rehearsal of new skills and behaviors to
      1. a. encourage skill development,
        b. normalize new behaviors, and
        c. increase probability that new skills and behaviors are utilized outside of treatment.
  3. Self-reinforcement strategies are encouraged as a means of providing reinforcement for new skills and behaviors and increase the probability that these skills and behaviors are utilized outside of treatment
  4. Increased emphasis is placed on proper use of the nicotine patch
Table 1: Clinical and environmental factors associated with disparities in tobacco dependence treatment outcomes and addressed in the revised treatment.