Intervention Strategy Perceptions, Enablers, Nurturers Suggested Revision
Description of intervention components throughout the treatment. • Negative perception. Participants are likely to have multiple beliefs about clinical language that will hinder their motivation to engage in treatment. • Use everyday language and metaphors. Examples include using the term “tool” instead of strategy; using the term “Big picture versus right-now thinking” when describing impulsive choices and long-term rewards; using change or improve instead of “manage” especially with regard to people.
• Don’t expect participants to learn therapy language, learn the language they use to describe what is needed.
Pre-session assessment of motivation, self-efficacy, cigarettes per day, carbon
monoxide levels, and progress toward goals.
• Negative perception. Participants are likely to have multiple negative beliefs about impersonally completing forms prior to receiving services that will hinder their motivation to engage in treatment and foster an external locus of control.  • Re-name the process of collecting and discussing pre-session assessment data to Feedback. Provide a copy of the feedback form to participants.
• Do not collect pre-session assessments before the first session. Instead, describe how the participants can use the Feedback information during the first session, demonstrate how to use the carbon monoxide monitor in session, prepare participants to complete the Feedback forms on their own prior to the rest of the sessions.
• Have a rotating in-group leader to assist with the collection of Feedback prior to sessions 2-6.
Preparing for abstinence after the group; countering beliefs that group is like a class; encouraging conceptualization of treatment as changing thoughts, behaviors, and feelings. • Negative perceptions. Negative value placed on interactions that have no continuity beyond the 6 sessions; no relevant concrete materials to share with others. • Develop a culturally relevant and complementary “Toolkit” with pockets to enable collection of related materials and for Feedback sheets.
Quit date set for session 3 • Negative perception. Multiple negative beliefs and attitudes about having a specified quit date that will hinder motivation to engage in treatment and foster an external locus of control.  • Reinforce the notion of preparation as part of the quitting process.
• Discuss the quit date as part of the quitting process and a target or a goal to work toward.
Multiple interventions to increase internal locus of control • Negative perception. Multiple negative beliefs about fate and the role of faith in one’s life. Culturally accepted to have no control over circumstances or to place the locus of control in a higher power.
• Negative enabler. Multiple systemic influences that reinforce and encourage an externally focused locus of control.
• Negative perception. Willpower is a personality defect and is not under one’s control.
• Negative perception. Willpower is provided by a higher power.
• Help them to see what controls they actually have. This can be associated with stress management as well.
• Use ‘tools’ analogy. Having the right tools was associated with more personal control and an internal locus of control.
Increase positive valence of treatment, reinforce attendance, and reinforce contributions to the group. • Negative perception. Negative beliefs about the importance of attendance.
• Negative perception. Negative beliefs about being “second-class” citizens.
• Positive perception. Positive beliefs about responsibility and respect for others that can be extended to the importance of attending and contributing to group.
• Use introductions to establish commonalities
• Overtly discuss feelings of being second-class citizens
• Establish group norms that reinforce participant contributions and the value of contributions and participation.
• Have participants actively give and receive positive feedback to each other.
• Develop group guidelines that reinforce attendance, individual contributions, helping others, and respecting group members.
• Reinforce attendance at the beginning of each session.
• Reinforce individual contributions throughout treatment.
Diaphragmatic breathing to manage stress and negative affect • Positive perception. Intervention is consistent with preference for behavioral interventions and practice of faith and prayer.
• Negative perception. Allowing stress to “get to you” is a personality defect.
• Normalize the experience of stress, the experience of negative affect, as well as the experience of relaxation.
• Encourage practice as much as possible.  
Nicotine replacement • Negative perception. Lack of trust in medications. • Have group facilitator and participants unwrap and apply a patch in session.
• Provide proactive explanations to questions about patch use.
• Provide information to counter common myths about nicotine patches.
Review and inform participants about limits of confidentiality. • Negative perception. Descriptions such as this (i.e., limits of rights) is often associated with institutions like the police, child protective services, lawyers, etc. and might hinder motivation for group participation.
• Positive perception. The term “respect” includes culturally congruent responsibilities or expectations for maintaining confidentiality in appropriate contexts and might facilitate motivation for group participation.
• Discuss confidentiality in terms of respect for others and keeping everyone’s business private.
Triggers include negative affect and significant stressors related to having limited resources and suffering from discrimination. • Negative perception. These types of distress are sometimes embarrassing and often discussed only in the context of close family and friends.
• Positive nurturer. Overtly discussing these issues in a group setting might normalize the experience and reinforce the notion that these topics are important to talk about when trying to quit.
• Tailor the trigger-urge-response cycle exercise in the first session to overtly include situations of financial stress, discrimination, and feelings of loss of control, and negative affect including anger and frustration.
Managing smoking in the home, social situations, and reinforcing rights as a nonsmoker • Negative enabler. Individuals often do not have much control over or power to change situations in the social structures in which they live and work.
• Positive nurturer. Family and friends are likely to be supportive.
• Negative nurturer. Family and friends who smoke might not be supportive or might not know how to be supportive.
• Identify a social network with both positive and negative social influences
• Clearly acknowledge situations in which individuals have a lack of control
• Focus on positive aspects of relationships that provide both positive and negative social support
• Develop methods within the social structure to encourage the type of support the individual needs
Using religion and/or spirituality to support quitting • Positive perception. Faith is often valued and used to manage many personal challenges.
• Negative nurturer. Smoking is sometimes viewed as a sin and giving in to temptation and difficult to discuss with religious leaders. 
• Negative perception. Faith is sometimes viewed as encouraging a passive, trusting approach (i.e., waiting for God to give you the power, inspiration, and/or means to quit).
• Discuss a common parable, “Getting into the Boat” 
• Invite participants to use religious/spiritual imagery during relaxation training.
Table 2: Summary of community consultants’ review of intervention strategies in terms of the PEN-3 Model.