Bethany R. Raiff

IntroductionContingency management (CM) is a viable intervention for increasing buprenorphine treatment for opioid use disorder engagement. This study is a secondary analysis of a randomized controlled trial of CM for buprenorphine treatment that originally found CM to increase treatment attendance and adherence (urine positive for buprenorphine and negative for other opioids). This secondary analysis examined whether receipt of financial incentives led to increases in nonmedical substance use during the 3-month CM intervention.MethodsParticipants (N = 92) were randomized to either treatment as usual (TAU) or CM, and received incentives contingent on treatment attendance, as well as urine-verified buprenorphine positivity and nonmedical opioid negativity. Participants’ urine drug screens were also coded as positive or negative for 18 different substance classes.ResultsThe majority of participants across both groups (83.3%) tested positive for at least one illicit substance at intake. The CM group did not significantly differ from TAU in any nonmedical substance use over 3 months. Although the CM group had some marginally higher rates of benzodiazepine-positive urine (CM: M = 12.94%, SD ± 28.21 vs. TAU: M = 4.68%, SD ± 18.57, t(66) = 1.447, p = .340) and stimulant positivity (CM: M = 65.53%, SD ± 44.66 vs. TAU: M = 46.57%, SD ± 45.74, t(66) = 1.725, p = .089), they also had higher attendance and therefore more urine samples available for analysis.ConclusionThis study suggests that CM, incentivizing only nonmedical opioid abstinence, does not increase risk for other illicit substance use.

Individuals with opioid use disorder have difficulty sustaining prolonged buprenorphine treatment engagement. Contingency management (CM; incentives) may increase treatment reinforcement, but most buprenorphine CM studies delivered incentives multiple times per week, more often than typical outpatient frequency. This exploratory, pragmatic study compared patients randomly assigned to CM versus treatment-as-usual (TAU; n = 46 per group) in visit attendance and treatment adherence (urine samples positive for buprenorphine and negative for other opioids) over 12 weeks in new opioid treatment clinic outpatients. Incentive delivery was aligned with scheduled clinic visits, which could create natural thinning of incentives as patients stabilized. The CM participants earned incentives on a reloadable debit card. The CM group, compared to TAU, had higher rates of attendance and adherence at first follow-up after intake (attendance: CM = 67.4% vs. TAU = 45.7%; adherence: CM = 30.4% vs. TAU = 26.1%) and perfect attendance and adherence over all 12 weeks (attendance: CM = 22.2% vs. TAU = 8.7%; adherence: CM = 17.8% vs. TAU = 4.3%). Secondary outcomes showed that the CM group had 1.56 times higher average attendance (95% CI [1.28, 1.91]), 1.63 times longer continuous attendance streak (95% CI [1.31, 2.02]), 1.98 times higher average adherence (95% CI [1.35, 2.14]), and a 1.94 times longer continuous adherence streak (95% CI [1.46, 2.59]) than TAU. Out of a possible $590.00, the CM group earned an average of $138.56 (SD ± 145.97). This study supports the pragmatic implementation of a low-cost CM intervention to increase early buprenorphine engagement. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

Contingency management is a well‐validated behavior change intervention; however, the financial incentives can prevent it from being widely adopted. Most Americans have a smartphone with applications (apps) that they find enjoyable and engage with for a considerable amount of time. A potential avenue for contingency management dissemination is a mobile smartphone application that leverages the existing reward value of smartphone apps as a tool for behavior change. The present study examined the acceptability of the Re‐Connect concept, which proposes to block nonessential but highly preferred apps and unlock them contingent on meeting the user's health goals. Out of the sample surveyed (N = 146), 63.02% reported that they would be likely to use Re‐Connect and 67.81% would recommend it to someone. Acceptability of Re‐Connect increased with greater user control. These results suggest that access to preferred smartphone apps could be a socially acceptable incentive in a contingency management intervention.

Background: Smartphone apps are a convenient, low-cost approach to delivering smoking cessation support to large numbers of individuals. Yet, the apps are susceptible to low rates of user engagement and retention. Objective: This study aims to test the effects of a new game module (called Inner Dragon) integrated into Smoke Free (23 Limited), a leading smoking cessation app with established efficacy. The primary outcomes measured user engagement with the app. Methods: A 2-arm, parallel-group, randomized controlled trial was conducted in the United States with an 8-week follow-up. Adult individuals who smoked ≥1 cigarettes daily and planned to quit smoking within 7 days were recruited and randomized (N=500), with equal allocation. Both groups received free access to the original Smoke Free app with “core” features of its smoking cessation program (eg, a diary and craving log). The treated group received additional access to the integrated Inner Dragon game that incorporated several game mechanics designed to increase user engagement. User engagement outcomes were the number of unique app sessions, average minutes per session, days with a session, and program adherence. Self-reported and verified smoking abstinence and app satisfaction were also assessed. The main analysis estimated the intention-to-treat effect of access to Inner Dragon on each outcome. Further analyses assessed effect modification by participant characteristics and the association of intensity of game use with program adherence and abstinence. Results: Overall, user engagement was greater for treated versus control participants: they had 5.3 more sessions of Smoke Free (mean 29.6, SD 36.5 sessions vs mean 24.3, SD 37.9 sessions; P=.06), 0.8 more minutes per session (mean 6.9, SD 5.4 min vs mean 6.1, SD 5.2 min; P=.047), and 3.4 more days with a session (mean 14.3, SD 15.3 days vs mean 11.9, SD 14.3 days; P=.03). Program adherence, based on the number of times core features of the original Smoke Free app were used, was higher for treated versus control participants (mean 29.4, SD 41.3 times vs mean 22.6, SD 35.6 times; P=.03). Self-reported 7-day and 30-day point-prevalence abstinence and verified 7-day point-prevalence abstinence at 8 weeks did not significantly differ by study group. The mean repeated 1-day prevalence of quitting was higher among the treated group versus the control group (mean 17.3%, SD 25.6 vs mean 12.4%, SD 21.3; P=.01). App satisfaction and the motivation to (stay) quit did not differ by study group. Higher intensity of game use was associated with increased program adherence and self-reported abstinence. Conclusions: Findings suggest that the Inner Dragon game increased user engagement and program adherence. Additional refinements to the game design may clarify whether the game increases abstinence rates. Overall, it is feasible to deploy games and gamification to enhance user engagement in existing smoking cessation interventions. Trial Registration: ClinicalTrials.gov NCT05227027; https://clinicaltrials.gov/study/NCT05227027

Contingency management (CM), which involves the delivery of incentives upon meeting behavioral goals, has the potential to improve substance use treatment outcomes. The intervention allows for flexibility through numerous modifiable components including changes to incentive magnitude and schedule, target behavior, and intervention structure. Unfortunately, numerous changes in the substance use landscape have occurred in the past 10 to 15 years: Substances are more potent, overdose risk has increased, new substances and methods of use have been introduced, and substance classes are increasingly being intentionally and unintentionally mixed. These developments potentially undermine CM outcomes. We explored recent substance use changes due to legislative, regulatory, social, and economic factors for four substance classes: stimulants, opioids, tobacco, and cannabis. We discuss potential adjustments to the modifiable components of CM for future research in response to these changes. By continually adapting to the shifting substance use landscape, CM can maintain optimal efficacy.

Background: Approximately half of smokers attempt to quit, but 90% of these attempts fail. Video game–based interventions have the potential to address common barriers to evidence-based smoking cessation treatment, including high cost, lack of health care access, and low engagement. Objective: The purpose of this study was to evaluate the feasibility and acceptability of a video game–based smoking cessation intervention called Inspired and its impact on the 7-day smoking point prevalence at the 30-day follow-up. Methods: US adults (n=48) were recruited via the web to use Inspired on their smartphones for 7 weeks. The object of the game was to defend a healing tree against attackers. Levels of the game were unlocked twice daily when participants self-reported the number of cigarettes they smoked since the previous entry. Completion of the levels awarded players in-game currency, which could strengthen in-game abilities. Participants received additional in-game rewards to aid gameplay by submitting either smoking self-reports only or self-reports indicating abstinence, determined through random assignment. In addition, participants completed a web-based survey at intake, week 4, week 7, and the 30-day follow-up. Results: Of the 48 participants, who had an average age of 39.8 (SD 10.7) years, 27 (56%) were female, 4 (8%) Hispanic, 37 (77%) White, and 27 (56%) employed; 26 (54%) earned <US $40,000 a year; and 14 (29%) lived in nonurban areas (eg, rural and suburban). There were no significant differences between the groups, so all outcome data were combined. Participants averaged 20.6 (SD 15.3) days of gameplay and reached a mean highest game level of 10.7 (SD 8.4), although there was a high degree of variability. Participants reported abstinence on 31.4% (SD 38.2%) of all cessation phase reports and averaged 5.4 (SD 9.8) consecutive abstinent smoke reports. For every 1 SD increase in the highest level achieved, there was a 27% increase in the percentage of abstinent samples and a 405% increase in longest continuous abstinence. At the 30-day follow-up, 23% (11/48) of the participants reported having not taken a cigarette puff in the prior 7 days and 31% (15/48) had spent at least 24 hours without smoking in the prior 14 days. On an 11-point scale, participants rated the intervention moderately favorably: if they had to do it again, they would use Inspired to help them quit (mean 6.4, SD 3.4), and Inspired was helpful in their current attempt to quit (mean 5.4, SD 3.6). Conclusions: These results support the acceptability of Inspired. Although high dropout rates prevent conclusions on feasibility, a subset of the participants responded favorably. Scalable and accessible video game–based smoking cessation interventions could be the key to addressing the foremost cause of preventable morbidity and mortality in the United States. Trial Registration: ClinicalTrials.gov NCT03929003; https://clinicaltrials.gov/ct2/show/NCT03929003

BACKGROUND Smartphone apps are a convenient, low-cost approach to delivering smoking cessation support to large numbers of individuals. Yet, the apps are susceptible to low rates of user engagement and retention. OBJECTIVE This study aims to test the effects of a new game module (called Inner Dragon) integrated into Smoke Free (23 Limited), a leading smoking cessation app with established efficacy. The primary outcomes measured user engagement with the app. METHODS A 2-arm, parallel-group, randomized controlled trial was conducted in the United States with an 8-week follow-up. Adult individuals who smoked ≥1 cigarettes daily and planned to quit smoking within 7 days were recruited and randomized (N=500), with equal allocation. Both groups received free access to the original Smoke Free app with “core” features of its smoking cessation program (eg, a diary and craving log). The treated group received additional access to the integrated Inner Dragon game that incorporated several game mechanics designed to increase user engagement. User engagement outcomes were the number of unique app sessions, average minutes per session, days with a session, and program adherence. Self-reported and verified smoking abstinence and app satisfaction were also assessed. The main analysis estimated the intention-to-treat effect of access to Inner Dragon on each outcome. Further analyses assessed effect modification by participant characteristics and the association of intensity of game use with program adherence and abstinence. RESULTS Overall, user engagement was greater for treated versus control participants: they had 5.3 more sessions of Smoke Free (mean 29.6, SD 36.5 sessions vs mean 24.3, SD 37.9 sessions; P=.06), 0.8 more minutes per session (mean 6.9, SD 5.4 min vs mean 6.1, SD 5.2 min; P=.047), and 3.4 more days with a session (mean 14.3, SD 15.3 days vs mean 11.9, SD 14.3 days; P=.03). Program adherence, based on the number of times core features of the original Smoke Free app were used, was higher for treated versus control participants (mean 29.4, SD 41.3 times vs mean 22.6, SD 35.6 times; P=.03). Self-reported 7-day and 30-day point-prevalence abstinence and verified 7-day point-prevalence abstinence at 8 weeks did not significantly differ by study group. The mean repeated 1-day prevalence of quitting was higher among the treated group versus the control group (mean 17.3%, SD 25.6 vs mean 12.4%, SD 21.3; P=.01). App satisfaction and the motivation to (stay) quit did not differ by study group. Higher intensity of game use was associated with increased program adherence and self-reported abstinence. CONCLUSIONS Findings suggest that the Inner Dragon game increased user engagement and program adherence. Additional refinements to the game design may clarify whether the game increases abstinence rates. Overall, it is feasible to deploy games and gamification to enhance user engagement in existing smoking cessation interventions. CLINICALTRIAL ClinicalTrials.gov NCT05227027; https://clinicaltrials.gov/study/NCT05227027

BACKGROUND The majority of smokers express an interest in quitting and about half make an attempt to quit, but about 90% of these attempts fail. Videogame-based interventions have the potential to address common barriers to evidence-based smoking cessation treatment including cost, lack of access to healthcare settings, and low engagement. OBJECTIVE The purpose of this study was to evaluate the feasibility and acceptability of a videogame-based smoking cessation intervention called InspiredTM. METHODS U.S. adults (n=48) were recruited online to use InspiredTM on their smartphone for 7 weeks (the final 6 of which had a goal of smoking abstinence for all participants). The object of the game was to grow and defend one healing tree per level against attackers. In each level, players allocated different colored gems from their bank to activate either healing or defensive structures. Levels of the game were unlocked twice daily when participants reported the number of cigarettes they smoked since the previous entry. Completion of the levels awarded players in-game currency, which was used to strategically strengthen their structures. Participants received additional in-game rewards from either submitting smoking self-reports (i.e., submission contingent) or for submitting self-reports indicating smoking abstinence (i.e., abstinent contingent), consisting of gem prisms (used to power their structures for longer) and larger amounts of in-game currency. Additionally, participants completed an online survey at intake, week 4, week 7, and during the 30-day follow-up. RESULTS Participants were 56.3% female, 8.3% Hispanic, 77.1% white, 56.2% employed, 54.2% earning less than $40,000 a year, and had an average age of 39.79 (SD=10.72). Geographically, 29.2% of the sample lived in non-urban areas (e.g., rural, suburban). There were no significant differences between groups, so all outcome data are combined. Participants reached a mean highest level of 10.71 in the game (SD=8.43), though there was a high degree of variability. Participants reported abstinence on 31.36% (SD=38.16%) of all cessation phase reports and averaged 5.40 samples of continuous abstinence (SD=9.78). For every one-standard deviation increase in highest level achieved, there was a 27% increase in the percentage of abstinent samples reported and a 405% increase in longest period of continuous abstinence. During the abstinence phase, 52.10% of participants submitted at least one abstinent report. On an 11-point scale, participants rated the intervention moderately favorably: if they had to do it again, they would use Inspired to help them quit (M=6.43, SD=3.44) and InspiredTM was helpful in this current attempt to quit (M=5.37, SD=3.57). CONCLUSIONS These results support acceptability a videogame-based smoking cessation intervention for a geographically diverse population. Though high rates of dropout prevent conclusions on the intervention’s feasibility (possibly due to the game being imbalanced), a subset of the participants responded favorably to the intervention. Scalable and accessible smoking cessation interventions could be the key to addressing the number one cause of preventable morbidity and mortality in the U.S. CLINICALTRIAL ClinicalTrials.gov NCT03929003

Background: Several stand-alone smartphone apps have used serious games to provide an engaging approach to quitting smoking. So far, the uptake of these games has been modest, and the evidence base for their efficacy in promoting smoking cessation is still evolving. The feasibility of integrating a game into a popular smoking cessation app is unclear. Objective: The aim of this paper was to describe the design and iterative development of the Inner Dragon game within Smoke Free, a smartphone app with proven efficacy, and the results of a single-arm feasibility trial as part of a broad program that seeks to assess the effectiveness of the gamified app for smoking cessation. Methods: In phase 1, the study team undertook a multistep process to design and develop the game, including web-based focus group discussions with end users (n=15). In phase 2, a single-arm study of Smoke Free users who were trying to quit (n=30) was conducted to assess the feasibility and acceptability of the integrated game and to establish the feasibility of the planned procedures for a randomized pilot trial. Results: Phase 1 led to the final design of Inner Dragon, informed by principles from psychology and behavioral economics and incorporating several game mechanics designed to increase user engagement and retention. Inner Dragon users maintain an evolving pet dragon that serves as a virtual avatar for the users’ progress in quitting. The phase-2 study established the feasibility of the study methods. The mean number of app sessions completed per user was 13.8 (SD 13.1; median 8; range 1-46), with a mean duration per session of 5.8 (median 1.1; range 0-81.1) minutes. Overall, three-fourths (18/24, 75%) of the participants entered the Inner Dragon game at least once and had a mean of 2.4 (SD 2.4) sessions of game use. The use of Inner Dragon was positively associated with the total number of app sessions (correlation 0.57). The mean satisfaction score of participants who provided ratings (11/24, 46%) was 4.2 (SD 0.6) on a 5-point scale; however, satisfaction ratings for Inner Dragon were only completed by 13% (3/24) of the participants. Conclusions: Findings supported further development and evaluation of Inner Dragon as a beneficial feature of Smoke Free. The next step of this study is to conduct a randomized pilot trial to determine whether the gamified version of the app increases user engagement over a standard version of the app.