Kelly JF, Hoeppner B, Stout RL, Pagano M. Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous: a multiple mediator analysis. Addiction. 2012;107 (2) :289-99.Abstract
AIMS: Evidence indicates that Alcoholics Anonymous (AA) participation reduces relapse risk but less is known about the mechanisms through which AA confers this benefit. Initial studies indicate self-efficacy, negative affect, adaptive social networks and spiritual practices are mediators of this effect, but because these have been tested in isolation, their relative importance remains elusive. This study tested multiple mediators simultaneously to help determine the most influential pathways. DESIGN: Prospective, statistically controlled, naturalistic investigation examined the extent to which these previously identified mechanisms mediated AA attendance effects on alcohol outcomes controlling for baseline outcome values, mediators, treatment, and other confounders. SETTING: Nine clinical sites within the United States. PARTICIPANTS: Adults (n = 1726) suffering from alcohol use disorder (AUD) initially enrolled in a randomized study with two arms: aftercare (n = 774); and out-patient (n = 952) comparing three out-patient treatments (Project MATCH). MEASUREMENTS: AA attendance during treatment; mediators at 9 months; and outcomes [percentage of days abstinent (PDA) and drinks per drinking day (DDD)] at 15 months. FINDINGS: Among out-patients the effect of AA attendance on alcohol outcomes was explained primarily by adaptive social network changes and increases in social abstinence self-efficacy. Among more impaired aftercare patients, in addition to mediation through adaptive network changes and increases in social self-efficacy, AA lead to better outcomes through increasing spirituality/religiosity and by reducing negative affect. The degree to which mediators explained the relationship between AA and outcomes ranged from 43% to 67%. CONCLUSION: While Alcoholics Anonymous facilitates recovery by mobilizing several processes simultaneously, it is changes in social factors which appear to be of primary importance.
Kelly JF, Urbanoski KA, Hoeppner BB, Slaymaker V. "Ready, willing, and (not) able" to change: young adults' response to residential treatment. Drug Alcohol Depend. 2012;121 (3) :224-30.Abstract
BACKGROUND: Young adulthood represents a key developmental period for the onset of substance use disorder (SUD). While the number of young adults entering treatment has increased, little is known about the mechanisms of change and early recovery processes in this important clinical population. This study investigated during-treatment change in key therapeutic processes (psychological distress, motivation, self-efficacy, coping skills, and commitment to AA/NA), and tested their relation to outcome at 3 months post-treatment. METHODS: Young adults undergoing residential treatment (N=303; age 18-24; 26% female; 95% Caucasian) were enrolled in a naturalistic prospective study and assessed at intake, mid-treatment, discharge, and 3 months following discharge. Repeated-measures and regression analyses modeled during-treatment change in process variables and impact on outcome. RESULTS: Statistically significant medium to large effect sizes were observed for changes in most processes during treatment, with the exception of motivation, which was high at treatment intake and underwent smaller, but still significant, change. In turn, these during-treatment changes all individually predicted 3-month abstinence to varying degrees, with self-efficacy emerging as the sole predictor in a simultaneous regression. CONCLUSIONS: Findings help to clarify the mechanisms through which treatment confers recovery-related benefit among young adults. At treatment intake, high levels of abstinence motivation but lower coping, self-efficacy, and commitment to AA/NA, suggests many entering treatment may be "ready and willing" to change, but "unable" to do so without help. Treatment appears to work, in part, by helping to maintain motivation while conferring greater ability and confidence to enact such change.
Rigotti NA, Bitton A, Kelley JK, Heoppner BB, Levy DE, Mort E. Offering population-based tobacco treatment in a healthcare setting: a randomized controlled trial. American Journal of Preventive Medicine. 2011;41 (5) :498-503.Abstract

Background: The healthcare system is a key channel for delivering treatment to tobacco users. Brief clinic-based interventions are effective but not reliably offered. Population management strategies might improve tobacco treatment delivery in a healthcare system. Purpose: To test the effectiveness of supplementing clinic-based care with a population-based direct-to-smoker (DTS) outreach offering easily accessible free tobacco treatment. Design: Randomized controlled trial, conducted in 2009–2010, comparing usual clinical care to usual care plus DTS outreach. Setting/participants: A total of 590 smokers registered for primary care at a community health center in Revere MA. Interventions: Three monthly letters offering a free telephone consultation with a tobacco coordinator who provided free treatment including up to 8 weeks of nicotine patches (NRT) and proactive referral to the state quitline for multisession counseling. Main outcome measures: Use of any tobacco treatment (primary outcome) and tobacco abstinence at the 3-month follow-up; cost per quit. Results: Of 413 eligible smokers, 43 (10.4%) in the DTS group accepted the treatment offer; 42 (98%) requested NRT and 30 (70%) requested counseling. In intention-to-treat analyses adjusted by logistic regression for age, gender, race, insurance, diabetes, and coronary heart disease, a higher proportion of the DTS group, compared to controls, had used NRT (11.6% vs 3.9%, OR = 3.47; 95% CI = 1.52, 7.92) or any tobacco treatment (14.5% vs 7.3%, OR = 1.95, 95% CI = 1.04, 3.65) and reported being tobacco abstinent for the past 7 days (5.3% vs 1.1%, OR = 5.35, 95% CI = 1.23, 22.32) and past 30 days (4.1% vs 0.6%, OR = 8.25, 95% CI = 1.08, 63.01). The intervention did not increase smokers’ use of counseling (1.7% vs 1.1%) or non-NRT medication (3.6% vs 3.9%). Estimated incremental cost per quit was $464. Conclusions: A population-based outreach offering free tobacco treatment to smokers in a health center was a feasible, cost-effective way to increase the reach of treatment (primarily NRT) and to increase short-term quit rates. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Hoeppner BB, Kelly JF, Urbanoski KA, Slaymaker V. Comparative utility of a single-item versus multiple-item measure of self-efficacy in predicting relapse among young adults. J Subst Abuse Treat. 2011;41 (3) :305-12.Abstract
Single-item measures of psychological experiences are often viewed as psychometrically suspect. The purpose of this study was to evaluate the validity and utility of a single-item measure of self-efficacy in a clinical sample of treatment-seeking young adults. Inpatient young adults (N = 303, age = 18-24, 26% female) were assessed at intake to residential treatment, end of treatment, and at 1, 3, and 6 months following discharge. The single-item measure of self-efficacy consistently correlated positively with a well-established 20-item measure of self-efficacy and negatively with temptation scores from the same scale, demonstrating convergent and discriminant validity. It also consistently predicted relapse to substance use at 1-, 3-, and 6-month assessments postdischarge, even after controlling for other predictors of relapse (e.g., controlled environment), whereas global or subscale scores of the 20-item scale did not. Based on these findings, we encourage the use of this single-item measure of self-efficacy in research and clinical practice.
Hoeppner BB, Kahler CW, Jackson KM. Evaluating the validity and utility of scaling alcohol consumption indices alongside AUD symptoms in treatment-seeking adolescents. Drug Alcohol Depend. 2011;115 (3) :196-204.Abstract
BACKGROUND: Current initiatives to update diagnostic criteria for alcohol use disorders (AUDs) have stimulated dialogue about the usefulness of indicators of alcohol consumption in the diagnosis of AUDs. METHODS: This study used Rasch model analyses to examine the properties of alcohol consumption descriptors and AUD symptoms among 3382 treatment-seeking adolescents, aged 12-18 years, in the DATOS-A (United States Department of Health and Human Services, 1993-1995) baseline assessment, and evaluated the predictive validity of different scoring methods (with and without alcohol consumption) for 12-month alcohol involvement. RESULTS: Rasch model analyses supported the unidimensionality of indices of alcohol consumption and AUD symptoms. Test information functions showed that adding consumption items provides further information at all points of the alcohol involvement severity spectrum. Combining AUD symptoms with indices of alcohol consumption provided better prediction of alcohol involvement after treatment than either AUD symptom counts or DSM-IV dependence diagnosis alone. Differential item functioning (DIF), however, was observed for select items. Generally, indices of drinking "too much too fast" were more severe for females, African Americans and Hispanics, while the opposite was true for items measuring "too much too often". For age, "too much too often" items were more severe for the younger (12-14 years) age group, and AUD symptoms were more severe for the older (15-18 years) age group. CONCLUSIONS: Indices of alcohol consumption can be validly scaled along with AUD symptoms in this population, and their inclusion provides statistical measurement advantages. Nevertheless, caution is necessary in using consumption items in measuring alcohol involvement due to DIF observed across sex, race and age.
Kelly JF, Urbanoski KA, Hoeppner BB, Slaymaker V. Facilitating comprehensive assessment of 12-step experiences: A Multidimensional Measure of Mutual-Help Activity. Alcohol Treat Q. 2011;29 (3) :181-203.Abstract
Existing measures of 12-step mutual-help activity typically capture only a narrow range of experiences and combine fellowships with explicitly different substance-specific emphases (e.g., Alcoholics versus Narcotics Anonymous). To help expand our knowledge in this important area, we report on the development and use of a comprehensive multidimensional measure of 12-step experiences in two clinical samples of young adults and adolescents (N=430). One-week test-retest reliability was verified on a subsample. Results indicated high content validity and reliability across seven dimensions of experience (meeting attendance, meeting participation, fellowship involvement, step work, mandated attendance, affiliation, and safety), and the measure successfully discriminated between samples on anticipated activity levels. This measure provides rich data on mutual-help activities and deepens our understanding of individuals' experiences across different 12-step organizations.
Proeschold-Bell RJ, Hoeppner B, Taylor B, Cohen S, Blouin R, Stringfield B, Muir AJ. An interrupted time series evaluation of a hepatitis C intervention for persons with HIV. AIDS Behav. 2011;15 (8) :1721-31.Abstract
Accurate HCV knowledge is lacking among high-risk groups, including people with HIV/AIDS (PLWHA). Liver disease primarily due to HCV has emerged as a serious cause of mortality among PLWHA. We used an Interrupted Time Series design to evaluate a social-ecologically based intervention for PLWHA, where an infectious disease clinic serving a six-county intervention area was monitored before (7 months) and after (17 months) intervention onset. The intervention included education of PLWHA and medical providers, HIV/HCV support groups, and adaptation of the patient chart top sheet to include HCV test information. Clinic-level outcomes were assessed prospectively every other week for 2 years by interviewing patients (n = 259) with clinic appointments on assessment days. Abrupt, gradual and delayed intervention effects were tested. Weighted regression analyses showed higher average HCV knowledge and a higher prevalence of patients reporting HCV discussion with their medical providers after intervention onset. A delayed effect was found for HCV awareness, and a gradually increasing effect was found for knowing one's HCV status. Other communities may consider adopting this intervention. Additional HCV interventions for PLWHA with HIV are needed.
Kelly JF, Hoeppner BB, Urbanoski KA, Slaymaker V. Predicting relapse among young adults: psychometric validation of the Advanced WArning of RElapse (AWARE) scale. Addict Behav. 2011;36 (10) :987-93.Abstract
OBJECTIVE: Failure to maintain abstinence despite incurring severe harm is perhaps the key defining feature of addiction. Relapse prevention strategies have been developed to attenuate this propensity to relapse, but predicting who will, and who will not, relapse has stymied attempts to more efficiently tailor treatments according to relapse risk profile. Here we examine the psychometric properties of a promising relapse risk measure-the Advance WArning of RElapse (AWARE) scale (Miller & Harris, 2000) in an understudied but clinically important sample of young adults. METHOD: Inpatient youth (N=303; Ages 18-24; 26% female) completed the AWARE scale and the Brief Symptom Inventory-18 (BSI) at the end of residential treatment, and at 1-, 3-, and 6-months following discharge. Internal and convergent validity was tested for each of these four timepoints using confirmatory factor analysis and correlations (with BSI scores). Predictive validity was tested for relapse 1, 3, and 6 months following discharge, as was incremental utility, where AWARE scores were used as predictors of any substance use while controlling for treatment entry substance use severity and having spent time in a controlled environment following treatment. RESULTS: Confirmatory factor analysis revealed a single, internally consistent, 25-item factor that demonstrated convergent validity and predicted subsequent relapse alone and when controlling for other important relapse risk predictors. CONCLUSIONS: The AWARE scale may be a useful and efficient clinical tool for assessing short-term relapse risk among young people and, thus, could serve to enhance the effectiveness of relapse prevention efforts.
Hoeppner BB, Stout RL, Jackson KM, Barnett NP. How good is fine-grained Timeline Follow-back data? Comparing 30-day TLFB and repeated 7-day TLFB alcohol consumption reports on the person and daily level. Addict Behav. 2010;35 (12) :1138-43.Abstract
OBJECTIVE: This study examined the correspondence of two types of Timeline Follow-back (TLFB) methods, a web-based self-administered, repeated 7-day TLFB and an interviewer-administered 30-day TLFB of alcohol consumption. METHOD: Participants were first- and second-year college students (n=323, 58.5% female). Day-to-day correspondence of drinking reports and correspondence of person-level indicators of drinking were assessed. RESULTS: Results indicated that correspondence between the TLFB-30 and TLFB-7 reports was generally good for summary indicators of drinking, but TLFB-7 data indicated a statistically significantly higher number of total drinks consumed, a higher number of days drinking 4+/5+ drinks per day, and a lower number of abstinent days than TLFB-30. Similarly, day-to-day comparison of drinking reports showed that drinking days were more frequently reported using the TLFB-7, a trend which was more pronounced for distal weekdays than recent weekdays. Correlations between TLFB-7 and TLFB-30 reports of drinks per drinking day were also lower for distal compared to recent weekdays (r=0.61 vs. r=0.76). Using a Poisson regression model, a linearly increasing trend in the absolute value of the difference between TLFB-7 and TLFB-30 drinking reports per day as length of recall increases was found (b=0.013, z=4.43, with p<0.001). CONCLUSIONS: Our results indicate that participants reported more drinking on the repeated TLFB-7 than on the standard TLFB-30. Furthermore, the result of daily level analyses showed that discrepancies between the methods increased as the length of recall increased. These findings suggest that TLFB assessments covering longer intervals may have reduced accuracy on a fine-grained scale.
Hoeppner BB, Hoeppner SS, Campbell JF. Examining trends in intake rates, client symptoms, hopelessness, and suicidality in a university counseling center over 12 years. Journal of College Student Development . 2009;50 (3) :539-550.Abstract

The question whether levels of psychopathology and symptom severity among university counseling center client populations are increasing or not has received a great deal of attention in professional psychology. We examined 12-year archival intake records of a university counseling center to test for trends regarding: (a) the overall number of student-clients seeking counseling, (b) the frequency with which specific symptoms were reported, (c) the number of times student-clients reported experiencing hopelessness at various levels of intensity, and (d) the number of times student-clients reported suicide ideation at two levels of intensity. The sample (n = 6,676) was predominantly female (69.2%), White (80.2%), and on average 23.1 years old (SD = 8.0). Individual intake records were converted into monthly counts, which were checked for linear trends over time using autoregressive models. No significant linear trends were found except for a small decreasing trend regarding the number of intake clients reporting advanced suicide ideation (β = -0.019, p = 0.027). Our findings suggest a long-term (i.e., more than 10-year) stability of student-clients' self-reported symptoms, and corroborate previous findings of short-term (i.e., 5-8 years) stability of client distress at intake over time. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

Spirito A, Hernandez L, Hoeppner BB, Mastroleo N, Wolff J. Underage drinking in a drinking society: three key issues. FIU Hospitality Review. 2009;27 (2) :112-120.Abstract

This paper discusses three key issues pertinent to adolescent drinking: (a) defining what is normative and what is problematic drinking in adolescence; (b) educating the public, especially parents, about who is at risk for problematic drinking; and (c) preventing the onset of risky drinking behaviours. The paper concludes that formulation and implementation of policies should be guided by efforts to disseminate information to better educate the public on identifying adolescents engaging in problematic drinking and those at risk for developing alcohol use problems. Furthermore, dissemination efforts should be particularly directly towards educating the parents who are in the best position to influence their children's drinking decisions and behaviours.

Kahler CW, Hoeppner BB, Jackson KM. A Rasch model analysis of alcohol consumption and problems across adolescence and young adulthood. Alcohol Clin Exp Res. 2009;33 (4) :663-73.Abstract
BACKGROUND: Recent investigations using item response modeling have begun to conceptualize alcohol consumption, problems, and dependence as representing points along a single continuum of alcohol involvement. Such a conceptualization may be of particular benefit to measurement of alcohol involvement in adolescents, but investigations to date have been limited to adult samples and may not generalize to adolescents due to age-related developmental differences. METHODS: This study used Rasch model analyses to examine the properties of indices of alcohol consumption and problems among 6,353 adolescents, aged 12 to 18 years, in Wave 1 of the Add Health survey. A particular focus was on whether the functioning of items changed when these adolescents were re-interviewed in Wave 3 when they were 18 to 24 years of age. RESULTS: Rasch model analyses supported the unidimensionality and additive properties of the items in the Wave 1 data. Comparisons of Wave 1 and Wave 3 data indicated differential item functioning in most of the items such that items related to alcohol consumption were more severe during adolescence, whereas items related to alcohol problems were more severe in young adulthood. CONCLUSIONS: A valid index of alcohol involvement in adolescents can be constructed combining indices of alcohol consumption and alcohol problems. Such an index covers a range of severity and functions similarly across sex and race/ethnicity. A similar index can be constructed in young adulthood. However, the interpretation of scores must be attentive to developmental differences. In particular, for adolescents, indices of alcohol consumption are relatively closer in severity to indices of alcohol problems than they are among young adults. Thus, alcohol problems are more likely among adolescents than young adults given a similar level of drinking.
Hoeppner BB, Goodwin MS, Velicer WF, Mooney ME, Hatsukami DK. Detecting longitudinal patterns of daily smoking following drastic cigarette reduction. Addict Behav. 2008;33 (5) :623-39.Abstract
To enhance prolonged smoking cessation or reduction, a better understanding of the process of change is needed. This study examines daily smoking rates following the end of an intensive smoking reduction program originally designed to evaluate the relationship of tobacco biomarkers with reduced levels of smoking. A novel pattern-oriented approach called time series-based typology is used to detect homogeneous smoking patterns in time-intensively (i.e., 40 occasions) observed smokers (n=57), who were predominantly Caucasian (94.7%), male (52.6%), and on average 47.9 years old (SD=11.3). The majority of the smokers exhibited a change in their daily smoking behavior over the course of 40 days with 47.4% increasing and 40.4% decreasing the number of cigarettes smoked per day, which is contrary to the results a group level approach would have found. Very few smokers (12.3%) maintained their average smoking rate, and exhibited an externally controlled smoking pattern. Trajectory type could be predicted by temporally proximal motivation and self-efficacy variables ((F(4, 106)=3.46, p=.011, eta2=.115), underscoring their importance in maintaining reduced smoking rates. Time series-based typology demonstrated good sensitivity to the identification of meaningfully different trajectories.
Hoeppner BB, Goodwin MS, WF V, Heltshe J. An applied example of pooled time series analysis: Cardiovascular reactivity to stressors in children with autism. Multivariate Behavioral Research [Internet]. 2007;42 (4) :707-727. Publisher's VersionAbstract

The advent of telemetric devices that sample data extensively over time has facilitated single subject or idiographic research to intensively study a single person over time. One of the challenges of idiographic research is combining single subject results to determine generalizability across subjects. This article demonstrates the first behavioral science application of pooled time series analysis, an extension of time series analysis that allows for the testing of between-person effects. The analysis used cardiovascular data gathered from 4 children with autism between the ages of 10 and 20 while exposed to 6 experimentally manipulated environmental stressors. A pooled time series analysis using the general transformation approach identified 1 general (a difficult learning task) and 3 specific stressors (exposure to a loud noise, unstructured time, and eating a preferred food) across the 4 participants. This application of pooled time series analysis demonstrates the challenges and potential for this method to address the issue of generalizability when using an idiographic research approach in the behavioral sciences.

Hoeppner BB, Velicer WF, Redding CA, Rossi JS, Prochaska JO, Pallonen UE, Meier KS. Psychometric evaluation of the smoking cessation Processes of Change scale in an adolescent sample. Addict Behav [Internet]. 2006;31 (8) :1363-1372. Publisher's VersionAbstract

The Processes of Change are the cognitions, behaviors, and emotions that people employ to change their behaviors. However, the processes of change remain the least studied dimension of the transtheoretical model. The present study presents a psychometric evaluation of the short form of the processes of change inventory for smoking cessation in an adolescent sample of 798 ninth-grade smokers from 22 Rhode Island high schools. The majority of the sample was white (87.2%), split approximately evenly as regards to gender (48.1% female), with an average age of 14.3 (SD=0.6) years of age. The same hierarchical model established on the adult sample was fit to the 20-item inventory. This model included 10 primary factors representing the processes of change and two second order factors that grouped the processes into five behavioral and five experiential processes of change. Model fit indices (RMSEA=0.08, CFI=0.92) supported the hypothesized structure. External validation was established by testing for stage differences in the use of the ten processes. A significant MANOVA (F(4,793)=18.517, p<0.001) and separate ANOVAs demonstrated that the use of all ten processes increased across the stages, as predicted by the transtheoretical model of behavior change. The processes of change help guide researchers, clinicians, and intervention program developers towards effective strategies to assist individuals at all stages of change progress towards healthier behaviors.