To drink or to drink less? Distinguishing between effects of implementation intentions on decisions to drink and how much to drink in treatment-seeking individuals with alcohol use disorder
Introduction
Alcohol use disorders are major contributors to morbidity and mortality in the United States and worldwide (Rehm et al., 2009). Treatments to cut back on alcohol use may help to reduce the overall burden of disease such as decreasing risk for several types of cancer, mental health problems, and heart disease (Rehm et al., 2003). One strategy to reduce drinking, called implementation intentions, identifies common antecedents to use and links these to alternative responses that aim to avoid or cope with these situations instead of drinking. Here, a pilot, proof-of-concept trial using ecological momentary assessments (EMAs) and ecological momentary interventions (EMIs) was employed to test the real-world efficacy of individually-tailored implementation intentions on alcohol use.
Proposed by Gollwitzer (1999), implementation intentions aim to decrease the disparity between goal setting and attainment. A prior meta-analysis found that implementation intentions have a medium to large effect size on goal attainment (Gollwitzer & Sheeran, 2006). Implementation intentions first seek to identify a critical risky situation (e.g., attending a party where others are drinking) and then to link them with appropriate responses (e.g., attending meetings with others who are attempting to remain abstinent) using an “if-then” framework. Implementation intentions increase healthy behaviors (e.g., de Vet et al., 2011, Guillaumie et al., 2012) and accumulating evidence suggests that implementation intentions are also effective in reducing unhealthy behaviors (e.g., Armitage, 2007, Armitage, 2008, Armitage, 2016, Sullivan and Rothman, 2008) including alcohol consumption (Armitage, 2009a, Armitage and Arden, 2012, Norman and Wrona-Clarke, 2016).
The implementation intention intervention used in the current study was adapted from the volitional help sheet developed by Armitage and Arden (2012). The active implementation intentions were in the form of if-then statements linking high-risk situations with healthier responses. In contrast, the control implementation intention condition presented the same critical situations and responses but participants choose useful phrases without linking them together in an if-then structure.
Previous studies have found reductions in alcohol use following implementation intention interventions when consumption is assessed retrospectively with the Timeline Followback (TLFB; Armitage & Arden, 2012). However, the TLFB is associated with underreporting of drinking on drinking days, compared to daily EMAs (Carney et al., 1998, Dulin et al., 2017, Searles et al., 2000). To increase reliability of amount of drinking on drinking days, daily EMAs were collected. The self-reports of previous day alcohol consumption were complemented by three breathalyzer samples throughout the day. The biologic breath alcohol content (BrAC) samples provide an objective measurement to corroborate the self-report EMAs.
Building on the innovations of EMAs, EMIs have more recently been recommended to provide frequent prompting or cueing of participants outside of the laboratory (Cohn et al., 2011, Heron and Smyth, 2010). EMIs can be stand alone treatments or treatment boosters that are provided to individuals in real-time and in the real world. For example, one study using EMIs observed reductions in alcohol use following daily text messages encouraging drinking moderation to incoming college students (Riordan, Conner, Flett, & Scarf, 2015). Similarly, in the current study EMIs of participant-tailored active or control implementation intention cues were provided via once-daily text message throughout the intervention period. To reduce barriers to participation and increase external validity of measures, all EMIs and EMAs were remotely delivered and collected, respectively.
This exploratory proof-of-concept study capitalizes on the availability of technological advancements to reduce the burden of treatment for individuals with alcohol use disorders. The current study provides two improvements to build on previous research showing that implementation intentions can help to reduce drinking. First, this study provides technological and assessment advancements to improve accuracy of measurement of alcohol consumption. Second, the frequent remote collection of alcohol consumption provides the ability to disentangle the effect of implementation intentions on two processes associated with alcohol reduction: (1) abstaining from alcohol and (2) reducing amount of alcohol consumption when drinking. The research team hypothesized that active implementation intentions would be associated with a greater reduction in alcohol consumption than control implementation intentions, and that biologic EMAs would corroborate the reliability and consistency of the self-reported EMAs.
Section snippets
Methods
Treatment-seeking participants completed either an active or active control implementation intention intervention. From the original sample that completed through the intervention period (n = 36), one participant in the control condition was excluded because of a disclosure to research staff that they had provided false responses throughout the study. To gain a representative sample, participants were recruited in a range of social and work settings, including flyers, online advertisements, and
Results
Of the fifteen participants who were screened but not randomized to treatment, two participants did not drink on at least two days during the baseline period, four participants did not return to the lab for the intervention session, four were referred to services because of high alcohol withdrawal scores, and five voluntarily withdrew (see Fig. 1). AUDIT scores and demographic characteristics were compared between the treatment conditions (Table 1). Independent samples t-tests indicate that
Discussion
This initial examination of an implementation intention treatment for alcohol use disorders capitalizes on technology to achieve frequent assessments of alcohol use and deliver intervention prompts repeatedly throughout treatment. The frequent EMAs of daily drinking provide the unique ability to distinguish between days of abstinence and days with drinking in order to identify more precisely the drinking processes influenced by implementation intentions. As such, two components of alcohol use
Role of funding sources
Funding for this study was provided by an NIAAA Grant R01-AA021529 awarded to WKB and R21-AA022727 and R21-AA023605 awarded to MNK. LNM's time was funded by NIAAA Grant F31-AA024368. NIAAA has no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or decision to submit this paper for publication.
Contributors
LNM, LMP, MNK, and WKB designed the study and wrote the protocol. LNM and LMP conducted literature searches and provided summaries of previous research studies. LNM and ANT conducted the statistical analysis. LNM and LMP wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript.
Conflict of interest
WKB declares HealthSim LLC and NotifiUS LLC as organizations that I have interest in as a principal. All other authors declare that they have no conflicts of interest.
Acknowledgements
The authors wish to thank the staff members at the Addiction Recovery Research Center for their help working with participants. The authors also wish to thank all of the voluntary participants at the Addiction Recovery Research Center for contributing to the better understanding of addiction and novel treatments.
References (33)
- et al.
More or better: Do the number and specificity of implementation intentions matter in increasing physical activity?
Psychology of Sport and Exercise
(2011) - et al.
Implementation intentions and goal achievement: A meta-analysis of effects and processes
Advances in Experimental Social Psychology
(2006) Sample selection versus two-part models revisited: The case of female smoking and drinking
Journal of Health Economics
(2008)- et al.
Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders
The Lancet
(2009) Diagnostic and statistical manual of mental disorders: DSM-5
(2013)Efficacy of a brief worksite intervention to reduce smoking: The roles of behavioral and implementation intentions
Journal of Occupational Health Psychology
(2007)A volitional help sheet to encourage smoking cessation: A randomized exploratory trial
Health Psychology
(2008)Effectiveness of experimenter-provided and self-generated implementation intentions to reduce alcohol consumption in a sample of the general population: A randomized exploratory trial
Health Psychology
(2009)Is there utility in the transtheoretical model?
British Journal of Health Psychology
(2009)Evidence that implementation intentions can overcome the effects of smoking habits
(2016)