A Randomized Controlled Trial of Mindfulness, Goal Setting, and MiCBT for Smoking Cessation and Resilience in Low SES Smokers

A Randomized Controlled Trial of Mindfulness, Goal Setting, and MiCBT for Smoking Cessation and Resilience in Low SES Smokers | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Randomized Controlled Trial of Mindfulness, Goal Setting, and MiCBT for Smoking Cessation and Resilience in Low SES Smokers Richard Woodman, Reece De Zylva, Elissa Mortimer, Sharon Lawn, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8282925/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Smoking rates remain disproportionately high among individuals of low socio-economic status (SES), contributing significantly to health inequities. Resilience-based interventions offer a potential strengths-focused approach to address this challenge. This study aimed to evaluate the efficacy of Mindfulness Training, Setting Realistic Goals, and Mindfulness-integrated Cognitive Behavioural Therapy (MiCBT) for promoting smoking cessation and enhancing resilience in low SES adult smokers. Methods A four-arm, parallel-group, 12-month online randomized controlled trial was conducted with 346 adult regular smokers in Australia classified as low SES. Participants were randomized to one of four conditions: Mindfulness Training, Setting Realistic Goals, MiCBT, or an active control group that received referrals to standard quit services. The active interventions consisted of eight 1-hour online group sessions over 6 months, followed by 6 months of online forum-based peer support. The primary outcome was self-reported 14-day smoking abstinence at 6 months. Secondary outcomes included internal resilience (Connor-Davidson Resilience Scale-25), external resilience (social support), nicotine dependence, self-efficacy, and stress. Data were analyzed using mixed-effects modelling. Results All study groups achieved substantial self-reported quit rates at the 6-month primary endpoint, ranging from 29.9% in the control group to 36.4% in the Mindfulness Training group. Significant reductions in nicotine dependence were also observed across all groups over the 18-month study period. However, there were no statistically significant between-group differences for the primary outcome of smoking abstinence or for secondary outcomes, including internal resilience and social support, at any time point. Conclusions Participation in a structured smoking cessation trial was associated with reduced smoking behaviors among low SES adults. However, none of the online resilience-enhancing interventions demonstrated superior efficacy for smoking cessation or for enhancing internal resilience compared to an active control. These findings suggest that low-intensity online interventions may be insufficient for this population and highlight the need for more intensive or blended support models. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12621000445875. Registered 19 April 2021. Smoking Cessation Socioeconomic Status Resilience Mindfulness Cognitive Behavioural Therapy Goal Setting Randomized Controlled Trial Health Equity. Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Tobacco smoking remains a paramount global public health issue, being a leading cause of preventable morbidity and mortality (1). Annually, smoking is responsible for approximately eight million deaths worldwide, a figure that includes the substantial impact of second-hand smoke exposure (2). The health consequences, such as lung cancer, heart disease, and stroke, are frequently fatal and invariably detrimental to an individual's quality of life (1). Within Australia, the scale of this burden is starkly illustrated by projections indicating that an estimated six million Quality Adjusted Life Years (QALYs) will be lost if the current population of smokers is tracked until the age of 70 (3). Beyond the profound health impacts, the economic burden is staggering; in 2012, smoking-attributable diseases were estimated to cost the global economy $ 1852 billion in purchasing power parity, equivalent to 1.8% of the world's annual gross domestic product (4). Despite overall declines in smoking prevalence observed in many high-income nations, these public health gains have not been equitably distributed across all societal segments. A significant and persistent challenge is the disproportionately high burden of smoking borne by individuals of low socio-economic status (SES). SES is a multifaceted construct reflecting an individual's or group's position within the societal hierarchy, typically assessed through indicators such as income, education, and occupation, which collectively influence health environments and access to essential resources (5). In Australia, smoking prevalence in the most disadvantaged areas is reported at 21%, markedly higher than the 8% observed in the least disadvantaged areas (6). Individuals from lower SES backgrounds are not only more likely to initiate smoking and become regular smokers but also face a greater likelihood of premature mortality from smoking-related diseases and tend to exhibit higher levels of nicotine dependence (7). Importantly, while low SES individuals attempt to quit smoking at rates comparable to those in higher socioeconomic strata, their success rates are substantially lower. For instance, Kotz and West (2009) reported a quit success rate of 11.4% for smokers in the lowest socioeconomic level, compared to 20.4% for those in the highest level, despite no significant difference in the frequency of quit attempts (8). This disparity underscores that broad, population-level public health campaigns and interventions may not be equally effective across all socioeconomic groups. Indeed, smoking cessation programs that have not specifically targeted lower SES groups may have inadvertently exacerbated inequalities in smoking prevalence (9). This persistent inequity highlights an urgent need for targeted, tailored interventions designed to address the unique challenges and circumstances faced by low SES smokers. In response to the limited success of traditional smoking cessation strategies among low SES populations, building resilience has emerged as a promising and innovative approach. Resilience, conceptualized as an asset-based framework, shifts the focus from individual deficits to the cultivation of strengths, capabilities, and protective factors. It is defined not merely as the ability to cope with difficulties, but as the capacity to "bounce back from adversity" and find hope and meaning in challenging circumstances (10). This study is grounded in the Psychosocial Interactive Model of Resilience, a conceptual framework that our research team developed (11). This model posits that resilience is a dynamic process arising from the interplay between an individual's internal psychological properties and their external social environment, evolving across the life course. The internal domain encompasses psychological attributes such as competence, identity formation, coping skills, locus of control, personality traits, problem-solving abilities, and autonomy. The external domain comprises resources and influences from the social environment, including policy, family support, community ties, education, the broader political and cultural milieu, friendships, and socio-economic opportunities. Individuals from low SES backgrounds often experience diminished levels of internal resilience factors, specifically self-efficacy, self-esteem, motivation, and confidence, which are correlated with feelings of powerlessness and higher perceived stress (12). Concurrently, they frequently face a greater accumulation of external stressors, including financial strain and limited social support, which can erode motivation and normalize smoking as a coping mechanism (13). The Psychosocial Interactive Model of Resilience suggests that interventions focusing solely on internal psychological factors may prove insufficient for low SES smokers, who contend with significant external environmental pressures (11). Therefore, building resilience in this population necessitates a comprehensive approach that addresses both internal capacities and external resources. The interventions in this study, particularly the inclusion of a peer support component, were designed with this dual focus in mind, aiming to bolster both internal psychological strengths and external social support networks, although the impact on the latter proved challenging to demonstrate empirically in this trial (11). The design and implementation of the resilience-enhancing interventions in this study were guided by the Behaviour Change Wheel (BCW) framework, developed by Michie and colleagues (14). The BCW offers a systematic and comprehensive method for characterizing and designing behaviour change interventions. At its core is the COM-B model, which posits that for any behaviour (B) to occur, an individual must possess the necessary Capability (C), Opportunity (O), and Motivation (M) (14). Capability refers to an individual's psychological and physical capacity to engage in the behaviour (e.g., knowledge, skills, self-efficacy). Opportunity encompasses all the external factors that make the behaviour possible or prompt it (e.g., physical environment, social influences, access to resources). Motivation involves the brain processes that energize and direct behaviour (e.g., reflective motivations like goal-setting and beliefs, and automatic motivations like emotions and habits). The BCW framework synergizes with the Psychosocial Interactive Model of Resilience by providing a structured approach to identifying intervention functions and policy categories that can target these COM-B components (11). In the context of this study, the selected interventions—Mindfulness Training (MT) and Setting Realistic Goals (SRG)—were expected to influence these determinants. For instance, MT was anticipated to enhance psychological capability (e.g., emotional regulation, coping skills) and motivation (e.g., reducing stress-induced cravings). SRG was aimed at improving psychological capability (e.g., planning skills, self-belief) and reflective motivation (e.g., commitment to quit goals). Mindfulness-integrated Cognitive Behavioural Therapy (MiCBT) was designed to integrate these domains, targeting psychological capability through the combination of attentional control and cognitive restructuring, while addressing reflective motivation by challenging maladaptive beliefs about smoking. The peer support component was designed to enhance social opportunity by providing a supportive environment and leveraging the experiential knowledge of ex-smokers. The overarching goal of this research was to address the high rates of smoking in low SES populations by testing novel, resilience-enhancing interventions. The specific aims of the study, as outlined in the protocol paper (11), were: To test the efficacy of three interventions (MT, SRG, and MiCBT) for smoking cessation in low SES groups. To assess the impact of these interventions on levels of resilience in low SES groups and track changes in resilience during exposure to the interventions. Based on these aims, the following hypotheses were formulated: Research hypothesis 1: The proportion of participants who report 14-day period abstinence from smoking at 6 months, 12 months and 18 months will be significantly higher for each intervention group compared to the control group. Research hypothesis 2: Levels of resilience measured by the Connor-Davidson CD-25 and ENRICHD Social Support Inventory, Internal composite score and External composite score will be significantly higher for each intervention group compared to the control group at 6, 12 and 18 months post randomisation. Methods Study Design This study employed a four-arm, parallel-group, 12-month Randomized Controlled Trial (RCT) design, with an additional 6-month follow-up period (11). The interventions were delivered online to small groups of participants, with an equal allocation ratio to each of the four study arms. The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) on April 19, 2021 (ID: ACTRN12621000445875; Universal Trial Number: U1111-1261-8951). The study protocol was developed in accordance with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines (15). The registration can be accessed at: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381007&isReview=true Participants and Recruitment Participants were adult smokers (aged 18 years or older) residing in Australia who had smoked regularly (defined as usually smoking at least one cigarette per day for at least the preceding two years) and were currently planning to quit (identified by a "yes" response to the question, "are you currently planning to quit smoking cigarettes?"). Additional inclusion criteria included having a smartphone, regular internet access, and willingness to dedicate approximately 14–20 hours online to complete the study over an 18-month period. Low SES was defined by meeting either of the following criteria: (a) a weekly household income below 457 AUD per adult before tax (identified as the Australian poverty line at the time of the protocol); or (b) current receipt of Australian social security benefits (e.g., aged pension, low-income pension, parenting payments, or disability support payments). This national recruitment strategy and SES definition aimed for broad generalizability and utilized a standardized, nationally relevant operationalization of low SES. Recruitment commenced on May 3, 2021, with a target of 812 participants. This target sample size was determined based on power calculations to detect meaningful differences between intervention arms and the control group in smoking abstinence between groups of 11.6% and also allowing for 10% dropout. Modification of the original trial design was necessary due to external events (16), primarily related to the COVID-19 pandemic. Due to the considerably slower than anticipated recruitment rate and the lack of any evidence for a meaningful difference between groups in a planned interim analysis, the trial was halted on 30 April 2024 on the basis of futility. This resulted in a final enrolled sample of 346 participants. This amendment significantly impacted the final sample size and statistical power. Recruitment strategies included web-based advertisements on social media platforms, news stories on local radio and television, and promotion through the networks of Project Reference Group members and other stakeholder organizations providing services to low SES populations across Australia. Prospective participants completed an online screening questionnaire via Qualtrics. Eligible individuals who provided informed consent were then randomly allocated to one of the four study arms using a computerized sequence generation (Mersenne Twister algorithm) embedded within the Qualtrics survey platform. Interventions Rationale for selected interventions The rationale for the selected Interventions (MT, SRG, MiCBT) and Peer Support was informed by the research team's extensive prior work, including qualitative studies and a consensus-development study with low SES smokers (17–19). MT and SRG were identified as the most feasible, acceptable, and potentially efficacious resilience-based strategies from the perspective of the target population (11). MT offers the potential to mitigate common challenges faced by low SES smokers including managing high levels of perceived stress, enhancing emotional regulation to cope with negative affect and cravings, and reducing the perceived severity of nicotine withdrawal symptoms (20), which is particularly relevant given the higher nicotine dependence often observed in this group (21). MiCBT, has demonstrated efficacy for addictive behaviours and incorporates stages focusing on attention and emotion regulation, behavioural regulation, interpersonal regulation, and an empathic stage to build internal resources (22–24). SRG interventions are designed to empower individuals by helping them develop clear, feasible, and specific quit plans. The process of setting and achieving personally defined short-term goals related to smoking cessation and associated lifestyle changes can foster a sense of control, increase confidence and self-belief, and thereby enhance both internal and external resilience (25). Recognizing the potential synergies between mindfulness, goal-setting, and established cognitive-behavioural techniques, an MiCBT arm was included (11). This integrated approach aimed to leverage the strengths of each component to provide a comprehensive intervention. The inclusion of a peer support component was based on evidence suggesting its efficacy in promoting smoking cessation among socioeconomically disadvantaged groups (26). Low SES individuals often report lower baseline levels of social support and may be skeptical of traditional counselling services. Peer mentors, being ex-smokers from similar backgrounds, can offer credible, experiential knowledge and serve as positive role models, potentially overcoming barriers to engagement and fostering a supportive community (11). Intervention administration All interventions were administered online. The active intervention arms (MiCBT, MT, SRG) involved an initial 6-month phase of group-based sessions, followed by a 6-month phase of online forum-based peer support. Common Intervention Elements: Participants in the MiCBT, MT, and SRG arms attended eight 1-hour group sessions delivered online via Zoom over a 6-month period, according to a prescribed delivery schedule. These sessions were conducted by facilitators with formal qualifications in Cognitive Behavioural Therapy (CBT) who received specialized training from experts in MT and SRG. Group 1 : Mindfulness-integrated Cognitive Behavioural Therapy (MiCBT): This intervention integrated principles and techniques from mindfulness, goal setting, and standard CBT. The content was designed to acknowledge the importance of all three components in fostering resilience and supporting smoking cessation. Group 2 : Mindfulness Training (MT): The MT intervention focused on enhancing participants' capacity for mindfulness to improve emotional regulation, manage cravings effectively, and reduce the perceived severity of nicotine withdrawal symptoms. Group 3 : Setting Realistic Goals (SRG): The SRG intervention aimed to assist participants in developing clear, feasible, and specific plans to quit smoking. Emphasis was placed on setting and achieving small, personally relevant goals related to smoking cessation and associated lifestyle changes, thereby building self-efficacy, confidence, and a sense of agency. Participants in all three intervention arms were also invited to opt-in for referral to their local Quitline service as part of the 'Ask, Advise, Help' model for smoking cessation, recommended by the Royal Australian College of General Practitioner’s, as described below for the Active Control group. As part of this best-practice model, intervention group participants were provided with a link to written materials on accessing Nicotine Replacement Therapy and stop-smoking medications. Group 4 : Active Control Group (CTRL):The active control group received the best practice intervention for smoking cessation at the time of the trial which was the ‘Ask, Advise, Help’ model recommended by the Royal Australian College of General Practitioners (27). This involved referral to Quitline, a national telephone service providing behavioural intervention counselling for smoking cessation, and provision of links to written information to assist in accessing nicotine replacement therapy or stop-smoking medications. Peer Support Component (MiCBT, MT, SRG groups) Following the initial 6-month group session phase, participants in the three active intervention arms received an additional 6 months of online peer support. This support was delivered via separate, dedicated online interactive blog forums for each intervention type. These forums were led by peer mentors who had successfully quit smoking themselves and were from similar low SES backgrounds, aiming to provide experiential knowledge and foster a supportive community. This online forum-based delivery represented a modification from the Facebook chat room model initially described in the grant proposal, potentially reflecting considerations for enhanced platform control, data management, or the creation of a more structured and dedicated community environment for participants. Outcome Measures A comprehensive suite of primary and secondary outcome measures was employed, assessed at multiple timepoints. Primary Outcome: The primary outcome was self-reported 14-day period prevalence of smoking abstinence at 6 months post-randomization. Self-reported abstinence was subject to remote biochemical verification using a saliva cotinine test, with a threshold of < 30 ng/mL indicating non-smoking status. Secondary Outcomes: Secondary outcomes were assessed using validated instruments that included: Smoking Behaviour and Nicotine Dependence: Weekly Smoking Questionnaire (WSQ): Assessed the probability of smoking at 9, 12 and 18 months. Fagerstrom Test for Nicotine Dependency (FTND): Measured level of nicotine dependence (28). Resilience: Internal Resilience: Connor-Davidson Resilience Scale-25 (CD-RISC-25) (29). External Resilience (Social Support): ENRICHD Social Support Inventory (ENRICHD SSI) (30). Psychological Factors: Equanimity: Equanimity Scale-16 (ES-16) (31). Motivation to Quit Smoking: Biener and Abrams Contemplation Ladder (BACL) (32). Smoking Self-Efficacy Questionnaire-12 (SEQ-12) and Composite Scores (33,34). The 12-item SEQ-12 was used to measure self-efficacy. From this, two derived composite scores were also analyzed: the Internal Composite Score (self-efficacy against internal cues, e.g., feelings) and the External Composite Score (self-efficacy against external cues, e.g., peers smoking). Stress: Perceived Stress Scale-10 (PSS-10) (35). Alcohol Use: Alcohol Use Disorders Identification Test (AUDIT-C) (36) (37). Assessment Timepoints: Data for primary and secondary outcomes were collected at baseline and at multiple follow-up points. Most outcomes (WSQ, FTND, CD-RISC, Motivation, SEQ-12, STRESS, ENRICHD, Internal/External Composites) were assessed at baseline, 3, 6, 9, 12, and 18 months. Equanimity was assessed at baseline, 2, 3, and 5 months. AUDIT was assessed at baseline, 6, 12, and 18 months. The primary outcome of smoking abstinence was specifically evaluated at 6 months (primary endpoint), 12 months, and 18 months. Data Analysis Statistical analyses were conducted to evaluate within-group changes from baseline and between-group differences in primary and secondary outcomes. Mixed-effects modelling (logistic regression for binary outcomes like smoking abstinence, and linear regression for continuous outcomes) was used to account for the correlation of data from repeated measures over time and to manage missing data (11). A modified intention-to-treat analysis was performed as the primary analysis, using all available data points, including those from subjects that withdrew from the study. As a sensitivity analysis, we also performed a full intention-to-treat analysis that used multiple imputation techniques to handle missing data. Imputation variables including all measured outcomes at each timepoint, quit-status, baseline smoking characteristics (cigarettes smoked, time since last quit attempt), participant demographics (age, gender, education), subject ID, and treatment group allocation. Data analysis was performed using Stata (version 17.0). A Type 1 error rate of α = 0.05 was set for hypothesis testing, with adjustments for multiple comparisons using a Bonferroni correction with α = 0.05/3 = 0.0167 when assessing outcomes across three primary time points to maintain the overall significance level. Ethics Committee approval This study was approved by the Southern Adelaide Clinical Human Research Ethics Committee (SACHREC; number 270.19). All participants provide informed consent prior to enrolment. Results Participant Flow and Baseline Characteristics A total of n = 346 participants were enrolled in the study (n = 101 controls, n = 82 MiCBT, n = 72 MT, n = 91 SRG). The Fig. 1 CONSORT flow diagram displays information regarding participant flow through the trial (including numbers recruited, allocated to each arm, retained at each follow-up assessment, and reasons for withdrawal). No adverse events or study-related harms were systematically monitored or reported by participants in any group. Detailed baseline demographic and smoking characteristics of the participants by study group are shown in Table 1 . Most subjects were in either the most disadvantaged or second most disadvantaged quintile of the Index of Relative Social Disadvantage (IRSD). There was however a slightly more even distribution of subjects across the 5 quintiles for the MT group, although this did not reach statistical significance (p = 0.056). There were no other differences across the four groups in baseline characteristics in terms of age, gender, level of education, nicotine dependence and the daily consumption of cigarettes. Table 1 Baseline characteristics of participants by study group (N = 346). CTRL (n = 101) MT (n = 72) MiCBT (n = 82) SRG (n = 91) P-value 1 Age, years (mean ± SD) 50.3 ± 15.1 51.0 ± 15.8 50.7 ± 14.6 50.0 ± 15.3 0.951 Male gender, n (%) 28 (27.7) 12 (16.7) 19 (23.2) 15 (16.5) 0.220 Education, n (%) Primary school 1 (1.0) 1 (1.4) 0 (0.0) 0 (0.0) High school 39 (38.6) 21 (29.2) 27 (32.9) 38 (41.8) Trade qualification 11 (10.9) 7 (9.7) 4 (4.9) 7 (7.7) TAFE 26 (25.7) 26 (36.1) 34 (41.5) 27 (29.7) University 24 (23.8) 17 (23.6) 16 (19.5) 19 (20.9) 0.527 IRSD quintile, n (%) Quintile 1 (Most disadvantaged) 46 (45.5) 26 (36.1) 35 (43.7) 35 (38.5) Quintile 2 (Second most disadvantaged) 26 (25.7) 15 (20.8) 22 (26.8) 29 (31.9) Quintile 3 (Middle group) 14 (13.9) 10 (13.8) 13 (15.8) 11 (12.1) Quintile 4 (Second most advantaged) 9 (8.9) 17 (23.6) 4 (4.9) 7 (7.7) Quintile 5 (Least disadvantaged) 5 (5.0) 3 (4.2) 7 (8.5) 8 (8.8) 0.056 Nicotine dependence (FTND) (mean ± SD) 5.4 ± 1.9 5.4 ± 2.3 5.1 ± 2.3 4.9 ± 2.3 0.457 Cigarettes smoked daily, n (%) <10 15 (14.9) 13 (18.1) 19 (23.2) 23 (25.3) 11–20 59 (58.4) 37 (51.4) 34 (41.5) 34 (37.4) 21–30 24 (23.8) 19 (26.4) 23 (28.0) 27 (29.7) 30+ 3 (3.0) 3 (4.2) 6 (7.3) 5 (5.5) 0.274 1 Differences assessed using ANOVA or chi-squared test as appropriate. FTND = Fagerstrom Test for Nicotine Dependence. Primary Outcome: Smoking Abstinence The primary outcome of smoking abstinence was assessed through the self-reported weekly smoking questionnaire (WSQ) and nicotine dependence (FTND). The mean (SD) number of non-missing surveys for the 5 WSQ questionnaires administered at 3, 6, 9, 12 and 18 months was 1.80 ± 1.79. Within-Group Changes: All four study groups (CTRL, MT, MiCBT, SRG) showed statistically significant reductions in the WSQ from their respective baselines at multiple post-baseline evaluations across the 18-month study period (Table 2 ). Specifically, these reductions were observed at 3, 6, 9, 12, and 18 months for the CTRL group; at 6, 9, 12, and 18 months for the MT group; at 6, 12 and 18 months for the MiCBT group; and at 3, 6, 12, and 18 months for the SRG group (Table 2 and Fig. 2 ). Similarly, FTND scores, indicating nicotine dependence, significantly decreased from the overall mean score at baseline in all four groups. These reductions were evident at 3, 6, 9, 12, and 18 months for all four groups (Table 2 and Fig. 3 ). Table 2 Time points (months) of significant within-group changes (p < 0.05) from baseline for primary and secondary outcomes by study group. Results are from the raw (non-imputed) data. Outcome CTRL (n = 101) MT (n = 72) MiCBT (n = 82) SRG (n = 91) WSQ (“Have you smoked in the last 2-weeks”?) 3,6,9,12,18 6,9,12,18 6,12, 18 3,6,12,18 WSQ (CD-RISC adjusted) 3,6,9,12,18 6 18 3,9, 12 Quit Status - Have you quit smoking? 3, 6, 9, 12, 18 6, 9, 12, 18 3, 6, 9, 18 3, 6, 9, 12, 18 CD-RISC-25 None 6, 9, 18 6, 9, 18 None Equanimity N/A 3 2,3,5 N/A FTND 3,6,9,12,18 3,6,9,12,18 3,6,9,12,18 3,6,9,12,18 SEQ-12 6, 9, 12, 18 3,6, 12 None 18 SEQ-12 External Composite (External stimuli) 9 6,12 None 9 SEQ-12 Internal composite (Internal stimuli) 3, 6, 9, 12, 18 3, 6, 12 None 18 Motivation to quit smoking None None None None STRESS None 6, 9 6 None ENRICHD None None None None AUDIT None 6, 18 None None Integers indicate months where a statistically significant (p < 0.05) change from baseline was observed for that group. "None" indicates no significant change at any post-baseline timepoint. WSQ = Weekly Smoking Questionnaire. Quit Status=“Have you quit smoking - meaning have you not smoked a cigarette, even a puff”, CD-RISC-25 = Connor-Davidson Resilience Questionnaire, Equanimity = Equanimity Scale-16, FTND = Fagerstrom Test for Nicotine Dependence, Motivation to quit smoking = Biener and Abrams contemplation ladder, SEQ-12 = Smoking self-efficacy questionnaire-12, STRESS = Perceived stress scale-10, ENRICHD = ENRICHD Social support Inventory, AUDIT = Alcohol use Disorders Identification Test (AUDIT-C) Between-Group Comparisons: Despite the within-group improvements, there were no statistically significant differences between the four groups in the probability of smoking (WSQ, global p = 0.975) or in FTND scores (global p = 0.241) across the assessed 7 follow-up timepoints when intervention groups were compared to the control group, or when compared against each other (Table 3 ). Therefore, although all intervention groups and the active control condition reduced their smoking, none of the active interventions (MT, SRG, MiCBT) demonstrated superiority over the active control or each other in terms of these primary smoking outcome measures. Table 3 Between-Group Comparisons for Secondary Outcome Measures (Pairwise comparisons at each timepoint and Global p-values. Results are from the raw (non-imputed) data. Group x Baseline p-value Group x 2M p-value Group x 3M p-value Group x 5M p-value Group x 6M p-value Group x 9M p-value Group x 12M p-value Group x 18M p-value Global p-value 1 WSQ 1.000 - 0.622 - 0.992 0.959 0.986 0.992 0.975 WSQ (CDRISC adjusted) 1.000 - 0.403 - 0.518 0.539 0.643 0.757 0.525 Quit Status 1.000 0.719 0.765 0.766 0.758 0.766 0.526 CD-RISC-25 1 0.934 - 0.865 - 0.419 0.019 0.678 0.107 0.123 ENRICHD 0.248 - 0.098 - 0.932 0.666 0.906 0.836 0.161 Equanimity 0.011 0.693 0.112 0.747 - - - - 0.026 External Composite 0.997 - 0.475 - 0.344 0.965 0.160 0.862 0.901 Internal composite 0.662 - 0.140 - 0.499 0.954 0.524 0.960 0.880 FTND 0.241 - 0.600 - 0.167 0.813 0.548 0.430 0.241 Motivation 0.321 - 0.914 - 0.134 0.279 0.399 0.691 0.369 SEQ-12 0.947 - 0.265 - 0.328 0.989 0.310 0.919 0.889 STRESS 0.832 - 0.776 - 0.051 0.330 0.441 0.996 0.428 AUDIT 0.415 - - - 0.085 - 0.704 0.002 0.019 1 Global p-value refers to the overall difference between groups across all measured timepoints. Pairwise comparisons are highlighted where statistically significant (global p < 0.05 and pairwise-comparison p < 0.0167). Self-Reported Quit Status In addition to the probability of smoking (WSQ) and nicotine dependence (FTND), participants' self-reported quit status was assessed at each follow-up. Table 4 presents the percentage of participants in each group who responded "Yes" to the question "Have you quit smoking?" at 3, 6, 9, 12, and 18 months, based on multiply imputed data. At the 6-month primary endpoint, self-reported quit rates were 29.9% (95% CI: 13.4–46.4) for the CTRL group, 36.4% (95% CI: 18.2–54.6) for the MT group, 33.7% (95% CI: 14.9–52.5) for the MiCBT group, and 35.2% (95% CI: 17.3–53.0) for the SRG group. Whilst the MT group showed the highest rate, the 95% confidence intervals were wide and substantially overlapped across all four groups. In particular, there were no significant differences between groups, at the key 6-month timepoint. The pattern of overlapping confidence intervals persisted across other follow-up periods. For example, at 3 months, quit rates ranged from 23.7% (CTRL) to 29.3% (MiCBT). At 9 months, the SRG group reported the highest quit rate at 40.2% (95% CI: 20.6–59.9), while at 12 months, the MT group reported 36.7% (95% CI: 16.2–57.2). At the final 18-month follow-up, reported quit rates were 29.9% (CTRL), 34.4% (MT), 33.6% (MiCBT), and 34.9% (SRG). In all instances, there were no significant differences. Overall, although a substantial proportion of participants in each arm reported quitting, these self-reported quit rates were consistent with the WSQ and FTND results, indicating that no intervention was more effective than the active control or other interventions in achieving higher self-reported quit rates. Table 4 Quit status percentages (95% confidence intervals) by group. Results are from multiply imputed data (N = 346). Time Point CTRL Group (N = 101) MT Group (N = 72) MiCBT Group (N = 82) SRG Group (N = 91) 3-Months 23.7 (10.6–36.7) 24.2 (5.3–43.2) 29.3 (13.4–45.2) 26.5 (11.8–41.2) 6-Months 29.9 (13.4–46.4) 36.4 (18.2–54.6) 33.7 (14.9–52.5) 35.2 (17.3–53.0) 9-Months 32.5 (13.7–51.3) 34.9 (11.7–58.1) 36.6 (7.5–65.8) 40.2 (20.6–59.9) 12-Months 28.6 (16.0–41.3) 36.7 (16.2–57.2) 30.3 (12.5–48.1) 33.2 (14.1–52.3) 18-Months 29.9 (10.8–49.0) 34.4 (11.8–56.9) 33.6 (14.1–53.1) 34.9 (16.1–53.6) Quit status rates are the percentage responding “Yes” to the survey question “Have you quit smoking - meaning, have you not smoked a cigarette, even a puff”. Remote biochemical verification of smoking abstinence (saliva cotinine < 30 ng/mL) Biochemical verification of self-reported smoking abstinence was attempted using remote saliva cotinine testing for a subset of participants at the 6, 9, and 12-month follow-ups. Across these timepoints, a total of 37 participants who reported quitting were invited to provide a sample. Of those invited, 6 participants responded, and test kits were sent out to them by the research team. A total of 4 completed tests were ultimately returned for analysis, with one test received from a participant in each of the four study arms (SRG, MT, MiCBT, and Control). All tests were negative for nicotine, but due to the extremely low number of returned samples, these data were insufficient for a meaningful statistical analysis or for robust confirmation of the self-reported cessation rates. Secondary Outcomes The impact of the interventions on various secondary outcomes related to resilience and psychological well-being are presented in Table 2 (within-group changes) and Table 3 (between-group changes). Resilience Measures: CD-RISC-25 (Resilience) Table 2 and Fig. 4 illustrate the CD-RISC-25 score changes over time. In between-group comparisons (Table 3 ), there was no statistically significant overall difference in CD-RISC scores across the study arms (global p = 0.123). Pairwise comparisons at the 9-month timepoint approached statistical significance (p = 0.019) but did not meet the Bonferroni-corrected threshold for significance. Overall, no intervention demonstrated a superior effect on this measure of internal resilience. ENRICHD (Social Support) There were no significant within-group changes from baseline in ENRICHD scores for any of the four study groups at any time point (Table 2 and Suppl Fig. 2). Correspondingly, no significant between-group differences were observed (global p = 0.161) (Table 3 ). Psychological Factors: Equanimity Equanimity was measured in the MT and MiCBT groups at baseline and months 2, 3 and 5. The MT group demonstrated significant improvements at 3 months compared to baseline and the MiCBT group improved significantly at month 2 (Table 2 and Suppl Fig. 3). A significant overall difference was observed between groups for equanimity (global p = 0.026) (Table 3 ). However, this difference appears to be attributable to a pre-existing significant difference between the groups at baseline (p = 0.011). No significant pairwise differences between groups were observed at any post-randomization timepoint (months 2, 3, or 5). Motivation No significant within-group increases in motivation scores from baseline were observed for any groups at any of the timepoints (Table 2 and Suppl Fig. 4). There were also no significant between-group differences (global p = 0.201) (Table 3 ). Self-Efficacy The CTRL group showed significant within-group increases in SEQ-12 scores at 6, 9, 12 and 18 months, for the MT group at 3, 6 and 12 months, and for the SRG group at 18 months (Suppl Fig. 5 and Table 2 ). No changes were observed for the MiCBT group. No significant between-group differences were found (global p = 0.889) (Table 3 ). Internal Composite Score Significant within-group increases were observed for the CTRL group at 3, 6, 9, 12 and 18 months, for the MT group at 3, 6 and 12 months, and for the SRG at 18 months. No changes were seen for the MiCBT group (Table 2 and Suppl Fig. 1). There were no significant between-group differences (global p = 0.880) (Table 3 ). External Composite Score The MT group showed significant within-group increases at 6 and 12 months, and the CTRL and SRG groups at 9 months. No changes were observed for the MiCBT group (Table 2 and Suppl Fig. 2). No significant between-group differences were found (global p = 0.901) (Table 3 ). Stress Significant within-group reductions in stress scores were observed for the MT group at 6 and 9 months, and for MiCBT at 6 months (Suppl Fig. 6 and Table 2 ). No changes were noted for the other groups. There were no significant between-group differences (global p = 0.428) (Table 3 ). Mediation Analysis: When WSQ (probability of smoking) scores were adjusted for CD-RISC scores (Suppl Fig. 7), the probability of smoking remained significantly reduced compared to baseline for the CTRL group (at 5 timepoints), the MT and MiCBT groups (at 1 timepoint), and the SRG group (at 3 timepoints). This was not however the case for the multiple imputation analysis in which the smoking probabilities were all significantly lower than at baseline for all timepoints except for MT at 3 months. This suggests that the observed reduction in the probability of smoking (WSQ) was not mediated by any changes in resilience as measured by the CD-RISC. AUDIT (Alcohol Use): Significant within-group reductions in alcohol use were observed for the MT group at 6 and 18 months (Suppl Fig. 8 and Table 2 ). No within-group changes were observed for the other groups. There was a significant between-group change (global p = 0.019) due to significant differences between groups at 18 months (p = 0.002) (Table 3 ). MT was lower than CTRL at 6 months (p = 0.013) and at 18 months (p = 0.026), and MiCBT was lower than CTRL at 18 months (p = 0.013). Discussion This randomized controlled trial investigated the efficacy of three online resilience-enhancing interventions; Mindfulness Training (MT), Setting Realistic Goals (SRG), and Mindfulness-integrated Cognitive Behavioural Therapy (MiCBT) compared to an active control condition for smoking cessation and resilience-building among low SES adult smokers in Australia. All study groups, including the active control, demonstrated significant reductions in the probability of smoking and levels of nicotine dependence over the 18-month study duration. However, no significant differences were found between the intervention groups and the active control, or among the intervention groups themselves, for these primary smoking outcome measures. Regarding secondary outcomes, no intervention demonstrated a statistically significant effect on the primary measures of resilience. There were no significant between-group differences in internal resilience (CD-RISC) or external social support (ENRICHD SSI). Although a significant overall difference between groups was found for equanimity, this was attributable to baseline differences and did not reflect a post-intervention effect. The observation that all study arms, including the active control group, experienced significant reductions in smoking probability (WSQ) and nicotine dependence (FTND) was a positive outcome, suggesting that engagement in a structured program with regular contact and monitoring can facilitate smoking reduction in this high-need population. The active control group received referrals to Quitline and educational materials, which are evidence-based supports. The effectiveness of this active control condition may have contributed to the lack of statistically significant superiority of the MT, SRG, or MiCBT interventions for direct smoking cessation outcomes. Since neither the WSQ or FTND showed significant between-group differences, based on these specific measures, our hypotheses regarding the superiority of the interventions for direct smoking cessation were not fully supported. The overall high rates of smoking reduction in each arm may also be a result of selection-bias since participants that stayed in the trial may be more likely to have quit compared to those lost to follow-up. Assuming on the other hand that participants were lost to follow-up at random, our results using multiple imputation support the high smoking cessation rates across all four arms Our second hypothesis posited that levels of resilience would be significantly higher for intervention groups compared to the control group at 6, 12, and 18 months (11), was not supported. The analysis revealed no significant between-group differences for internal resilience as measured by the CD-RISC. This indicates that none of the interventions, including the targeted MT and SRG arms, were effective in significantly bolstering this psychological resource compared to the active control. Our hypothesis regarding resilience was not supported for either internal or external domains. Consistent with the null finding for CD-RISC, no changes in perceived external social support (ENRICHD SSI) were observed for any group. This finding is important, since the Psychosocial Interactive Model of Resilience underlines the importance of external resources and social support. The peer support component, delivered via online forums, was specifically intended to bolster this external domain and so the null finding for ENRICHD suggests that this forum-based peer support, as implemented, may have been insufficient in intensity, duration, or mode of delivery to significantly alter perceived social support. This contrasts with some literature suggesting the benefits of peer support (26), which often involves more intensive or face-to-face interactions. Within-group improvements on secondary measures were observed across several arms. For instance, multiple groups, including MT, demonstrated significant increases in self-efficacy (SEQ-12) over time, and the MT group also showed reductions in stress. The SRG intervention also showed positive within-group changes, for SEQ-12 (at 18m), suggesting it may contribute to building resilience and self-efficacy. The MiCBT intervention also showed fewer within-group improvements on the secondary measures compared to MT. The study's findings offer critical insights into the Psychosocial Interactive Model of Resilience. Although the interventions were designed to strengthen the 'Internal Domain' of resilience, the lack of a significant between-group effect on CD-RISC scores suggests this was not achieved more effectively than in the control group. Similarly, the lack of significant change in ENRICHD scores across all groups, despite the inclusion of a peer support component designed to bolster external resources, highlights a challenge in effectively influencing the 'External Domain' of resilience within the parameters of this online intervention format. This suggests that more intensive or differently structured approaches may be needed to significantly impact perceived social support and other external resilience factors in this population. The interventions likely influenced different components of the Behaviour Change Wheel (COM-B) model. MT appears to have enhanced 'Capability' (e.g., emotional regulation, coping skills leading to stress reduction and increased equanimity) and 'Motivation' (e.g., increased motivation scores at one timepoint, potentially reduced cravings). SRG also aimed to improve 'Capability' (planning, self-belief) and 'Motivation' through goal achievement, which was reflected in within-group improvements on SEQ-12. The peer support component was intended to positively influence social 'Opportunity'; however, the null ENRICHD findings suggest this aspect was not meaningfully changed. The overall reduction in smoking across all groups indicates a shift in 'Behaviour', but the specific contributions of Capability, Opportunity, and Motivation likely varied by intervention and individual. Our finding of no significant effect of MT on psychological resilience (CD-RISC) in between-group comparisons presents a contrast to some literature that has indicated the efficacy of MT for enhancing such resources (38). This may suggest that the online, group-based format used in this trial was of insufficient intensity or duration to produce these effects in a low SES population, or that the benefits were not superior to those gained from engagement with standard quit services. The within-group improvements seen with SRG on SEQ-12 are consistent with theories that goal achievement builds self-efficacy (25), and literature supporting goal setting as a core component of behaviour change interventions. The lack of significant impact on ENRICHD scores, despite the online peer support, warrants careful consideration. While literature supports peer support for disadvantaged groups (26), the mode of delivery is crucial. The online forum approach used here may differ in impact from more intensive, potentially face-to-face, peer support models described by Ford et al. (26). The research team's own extensive prior work on resilience and smoking in low SES groups provided the foundation for this trial, and these results contribute further to understanding the complexities of intervening in this population (17–19). An interesting and unexpected finding emerged in relation to alcohol use. The MT group demonstrated significant within-group reductions in AUDIT scores, and in between-group comparisons, both the MT and MiCBT groups showed significantly lower AUDIT scores than the control group at later timepoints. Although alcohol use was a secondary outcome and these findings should be interpreted with caution, they suggest a potential ancillary benefit of mindfulness-based interventions on reducing hazardous alcohol consumption in this population. This spillover effect is plausible, as mindfulness training aims to enhance self-regulation and awareness of automatic behaviors, which are relevant to both smoking and alcohol use. This finding therefore merits further investigation in future trials where alcohol use may be a primary or key secondary outcome. This study has several notable strengths. It is among the first to rigorously test resilience-enhancing interventions specifically tailored for and identified as acceptable to low SES smokers, thereby addressing a critical health inequity. The RCT design was robust, and the interventions were grounded in established theoretical frameworks (Psychosocial Interactive Model of Resilience, Behaviour Change Wheel). The online delivery format enhanced accessibility for a geographically dispersed, national sample. Methodologically, the analytical approach adds to the study's rigor; we performed both a modified intention-to-treat analysis on the raw data and a full intention-to-treat analysis using multiple imputation to account for missing data. Presenting these results side-by-side provides a transparent and comprehensive view of the outcomes under different analytical assumptions. However, certain limitations must be acknowledged. The primary outcome of smoking abstinence relied on self-report, and although there was an effort to supplement this with biochemical verification, insufficient test samples were returned to allow any meaningful analysis. However, the inclusion of participant flow data and baseline characteristics suggests that groups were similar in both baseline characteristics and attrition. The latter varied between 10 and 20% across the 4 groups, meaning some selection bias may have been introduced into our results. Although recruitment was Australia-wide, findings may still be specific to the Australian low SES context and not universally generalizable. A significant limitation is the lack of observed change in the ENRICHD Social Support Inventory, suggesting the online peer support component may not have adequately impacted perceived external social support, or that the measure was not sensitive to the changes induced. A further significant limitation was the failure to achieve robust biochemical verification of smoking abstinence. Although planned as part of the protocol, the remote saliva cotinine testing process yielded a very low return rate. Across the 6, 9, and 12-month follow-up periods, a total of 37 participants who reported abstinence were invited to test, but only 6 kits were dispatched, and just 4 completed tests were ultimately received for analysis. This number is insufficient to validate the self-reported smoking cessation outcomes (WSQ and quit status percentages) or to detect potential differential misreporting between groups. Therefore, the primary smoking outcomes must be interpreted with the caution appropriate for unverified self-report data, which is a common challenge in online, remote trials. Finally, the effectiveness of the active control group, while ethically appropriate, may have attenuated the ability to detect significant differences in direct smoking cessation outcomes between the intervention arms and the control. The findings from this trial have important, albeit sobering, implications for public health policy and clinical practice. Although participation in a structured program was beneficial, the novel online resilience-enhancing interventions failed to demonstrate superiority over standard care referrals for either smoking cessation or bolstering psychological resilience. This suggests that low-intensity, online-only interventions may be insufficient to overcome the complex web of factors that sustain smoking in low SES populations. Some within-group improvements in stress and self-efficacy were noted, particularly for the MT group, but these did not translate into significant between-group effects. The null findings for both internal (CD-RISC) and external (ENRICHD) resilience underscore the need for more intensive, multifaceted, or blended (online and face-to-face) support models. Policymakers should be cautious about funding scalable online-only solutions without stronger evidence of their efficacy in high-need groups (39). This study opens several avenues for future research driven by its null findings. Investigating alternative or more intensive methods for bolstering both internal and external social support is crucial. For external support, this could involve blended online and face-to-face peer support, or community-based initiatives that move beyond online forums. For internal resilience, future research should explore whether interventions of a longer duration, with higher contact frequency, or delivered in a different modality could produce the effects on resilience that were not observed here. The adaptation and testing of these interventions for other addictive behaviors, such as the potential ancillary benefit on alcohol use suggested by our secondary analysis, also represents a significant area for future inquiry. In conclusion, this randomized controlled trial demonstrates that participation in a structured smoking cessation program, whether involving specific resilience-enhancing interventions or referral to active quit services, is associated with significant reductions in smoking probability and nicotine dependence among low SES adult smokers. However, no single intervention arm proved statistically superior for direct smoking cessation outcomes, nor did they demonstrate a significant effect on enhancing internal psychological resilience (CD-RISC) or external social support (ENRICHD) compared to the active control. Furthermore, the study observed significant participant attrition, a finding consistent with the known difficulties of retaining socioeconomically disadvantaged populations in smoking cessation trials (40). This high attrition, combined with the lack of superior intervention efficacy, highlights the profound challenge of designing effective, low-intensity online interventions for this vulnerable population and underscores that more intensive or differently structured approaches may be necessary to impact both smoking behavior and its underlying psychosocial determinants. The study highlights the profound challenge of designing effective, low-intensity online interventions for this vulnerable population and underscores that more intensive or differently structured approaches may be necessary to impact both smoking behavior and its underlying psychosocial determinants. These findings contribute valuable evidence to the effort to address smoking-related health inequities by demonstrating the limitations of the tested online models. Abbreviations ANZCTR Australian New Zealand Clinical Trials Registry AUDIT Alcohol Use Disorders Identification Test BACL Biener and Abrams Contemplation Ladder BCW Behaviour Change Wheel CBT Cognitive Behavioural Therapy CD-RISC Connor-Davidson Resilience Scale COM-B Capability, Opportunity, Motivation-Behaviour model CTRL Control Group ENRICHD SSI ENRICHD Social Support Inventory ES-16 Equanimity Scale-16 FTND Fagerstrom Test for Nicotine Dependency IRSD Index of Relative Social Disadvantage MiCBT Mindfulness-integrated Cognitive Behavioural Therapy MT Mindfulness Training PSS-10 Perceived Stress Scale-10 QALY Quality Adjusted Life Year RCT Randomized Controlled Trial SACHREC Southern Adelaide Clinical Human Research Ethics Committee SEQ-12 Smoking Self-Efficacy Questionnaire-12 SES Socio-economic Status SPIRIT Standard Protocol Items:Recommendations for Interventional Trials SRG Setting Realistic Goals WSQ Weekly Smoking Questionnaire Declarations Ethics approval and consent to participate: Ethics approval and consent to participate: Informed consent was obtained from all participants. The trial was registered with the Australian New Zealand Clinical Trials Registry (ID: ACTRN12621000445875). Specific ethics committee approval details are as outlined in the original protocol publication 11 . Consent for Publication: Not applicable. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: This study was primarily funded by an IDEAS Grant funding commencing in 2020 (Application ID: APP1182598). The principal investigator and research team members have also received funding from the National Health and Medical Research Council (NHMRC) and the Australian Research Council (ARC) for related work. Flinders University, particularly the College of Medicine and Public Health, the Flinders Centre for Innovation in Cancer, and the Southgate Institute for Health, Society and Equity, provided institutional support and resources. The Olivia Newton John Cancer Research Institute at La Trobe University was a collaborating institution. Authors' contributions: PW was the Chief Investigator, conceived the study, led the proposal development, and has expertise in resilience, smoking cessation, and mixed methodologies. R DeZ was the corresponding author for the published protocol paper 11 . EM, GT, SL, CW, and RW were co-investigators involved in the study design, and methodology. RW performed all power and sample size calculations, statistical analysis and provided the first draft of the manuscript. Acknowledgements: The research team acknowledges the participants who dedicated their time to this study, the peer mentors for their valuable contributions, and the funding bodies for their financial support. During the preparation of this work the author(s) used Google AI Studio in order to assist with the initial drafting of the manuscript and to refine language for clarity and readability. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the published article. References WHO report on the global tobacco epidemic, 2023: protect people from tobacco smoke [Internet]. [cited 2025 Oct 17]. Available from: https://www.who.int/publications/i/item/9789240077164 Yousuf H, Hofstra M, Tijssen J, Leenen B, Lindemans JW, van Rossum A, et al. Estimated Worldwide Mortality Attributed to Secondhand Tobacco Smoke Exposure, 1990–2016. JAMA Netw Open. 2020 Mar 17;3(3):e201177. 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2","display":"","copyAsset":false,"role":"figure","size":1670909,"visible":true,"origin":"","legend":"\u003cp\u003eProbability of smoking (WSQ) at 3, 6, 9, 12 and 18 months\u003c/p\u003e","description":"","filename":"Fig2probabilityofsmoking.png","url":"https://assets-eu.researchsquare.com/files/rs-8282925/v1/5f27df6c659b11bdcd150ed1.png"},{"id":99794740,"identity":"862f8902-ca8f-4155-9784-e06153c3f23b","added_by":"auto","created_at":"2026-01-08 13:36:09","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1800316,"visible":true,"origin":"","legend":"\u003cp\u003eFTND at baseline, 3, 6, 9, 12 and 18 months\u003c/p\u003e","description":"","filename":"Fig3FTND.png","url":"https://assets-eu.researchsquare.com/files/rs-8282925/v1/b05ab9304baf96a58f32c5f6.png"},{"id":99794574,"identity":"c5e2fc1b-decb-49da-9762-0e53d3e61fed","added_by":"auto","created_at":"2026-01-08 13:35:26","extension":"png","order_by":4,"title":"Figure 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smoking remains a paramount global public health issue, being a leading cause of preventable morbidity and mortality (1). Annually, smoking is responsible for approximately eight million deaths worldwide, a figure that includes the substantial impact of second-hand smoke exposure (2). The health consequences, such as lung cancer, heart disease, and stroke, are frequently fatal and invariably detrimental to an individual's quality of life (1). Within Australia, the scale of this burden is starkly illustrated by projections indicating that an estimated six million Quality Adjusted Life Years (QALYs) will be lost if the current population of smokers is tracked until the age of 70 (3). Beyond the profound health impacts, the economic burden is staggering; in 2012, smoking-attributable diseases were estimated to cost the global economy \u003cspan\u003e$\u003c/span\u003e1852\u0026nbsp;billion in purchasing power parity, equivalent to 1.8% of the world's annual gross domestic product (4).\u003c/p\u003e \u003cp\u003eDespite overall declines in smoking prevalence observed in many high-income nations, these public health gains have not been equitably distributed across all societal segments. A significant and persistent challenge is the disproportionately high burden of smoking borne by individuals of low socio-economic status (SES). SES is a multifaceted construct reflecting an individual's or group's position within the societal hierarchy, typically assessed through indicators such as income, education, and occupation, which collectively influence health environments and access to essential resources (5). In Australia, smoking prevalence in the most disadvantaged areas is reported at 21%, markedly higher than the 8% observed in the least disadvantaged areas (6). Individuals from lower SES backgrounds are not only more likely to initiate smoking and become regular smokers but also face a greater likelihood of premature mortality from smoking-related diseases and tend to exhibit higher levels of nicotine dependence (7). Importantly, while low SES individuals attempt to quit smoking at rates comparable to those in higher socioeconomic strata, their success rates are substantially lower. For instance, Kotz and West (2009) reported a quit success rate of 11.4% for smokers in the lowest socioeconomic level, compared to 20.4% for those in the highest level, despite no significant difference in the frequency of quit attempts (8). This disparity underscores that broad, population-level public health campaigns and interventions may not be equally effective across all socioeconomic groups. Indeed, smoking cessation programs that have not specifically targeted lower SES groups may have inadvertently exacerbated inequalities in smoking prevalence (9). This persistent inequity highlights an urgent need for targeted, tailored interventions designed to address the unique challenges and circumstances faced by low SES smokers.\u003c/p\u003e \u003cp\u003eIn response to the limited success of traditional smoking cessation strategies among low SES populations, building resilience has emerged as a promising and innovative approach. Resilience, conceptualized as an asset-based framework, shifts the focus from individual deficits to the cultivation of strengths, capabilities, and protective factors. It is defined not merely as the ability to cope with difficulties, but as the capacity to \"bounce back from adversity\" and find hope and meaning in challenging circumstances (10). This study is grounded in the Psychosocial Interactive Model of Resilience, a conceptual framework that our research team developed (11). This model posits that resilience is a dynamic process arising from the interplay between an individual's internal psychological properties and their external social environment, evolving across the life course. The internal domain encompasses psychological attributes such as competence, identity formation, coping skills, locus of control, personality traits, problem-solving abilities, and autonomy. The external domain comprises resources and influences from the social environment, including policy, family support, community ties, education, the broader political and cultural milieu, friendships, and socio-economic opportunities.\u003c/p\u003e \u003cp\u003eIndividuals from low SES backgrounds often experience diminished levels of internal resilience factors, specifically self-efficacy, self-esteem, motivation, and confidence, which are correlated with feelings of powerlessness and higher perceived stress (12). Concurrently, they frequently face a greater accumulation of external stressors, including financial strain and limited social support, which can erode motivation and normalize smoking as a coping mechanism (13). The Psychosocial Interactive Model of Resilience suggests that interventions focusing solely on internal psychological factors may prove insufficient for low SES smokers, who contend with significant external environmental pressures (11). Therefore, building resilience in this population necessitates a comprehensive approach that addresses both internal capacities and external resources. The interventions in this study, particularly the inclusion of a peer support component, were designed with this dual focus in mind, aiming to bolster both internal psychological strengths and external social support networks, although the impact on the latter proved challenging to demonstrate empirically in this trial (11).\u003c/p\u003e \u003cp\u003eThe design and implementation of the resilience-enhancing interventions in this study were guided by the Behaviour Change Wheel (BCW) framework, developed by Michie and colleagues (14). The BCW offers a systematic and comprehensive method for characterizing and designing behaviour change interventions. At its core is the COM-B model, which posits that for any behaviour (B) to occur, an individual must possess the necessary Capability (C), Opportunity (O), and Motivation (M) (14). Capability refers to an individual's psychological and physical capacity to engage in the behaviour (e.g., knowledge, skills, self-efficacy). Opportunity encompasses all the external factors that make the behaviour possible or prompt it (e.g., physical environment, social influences, access to resources). Motivation involves the brain processes that energize and direct behaviour (e.g., reflective motivations like goal-setting and beliefs, and automatic motivations like emotions and habits).\u003c/p\u003e \u003cp\u003eThe BCW framework synergizes with the Psychosocial Interactive Model of Resilience by providing a structured approach to identifying intervention functions and policy categories that can target these COM-B components (11). In the context of this study, the selected interventions\u0026mdash;Mindfulness Training (MT) and Setting Realistic Goals (SRG)\u0026mdash;were expected to influence these determinants. For instance, MT was anticipated to enhance psychological capability (e.g., emotional regulation, coping skills) and motivation (e.g., reducing stress-induced cravings). SRG was aimed at improving psychological capability (e.g., planning skills, self-belief) and reflective motivation (e.g., commitment to quit goals). Mindfulness-integrated Cognitive Behavioural Therapy (MiCBT) was designed to integrate these domains, targeting psychological capability through the combination of attentional control and cognitive restructuring, while addressing reflective motivation by challenging maladaptive beliefs about smoking. The peer support component was designed to enhance social opportunity by providing a supportive environment and leveraging the experiential knowledge of ex-smokers.\u003c/p\u003e \u003cp\u003eThe overarching goal of this research was to address the high rates of smoking in low SES populations by testing novel, resilience-enhancing interventions. The specific aims of the study, as outlined in the protocol paper (11), were:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eTo test the efficacy of three interventions (MT, SRG, and MiCBT) for smoking cessation in low SES groups.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo assess the impact of these interventions on levels of resilience in low SES groups and track changes in resilience during exposure to the interventions.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eBased on these aims, the following hypotheses were formulated:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eResearch hypothesis 1: The proportion of participants who report 14-day period abstinence from smoking at 6 months, 12 months and 18 months will be significantly higher for each intervention group compared to the control group.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eResearch hypothesis 2: Levels of resilience measured by the Connor-Davidson CD-25 and ENRICHD Social Support Inventory, Internal composite score and External composite score will be significantly higher for each intervention group compared to the control group at 6, 12 and 18 months post randomisation.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis study employed a four-arm, parallel-group, 12-month Randomized Controlled Trial (RCT) design, with an additional 6-month follow-up period (11). The interventions were delivered online to small groups of participants, with an equal allocation ratio to each of the four study arms. The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) on April 19, 2021 (ID: ACTRN12621000445875; Universal Trial Number: U1111-1261-8951). The study protocol was developed in accordance with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines (15).\u003c/p\u003e \u003cp\u003eThe registration can be accessed at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381007\u0026amp;isReview=true\u003c/span\u003e\u003cspan address=\"https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381007\u0026amp;isReview=true\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and Recruitment\u003c/h3\u003e\n\u003cp\u003eParticipants were adult smokers (aged 18 years or older) residing in Australia who had smoked regularly (defined as usually smoking at least one cigarette per day for at least the preceding two years) and were currently planning to quit (identified by a \"yes\" response to the question, \"are you currently planning to quit smoking cigarettes?\"). Additional inclusion criteria included having a smartphone, regular internet access, and willingness to dedicate approximately 14\u0026ndash;20 hours online to complete the study over an 18-month period. Low SES was defined by meeting either of the following criteria: (a) a weekly household income below 457 AUD per adult before tax (identified as the Australian poverty line at the time of the protocol); or (b) current receipt of Australian social security benefits (e.g., aged pension, low-income pension, parenting payments, or disability support payments). This national recruitment strategy and SES definition aimed for broad generalizability and utilized a standardized, nationally relevant operationalization of low SES.\u003c/p\u003e \u003cp\u003eRecruitment commenced on May 3, 2021, with a target of 812 participants. This target sample size was determined based on power calculations to detect meaningful differences between intervention arms and the control group in smoking abstinence between groups of 11.6% and also allowing for 10% dropout. Modification of the original trial design was necessary due to external events (16), primarily related to the COVID-19 pandemic. Due to the considerably slower than anticipated recruitment rate and the lack of any evidence for a meaningful difference between groups in a planned interim analysis, the trial was halted on 30 April 2024 on the basis of futility. This resulted in a final enrolled sample of 346 participants. This amendment significantly impacted the final sample size and statistical power. Recruitment strategies included web-based advertisements on social media platforms, news stories on local radio and television, and promotion through the networks of Project Reference Group members and other stakeholder organizations providing services to low SES populations across Australia. Prospective participants completed an online screening questionnaire via Qualtrics. Eligible individuals who provided informed consent were then randomly allocated to one of the four study arms using a computerized sequence generation (Mersenne Twister algorithm) embedded within the Qualtrics survey platform.\u003c/p\u003e\n\u003ch3\u003eInterventions\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eRationale for selected interventions\u003c/h2\u003e \u003cp\u003eThe rationale for the selected Interventions (MT, SRG, MiCBT) and Peer Support was informed by the research team's extensive prior work, including qualitative studies and a consensus-development study with low SES smokers (17\u0026ndash;19). MT and SRG were identified as the most feasible, acceptable, and potentially efficacious resilience-based strategies from the perspective of the target population (11). MT offers the potential to mitigate common challenges faced by low SES smokers including managing high levels of perceived stress, enhancing emotional regulation to cope with negative affect and cravings, and reducing the perceived severity of nicotine withdrawal symptoms (20), which is particularly relevant given the higher nicotine dependence often observed in this group (21). MiCBT, has demonstrated efficacy for addictive behaviours and incorporates stages focusing on attention and emotion regulation, behavioural regulation, interpersonal regulation, and an empathic stage to build internal resources (22\u0026ndash;24). SRG interventions are designed to empower individuals by helping them develop clear, feasible, and specific quit plans. The process of setting and achieving personally defined short-term goals related to smoking cessation and associated lifestyle changes can foster a sense of control, increase confidence and self-belief, and thereby enhance both internal and external resilience (25). Recognizing the potential synergies between mindfulness, goal-setting, and established cognitive-behavioural techniques, an MiCBT arm was included (11). This integrated approach aimed to leverage the strengths of each component to provide a comprehensive intervention. The inclusion of a peer support component was based on evidence suggesting its efficacy in promoting smoking cessation among socioeconomically disadvantaged groups (26). Low SES individuals often report lower baseline levels of social support and may be skeptical of traditional counselling services. Peer mentors, being ex-smokers from similar backgrounds, can offer credible, experiential knowledge and serve as positive role models, potentially overcoming barriers to engagement and fostering a supportive community (11).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eIntervention administration\u003c/h3\u003e\n\u003cp\u003eAll interventions were administered online. The active intervention arms (MiCBT, MT, SRG) involved an initial 6-month phase of group-based sessions, followed by a 6-month phase of online forum-based peer support.\u003c/p\u003e \u003cp\u003eCommon Intervention Elements: Participants in the MiCBT, MT, and SRG arms attended eight 1-hour group sessions delivered online via Zoom over a 6-month period, according to a prescribed delivery schedule. These sessions were conducted by facilitators with formal qualifications in Cognitive Behavioural Therapy (CBT) who received specialized training from experts in MT and SRG.\u003c/p\u003e \u003cp\u003e \u003cb\u003eGroup 1\u003c/b\u003e: Mindfulness-integrated Cognitive Behavioural Therapy (MiCBT): This intervention integrated principles and techniques from mindfulness, goal setting, and standard CBT. The content was designed to acknowledge the importance of all three components in fostering resilience and supporting smoking cessation.\u003c/p\u003e \u003cp\u003e \u003cb\u003eGroup 2\u003c/b\u003e: Mindfulness Training (MT): The MT intervention focused on enhancing participants' capacity for mindfulness to improve emotional regulation, manage cravings effectively, and reduce the perceived severity of nicotine withdrawal symptoms.\u003c/p\u003e \u003cp\u003e \u003cb\u003eGroup 3\u003c/b\u003e: Setting Realistic Goals (SRG): The SRG intervention aimed to assist participants in developing clear, feasible, and specific plans to quit smoking. Emphasis was placed on setting and achieving small, personally relevant goals related to smoking cessation and associated lifestyle changes, thereby building self-efficacy, confidence, and a sense of agency.\u003c/p\u003e \u003cp\u003eParticipants in all three intervention arms were also invited to opt-in for referral to their local Quitline service as part of the 'Ask, Advise, Help' model for smoking cessation, recommended by the Royal Australian College of General Practitioner\u0026rsquo;s, as described below for the Active Control group. As part of this best-practice model, intervention group participants were provided with a link to written materials on accessing Nicotine Replacement Therapy and stop-smoking medications.\u003c/p\u003e \u003cp\u003e \u003cb\u003eGroup 4\u003c/b\u003e: Active Control Group (CTRL):The active control group received the best practice intervention for smoking cessation at the time of the trial which was the \u0026lsquo;Ask, Advise, Help\u0026rsquo; model recommended by the Royal Australian College of General Practitioners (27). This involved referral to Quitline, a national telephone service providing behavioural intervention counselling for smoking cessation, and provision of links to written information to assist in accessing nicotine replacement therapy or stop-smoking medications.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePeer Support Component (MiCBT, MT, SRG groups)\u003c/strong\u003e \u003cp\u003eFollowing the initial 6-month group session phase, participants in the three active intervention arms received an additional 6 months of online peer support. This support was delivered via separate, dedicated online interactive blog forums for each intervention type. These forums were led by peer mentors who had successfully quit smoking themselves and were from similar low SES backgrounds, aiming to provide experiential knowledge and foster a supportive community. This online forum-based delivery represented a modification from the Facebook chat room model initially described in the grant proposal, potentially reflecting considerations for enhanced platform control, data management, or the creation of a more structured and dedicated community environment for participants.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eOutcome Measures\u003c/h2\u003e \u003cp\u003eA comprehensive suite of primary and secondary outcome measures was employed, assessed at multiple timepoints.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePrimary Outcome:\u003c/h3\u003e\n\u003cp\u003eThe primary outcome was self-reported 14-day period prevalence of smoking abstinence at 6 months post-randomization. Self-reported abstinence was subject to remote biochemical verification using a saliva cotinine test, with a threshold of \u0026lt;\u0026thinsp;30 ng/mL indicating non-smoking status.\u003c/p\u003e\n\u003ch3\u003eSecondary Outcomes:\u003c/h3\u003e\n\u003cp\u003eSecondary outcomes were assessed using validated instruments that included:\u003c/p\u003e \u003cp\u003eSmoking Behaviour and Nicotine Dependence:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eWeekly Smoking Questionnaire (WSQ): Assessed the probability of smoking at 9, 12 and 18 months.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eFagerstrom Test for Nicotine Dependency (FTND): Measured level of nicotine dependence (28).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eResilience:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eInternal Resilience: Connor-Davidson Resilience Scale-25 (CD-RISC-25) (29).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eExternal Resilience (Social Support): ENRICHD Social Support Inventory (ENRICHD SSI) (30).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003ePsychological Factors:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eEquanimity: Equanimity Scale-16 (ES-16) (31).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMotivation to Quit Smoking: Biener and Abrams Contemplation Ladder (BACL) (32).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSmoking Self-Efficacy Questionnaire-12 (SEQ-12) and Composite Scores (33,34). The 12-item SEQ-12 was used to measure self-efficacy. From this, two derived composite scores were also analyzed: the Internal Composite Score (self-efficacy against internal cues, e.g., feelings) and the External Composite Score (self-efficacy against external cues, e.g., peers smoking).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStress: Perceived Stress Scale-10 (PSS-10) (35).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAlcohol Use: Alcohol Use Disorders Identification Test (AUDIT-C) (36) (37).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAssessment Timepoints:\u003c/h2\u003e \u003cp\u003eData for primary and secondary outcomes were collected at baseline and at multiple follow-up points. Most outcomes (WSQ, FTND, CD-RISC, Motivation, SEQ-12, STRESS, ENRICHD, Internal/External Composites) were assessed at baseline, 3, 6, 9, 12, and 18 months. Equanimity was assessed at baseline, 2, 3, and 5 months. AUDIT was assessed at baseline, 6, 12, and 18 months. The primary outcome of smoking abstinence was specifically evaluated at 6 months (primary endpoint), 12 months, and 18 months.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were conducted to evaluate within-group changes from baseline and between-group differences in primary and secondary outcomes. Mixed-effects modelling (logistic regression for binary outcomes like smoking abstinence, and linear regression for continuous outcomes) was used to account for the correlation of data from repeated measures over time and to manage missing data (11). A modified intention-to-treat analysis was performed as the primary analysis, using all available data points, including those from subjects that withdrew from the study. As a sensitivity analysis, we also performed a full intention-to-treat analysis that used multiple imputation techniques to handle missing data. Imputation variables including all measured outcomes at each timepoint, quit-status, baseline smoking characteristics (cigarettes smoked, time since last quit attempt), participant demographics (age, gender, education), subject ID, and treatment group allocation. Data analysis was performed using Stata (version 17.0). A Type 1 error rate of α\u0026thinsp;=\u0026thinsp;0.05 was set for hypothesis testing, with adjustments for multiple comparisons using a Bonferroni correction with α\u0026thinsp;=\u0026thinsp;0.05/3\u0026thinsp;=\u0026thinsp;0.0167 when assessing outcomes across three primary time points to maintain the overall significance level.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eEthics Committee approval\u003c/h2\u003e \u003cp\u003e This study was approved by the Southern Adelaide Clinical Human Research Ethics Committee (SACHREC; number 270.19). All participants provide informed consent prior to enrolment.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Flow and Baseline Characteristics\u003c/h2\u003e \u003cp\u003eA total of n\u0026thinsp;=\u0026thinsp;346 participants were enrolled in the study (n\u0026thinsp;=\u0026thinsp;101 controls, n\u0026thinsp;=\u0026thinsp;82 MiCBT, n\u0026thinsp;=\u0026thinsp;72 MT, n\u0026thinsp;=\u0026thinsp;91 SRG). The Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e CONSORT flow diagram displays information regarding participant flow through the trial (including numbers recruited, allocated to each arm, retained at each follow-up assessment, and reasons for withdrawal).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eNo adverse events or study-related harms were systematically monitored or reported by participants in any group. Detailed baseline demographic and smoking characteristics of the participants by study group are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Most subjects were in either the most disadvantaged or second most disadvantaged quintile of the Index of Relative Social Disadvantage (IRSD). There was however a slightly more even distribution of subjects across the 5 quintiles for the MT group, although this did not reach statistical significance (p\u0026thinsp;=\u0026thinsp;0.056). There were no other differences across the four groups in baseline characteristics in terms of age, gender, level of education, nicotine dependence and the daily consumption of cigarettes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of participants by study group (N\u0026thinsp;=\u0026thinsp;346).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCTRL\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;101)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMT\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMiCBT\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;82)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSRG\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;91)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.3\u0026thinsp;\u0026plusmn;\u0026thinsp;15.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.0\u0026thinsp;\u0026plusmn;\u0026thinsp;15.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.7\u0026thinsp;\u0026plusmn;\u0026thinsp;14.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.0\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.951\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale gender, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (27.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (23.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (16.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.220\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (38.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (29.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (32.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38 (41.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrade qualification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTAFE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (25.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (36.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (41.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 (29.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (23.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (23.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (20.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.527\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIRSD quintile, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuintile 1 (Most disadvantaged)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (45.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (36.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (43.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35 (38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuintile 2 (Second most disadvantaged)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (25.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (26.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29 (31.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuintile 3 (Middle group)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (13.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuintile 4 (Second most advantaged)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (23.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuintile 5 (Least disadvantaged)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (8.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (8.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNicotine dependence (FTND) (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.457\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCigarettes smoked daily, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (14.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (23.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23 (25.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (58.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (51.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (41.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34 (37.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (23.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (26.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (28.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 (29.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.274\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e1\u003c/sup\u003eDifferences assessed using ANOVA or chi-squared test as appropriate. FTND\u0026thinsp;=\u0026thinsp;Fagerstrom Test for Nicotine Dependence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePrimary Outcome: Smoking Abstinence\u003c/h2\u003e \u003cp\u003eThe primary outcome of smoking abstinence was assessed through the self-reported weekly smoking questionnaire (WSQ) and nicotine dependence (FTND). The mean (SD) number of non-missing surveys for the 5 WSQ questionnaires administered at 3, 6, 9, 12 and 18 months was 1.80\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eWithin-Group Changes:\u003c/h2\u003e \u003cp\u003eAll four study groups (CTRL, MT, MiCBT, SRG) showed statistically significant reductions in the WSQ from their respective baselines at multiple post-baseline evaluations across the 18-month study period (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Specifically, these reductions were observed at 3, 6, 9, 12, and 18 months for the CTRL group; at 6, 9, 12, and 18 months for the MT group; at 6, 12 and 18 months for the MiCBT group; and at 3, 6, 12, and 18 months for the SRG group (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Similarly, FTND scores, indicating nicotine dependence, significantly decreased from the overall mean score at baseline in all four groups. These reductions were evident at 3, 6, 9, 12, and 18 months for all four groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTime points (months) of significant within-group changes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) from baseline for primary and secondary outcomes by study group. Results are from the raw (non-imputed) data.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCTRL\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;101)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMT\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMiCBT\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;82)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSRG\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;91)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWSQ (\u0026ldquo;Have you smoked in the last 2-weeks\u0026rdquo;?)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,6,9,12,18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6,9,12,18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6,12, 18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3,6,12,18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWSQ (CD-RISC adjusted)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,6,9,12,18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3,9, 12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuit Status - Have you quit smoking?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3, 6, 9, 12, 18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6, 9, 12, 18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 6, 9, 18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3, 6, 9, 12, 18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCD-RISC-25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6, 9, 18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6, 9, 18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEquanimity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2,3,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFTND\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,6,9,12,18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3,6,9,12,18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3,6,9,12,18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3,6,9,12,18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSEQ-12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6, 9, 12, 18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3,6, 12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSEQ-12 External Composite (External stimuli)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6,12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSEQ-12 Internal composite (Internal stimuli)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3, 6, 9, 12, 18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3, 6, 12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotivation to quit smoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSTRESS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6, 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eENRICHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAUDIT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6, 18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIntegers indicate months where a statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) change from baseline was observed for that group. \"None\" indicates no significant change at any post-baseline timepoint.\u003c/p\u003e \u003cp\u003eWSQ\u0026thinsp;=\u0026thinsp;Weekly Smoking Questionnaire. Quit Status=\u0026ldquo;Have you quit smoking - meaning have you not smoked a cigarette, even a puff\u0026rdquo;, CD-RISC-25\u0026thinsp;=\u0026thinsp;Connor-Davidson Resilience Questionnaire, Equanimity\u0026thinsp;=\u0026thinsp;Equanimity Scale-16, FTND\u0026thinsp;=\u0026thinsp;Fagerstrom Test for Nicotine Dependence, Motivation to quit smoking\u0026thinsp;=\u0026thinsp;Biener and Abrams contemplation ladder, SEQ-12\u0026thinsp;=\u0026thinsp;Smoking self-efficacy questionnaire-12, STRESS\u0026thinsp;=\u0026thinsp;Perceived stress scale-10, ENRICHD\u0026thinsp;=\u0026thinsp;ENRICHD Social support Inventory, AUDIT\u0026thinsp;=\u0026thinsp;Alcohol use Disorders Identification Test (AUDIT-C)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eBetween-Group Comparisons:\u003c/h2\u003e \u003cp\u003eDespite the within-group improvements, there were no statistically significant differences between the four groups in the probability of smoking (WSQ, global p\u0026thinsp;=\u0026thinsp;0.975) or in FTND scores (global p\u0026thinsp;=\u0026thinsp;0.241) across the assessed 7 follow-up timepoints when intervention groups were compared to the control group, or when compared against each other (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Therefore, although all intervention groups and the active control condition reduced their smoking, none of the active interventions (MT, SRG, MiCBT) demonstrated superiority over the active control or each other in terms of these primary smoking outcome measures.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBetween-Group Comparisons for Secondary Outcome Measures (Pairwise comparisons at each timepoint and Global p-values. Results are from the raw (non-imputed) data.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup x Baseline\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup x 2M\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup x 3M\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup x 5M\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGroup x 6M\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGroup x 9M\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGroup x 12M\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGroup x 18M\u003c/p\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGlobal\u003c/p\u003e \u003cp\u003ep-value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWSQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.622\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.992\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.959\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.986\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.992\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.975\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWSQ (CDRISC adjusted)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.403\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.518\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.539\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.643\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.757\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.525\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuit Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.719\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.765\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.766\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.758\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.766\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.526\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCD-RISC-25\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.934\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.865\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.419\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.678\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.123\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eENRICHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.248\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.932\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.666\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.906\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.836\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.161\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEquanimity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.693\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.747\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.026\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExternal Composite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.997\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.475\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.344\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.965\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.862\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.901\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal composite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.662\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.499\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.954\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.524\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.960\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.880\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFTND\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.241\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.813\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.548\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.430\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.241\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotivation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.321\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.914\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.279\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.399\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.691\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.369\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSEQ-12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.947\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.265\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.328\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.989\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.310\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.919\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.889\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSTRESS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.832\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.776\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.330\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.441\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.996\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.428\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAUDIT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.415\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.085\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.704\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.019\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e1\u003c/sup\u003eGlobal p-value refers to the overall difference between groups across all measured timepoints. Pairwise comparisons are highlighted where statistically significant (global p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 and pairwise-comparison p\u0026thinsp;\u0026lt;\u0026thinsp;0.0167).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eSelf-Reported Quit Status\u003c/h2\u003e \u003cp\u003eIn addition to the probability of smoking (WSQ) and nicotine dependence (FTND), participants' self-reported quit status was assessed at each follow-up. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents the percentage of participants in each group who responded \"Yes\" to the question \"Have you quit smoking?\" at 3, 6, 9, 12, and 18 months, based on multiply imputed data. At the 6-month primary endpoint, self-reported quit rates were 29.9% (95% CI: 13.4\u0026ndash;46.4) for the CTRL group, 36.4% (95% CI: 18.2\u0026ndash;54.6) for the MT group, 33.7% (95% CI: 14.9\u0026ndash;52.5) for the MiCBT group, and 35.2% (95% CI: 17.3\u0026ndash;53.0) for the SRG group. Whilst the MT group showed the highest rate, the 95% confidence intervals were wide and substantially overlapped across all four groups. In particular, there were no significant differences between groups, at the key 6-month timepoint. The pattern of overlapping confidence intervals persisted across other follow-up periods. For example, at 3 months, quit rates ranged from 23.7% (CTRL) to 29.3% (MiCBT). At 9 months, the SRG group reported the highest quit rate at 40.2% (95% CI: 20.6\u0026ndash;59.9), while at 12 months, the MT group reported 36.7% (95% CI: 16.2\u0026ndash;57.2). At the final 18-month follow-up, reported quit rates were 29.9% (CTRL), 34.4% (MT), 33.6% (MiCBT), and 34.9% (SRG). In all instances, there were no significant differences. Overall, although a substantial proportion of participants in each arm reported quitting, these self-reported quit rates were consistent with the WSQ and FTND results, indicating that no intervention was more effective than the active control or other interventions in achieving higher self-reported quit rates.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuit status percentages (95% confidence intervals) by group. Results are from multiply imputed data (N\u0026thinsp;=\u0026thinsp;346).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime Point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCTRL Group\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;101)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMT Group\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMiCBT Group\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;82)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSRG Group\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;91)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3-Months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.7\u003c/p\u003e \u003cp\u003e(10.6\u0026ndash;36.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.2\u003c/p\u003e \u003cp\u003e(5.3\u0026ndash;43.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.3\u003c/p\u003e \u003cp\u003e(13.4\u0026ndash;45.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26.5\u003c/p\u003e \u003cp\u003e(11.8\u0026ndash;41.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6-Months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.9\u003c/p\u003e \u003cp\u003e(13.4\u0026ndash;46.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.4\u003c/p\u003e \u003cp\u003e(18.2\u0026ndash;54.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.7\u003c/p\u003e \u003cp\u003e(14.9\u0026ndash;52.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35.2\u003c/p\u003e \u003cp\u003e(17.3\u0026ndash;53.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9-Months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.5\u003c/p\u003e \u003cp\u003e(13.7\u0026ndash;51.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.9\u003c/p\u003e \u003cp\u003e(11.7\u0026ndash;58.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.6\u003c/p\u003e \u003cp\u003e(7.5\u0026ndash;65.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40.2\u003c/p\u003e \u003cp\u003e(20.6\u0026ndash;59.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12-Months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.6\u003c/p\u003e \u003cp\u003e(16.0\u0026ndash;41.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.7\u003c/p\u003e \u003cp\u003e(16.2\u0026ndash;57.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.3\u003c/p\u003e \u003cp\u003e(12.5\u0026ndash;48.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33.2\u003c/p\u003e \u003cp\u003e(14.1\u0026ndash;52.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18-Months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.9\u003c/p\u003e \u003cp\u003e(10.8\u0026ndash;49.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.4\u003c/p\u003e \u003cp\u003e(11.8\u0026ndash;56.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.6\u003c/p\u003e \u003cp\u003e(14.1\u0026ndash;53.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.9\u003c/p\u003e \u003cp\u003e(16.1\u0026ndash;53.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eQuit status rates are the percentage responding \u0026ldquo;Yes\u0026rdquo; to the survey question \u0026ldquo;Have you quit smoking - meaning, have you not smoked a cigarette, even a puff\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eRemote biochemical verification of smoking abstinence (saliva cotinine\u0026thinsp;\u0026lt;\u0026thinsp;30 ng/mL)\u003c/h2\u003e \u003cp\u003eBiochemical verification of self-reported smoking abstinence was attempted using remote saliva cotinine testing for a subset of participants at the 6, 9, and 12-month follow-ups. Across these timepoints, a total of 37 participants who reported quitting were invited to provide a sample. Of those invited, 6 participants responded, and test kits were sent out to them by the research team. A total of 4 completed tests were ultimately returned for analysis, with one test received from a participant in each of the four study arms (SRG, MT, MiCBT, and Control). All tests were negative for nicotine, but due to the extremely low number of returned samples, these data were insufficient for a meaningful statistical analysis or for robust confirmation of the self-reported cessation rates.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eSecondary Outcomes\u003c/h2\u003e \u003cp\u003eThe impact of the interventions on various secondary outcomes related to resilience and psychological well-being are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e (within-group changes) and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e (between-group changes).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eResilience Measures:\u003c/h2\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eCD-RISC-25 (Resilience)\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e illustrate the CD-RISC-25 score changes over time. In between-group comparisons (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), there was no statistically significant overall difference in CD-RISC scores across the study arms (global p\u0026thinsp;=\u0026thinsp;0.123). Pairwise comparisons at the 9-month timepoint approached statistical significance (p\u0026thinsp;=\u0026thinsp;0.019) but did not meet the Bonferroni-corrected threshold for significance. Overall, no intervention demonstrated a superior effect on this measure of internal resilience.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eENRICHD (Social Support)\u003c/strong\u003e \u003cp\u003eThere were no significant within-group changes from baseline in ENRICHD scores for any of the four study groups at any time point (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Suppl Fig.\u0026nbsp;2). Correspondingly, no significant between-group differences were observed (global p\u0026thinsp;=\u0026thinsp;0.161) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003ePsychological Factors:\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEquanimity\u003c/strong\u003e \u003cp\u003eEquanimity was measured in the MT and MiCBT groups at baseline and months 2, 3 and 5. The MT group demonstrated significant improvements at 3 months compared to baseline and the MiCBT group improved significantly at month 2 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Suppl Fig.\u0026nbsp;3). A significant overall difference was observed between groups for equanimity (global p\u0026thinsp;=\u0026thinsp;0.026) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). However, this difference appears to be attributable to a pre-existing significant difference between the groups at baseline (p\u0026thinsp;=\u0026thinsp;0.011). No significant pairwise differences between groups were observed at any post-randomization timepoint (months 2, 3, or 5).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eMotivation\u003c/strong\u003e \u003cp\u003eNo significant within-group increases in motivation scores from baseline were observed for any groups at any of the timepoints (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Suppl Fig.\u0026nbsp;4). There were also no significant between-group differences (global p\u0026thinsp;=\u0026thinsp;0.201) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSelf-Efficacy\u003c/strong\u003e \u003cp\u003eThe CTRL group showed significant within-group increases in SEQ-12 scores at 6, 9, 12 and 18 months, for the MT group at 3, 6 and 12 months, and for the SRG group at 18 months (Suppl Fig.\u0026nbsp;5 and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). No changes were observed for the MiCBT group. No significant between-group differences were found (global p\u0026thinsp;=\u0026thinsp;0.889) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInternal Composite Score\u003c/strong\u003e \u003cp\u003eSignificant within-group increases were observed for the CTRL group at 3, 6, 9, 12 and 18 months, for the MT group at 3, 6 and 12 months, and for the SRG at 18 months. No changes were seen for the MiCBT group (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Suppl Fig.\u0026nbsp;1). There were no significant between-group differences (global p\u0026thinsp;=\u0026thinsp;0.880) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eExternal Composite Score\u003c/strong\u003e \u003cp\u003eThe MT group showed significant within-group increases at 6 and 12 months, and the CTRL and SRG groups at 9 months. No changes were observed for the MiCBT group (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Suppl Fig.\u0026nbsp;2). No significant between-group differences were found (global p\u0026thinsp;=\u0026thinsp;0.901) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStress\u003c/strong\u003e \u003cp\u003eSignificant within-group reductions in stress scores were observed for the MT group at 6 and 9 months, and for MiCBT at 6 months (Suppl Fig.\u0026nbsp;6 and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). No changes were noted for the other groups. There were no significant between-group differences (global p\u0026thinsp;=\u0026thinsp;0.428) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eMediation Analysis:\u003c/h2\u003e \u003cp\u003eWhen WSQ (probability of smoking) scores were adjusted for CD-RISC scores (Suppl Fig.\u0026nbsp;7), the probability of smoking remained significantly reduced compared to baseline for the CTRL group (at 5 timepoints), the MT and MiCBT groups (at 1 timepoint), and the SRG group (at 3 timepoints). This was not however the case for the multiple imputation analysis in which the smoking probabilities were all significantly lower than at baseline for all timepoints except for MT at 3 months. This suggests that the observed reduction in the probability of smoking (WSQ) was not mediated by any changes in resilience as measured by the CD-RISC.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eAUDIT (Alcohol Use):\u003c/h2\u003e \u003cp\u003eSignificant within-group reductions in alcohol use were observed for the MT group at 6 and 18 months (Suppl Fig.\u0026nbsp;8 and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). No within-group changes were observed for the other groups. There was a significant between-group change (global p\u0026thinsp;=\u0026thinsp;0.019) due to significant differences between groups at 18 months (p\u0026thinsp;=\u0026thinsp;0.002) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). MT was lower than CTRL at 6 months (p\u0026thinsp;=\u0026thinsp;0.013) and at 18 months (p\u0026thinsp;=\u0026thinsp;0.026), and MiCBT was lower than CTRL at 18 months (p\u0026thinsp;=\u0026thinsp;0.013).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis randomized controlled trial investigated the efficacy of three online resilience-enhancing interventions; Mindfulness Training (MT), Setting Realistic Goals (SRG), and Mindfulness-integrated Cognitive Behavioural Therapy (MiCBT) compared to an active control condition for smoking cessation and resilience-building among low SES adult smokers in Australia. All study groups, including the active control, demonstrated significant reductions in the probability of smoking and levels of nicotine dependence over the 18-month study duration. However, no significant differences were found between the intervention groups and the active control, or among the intervention groups themselves, for these primary smoking outcome measures.\u003c/p\u003e \u003cp\u003eRegarding secondary outcomes, no intervention demonstrated a statistically significant effect on the primary measures of resilience. There were no significant between-group differences in internal resilience (CD-RISC) or external social support (ENRICHD SSI). Although a significant overall difference between groups was found for equanimity, this was attributable to baseline differences and did not reflect a post-intervention effect.\u003c/p\u003e \u003cp\u003eThe observation that all study arms, including the active control group, experienced significant reductions in smoking probability (WSQ) and nicotine dependence (FTND) was a positive outcome, suggesting that engagement in a structured program with regular contact and monitoring can facilitate smoking reduction in this high-need population. The active control group received referrals to Quitline and educational materials, which are evidence-based supports. The effectiveness of this active control condition may have contributed to the lack of statistically significant superiority of the MT, SRG, or MiCBT interventions for direct smoking cessation outcomes. Since neither the WSQ or FTND showed significant between-group differences, based on these specific measures, our hypotheses regarding the superiority of the interventions for direct smoking cessation were not fully supported. The overall high rates of smoking reduction in each arm may also be a result of selection-bias since participants that stayed in the trial may be more likely to have quit compared to those lost to follow-up. Assuming on the other hand that participants were lost to follow-up at random, our results using multiple imputation support the high smoking cessation rates across all four arms\u003c/p\u003e \u003cp\u003eOur second hypothesis posited that levels of resilience would be significantly higher for intervention groups compared to the control group at 6, 12, and 18 months (11), was not supported. The analysis revealed no significant between-group differences for internal resilience as measured by the CD-RISC. This indicates that none of the interventions, including the targeted MT and SRG arms, were effective in significantly bolstering this psychological resource compared to the active control.\u003c/p\u003e \u003cp\u003eOur hypothesis regarding resilience was not supported for either internal or external domains. Consistent with the null finding for CD-RISC, no changes in perceived external social support (ENRICHD SSI) were observed for any group. This finding is important, since the Psychosocial Interactive Model of Resilience underlines the importance of external resources and social support. The peer support component, delivered via online forums, was specifically intended to bolster this external domain and so the null finding for ENRICHD suggests that this forum-based peer support, as implemented, may have been insufficient in intensity, duration, or mode of delivery to significantly alter perceived social support. This contrasts with some literature suggesting the benefits of peer support (26), which often involves more intensive or face-to-face interactions.\u003c/p\u003e \u003cp\u003eWithin-group improvements on secondary measures were observed across several arms. For instance, multiple groups, including MT, demonstrated significant increases in self-efficacy (SEQ-12) over time, and the MT group also showed reductions in stress. The SRG intervention also showed positive within-group changes, for SEQ-12 (at 18m), suggesting it may contribute to building resilience and self-efficacy. The MiCBT intervention also showed fewer within-group improvements on the secondary measures compared to MT.\u003c/p\u003e \u003cp\u003eThe study's findings offer critical insights into the Psychosocial Interactive Model of Resilience. Although the interventions were designed to strengthen the 'Internal Domain' of resilience, the lack of a significant between-group effect on CD-RISC scores suggests this was not achieved more effectively than in the control group. Similarly, the lack of significant change in ENRICHD scores across all groups, despite the inclusion of a peer support component designed to bolster external resources, highlights a challenge in effectively influencing the 'External Domain' of resilience within the parameters of this online intervention format. This suggests that more intensive or differently structured approaches may be needed to significantly impact perceived social support and other external resilience factors in this population.\u003c/p\u003e \u003cp\u003eThe interventions likely influenced different components of the Behaviour Change Wheel (COM-B) model. MT appears to have enhanced 'Capability' (e.g., emotional regulation, coping skills leading to stress reduction and increased equanimity) and 'Motivation' (e.g., increased motivation scores at one timepoint, potentially reduced cravings). SRG also aimed to improve 'Capability' (planning, self-belief) and 'Motivation' through goal achievement, which was reflected in within-group improvements on SEQ-12. The peer support component was intended to positively influence social 'Opportunity'; however, the null ENRICHD findings suggest this aspect was not meaningfully changed. The overall reduction in smoking across all groups indicates a shift in 'Behaviour', but the specific contributions of Capability, Opportunity, and Motivation likely varied by intervention and individual.\u003c/p\u003e \u003cp\u003eOur finding of no significant effect of MT on psychological resilience (CD-RISC) in between-group comparisons presents a contrast to some literature that has indicated the efficacy of MT for enhancing such resources (38). This may suggest that the online, group-based format used in this trial was of insufficient intensity or duration to produce these effects in a low SES population, or that the benefits were not superior to those gained from engagement with standard quit services. The within-group improvements seen with SRG on SEQ-12 are consistent with theories that goal achievement builds self-efficacy (25), and literature supporting goal setting as a core component of behaviour change interventions. The lack of significant impact on ENRICHD scores, despite the online peer support, warrants careful consideration. While literature supports peer support for disadvantaged groups (26), the mode of delivery is crucial. The online forum approach used here may differ in impact from more intensive, potentially face-to-face, peer support models described by Ford et al. (26). The research team's own extensive prior work on resilience and smoking in low SES groups provided the foundation for this trial, and these results contribute further to understanding the complexities of intervening in this population (17\u0026ndash;19).\u003c/p\u003e \u003cp\u003eAn interesting and unexpected finding emerged in relation to alcohol use. The MT group demonstrated significant within-group reductions in AUDIT scores, and in between-group comparisons, both the MT and MiCBT groups showed significantly lower AUDIT scores than the control group at later timepoints. Although alcohol use was a secondary outcome and these findings should be interpreted with caution, they suggest a potential ancillary benefit of mindfulness-based interventions on reducing hazardous alcohol consumption in this population. This spillover effect is plausible, as mindfulness training aims to enhance self-regulation and awareness of automatic behaviors, which are relevant to both smoking and alcohol use. This finding therefore merits further investigation in future trials where alcohol use may be a primary or key secondary outcome.\u003c/p\u003e \u003cp\u003eThis study has several notable strengths. It is among the first to rigorously test resilience-enhancing interventions specifically tailored for and identified as acceptable to low SES smokers, thereby addressing a critical health inequity. The RCT design was robust, and the interventions were grounded in established theoretical frameworks (Psychosocial Interactive Model of Resilience, Behaviour Change Wheel). The online delivery format enhanced accessibility for a geographically dispersed, national sample.\u003c/p\u003e \u003cp\u003eMethodologically, the analytical approach adds to the study's rigor; we performed both a modified intention-to-treat analysis on the raw data and a full intention-to-treat analysis using multiple imputation to account for missing data. Presenting these results side-by-side provides a transparent and comprehensive view of the outcomes under different analytical assumptions. However, certain limitations must be acknowledged. The primary outcome of smoking abstinence relied on self-report, and although there was an effort to supplement this with biochemical verification, insufficient test samples were returned to allow any meaningful analysis. However, the inclusion of participant flow data and baseline characteristics suggests that groups were similar in both baseline characteristics and attrition. The latter varied between 10 and 20% across the 4 groups, meaning some selection bias may have been introduced into our results.\u003c/p\u003e \u003cp\u003eAlthough recruitment was Australia-wide, findings may still be specific to the Australian low SES context and not universally generalizable. A significant limitation is the lack of observed change in the ENRICHD Social Support Inventory, suggesting the online peer support component may not have adequately impacted perceived external social support, or that the measure was not sensitive to the changes induced. A further significant limitation was the failure to achieve robust biochemical verification of smoking abstinence. Although planned as part of the protocol, the remote saliva cotinine testing process yielded a very low return rate. Across the 6, 9, and 12-month follow-up periods, a total of 37 participants who reported abstinence were invited to test, but only 6 kits were dispatched, and just 4 completed tests were ultimately received for analysis. This number is insufficient to validate the self-reported smoking cessation outcomes (WSQ and quit status percentages) or to detect potential differential misreporting between groups. Therefore, the primary smoking outcomes must be interpreted with the caution appropriate for unverified self-report data, which is a common challenge in online, remote trials. Finally, the effectiveness of the active control group, while ethically appropriate, may have attenuated the ability to detect significant differences in direct smoking cessation outcomes between the intervention arms and the control.\u003c/p\u003e \u003cp\u003eThe findings from this trial have important, albeit sobering, implications for public health policy and clinical practice. Although participation in a structured program was beneficial, the novel online resilience-enhancing interventions failed to demonstrate superiority over standard care referrals for either smoking cessation or bolstering psychological resilience. This suggests that low-intensity, online-only interventions may be insufficient to overcome the complex web of factors that sustain smoking in low SES populations. Some within-group improvements in stress and self-efficacy were noted, particularly for the MT group, but these did not translate into significant between-group effects. The null findings for both internal (CD-RISC) and external (ENRICHD) resilience underscore the need for more intensive, multifaceted, or blended (online and face-to-face) support models. Policymakers should be cautious about funding scalable online-only solutions without stronger evidence of their efficacy in high-need groups (39).\u003c/p\u003e \u003cp\u003eThis study opens several avenues for future research driven by its null findings. Investigating alternative or more intensive methods for bolstering both internal and external social support is crucial. For external support, this could involve blended online and face-to-face peer support, or community-based initiatives that move beyond online forums. For internal resilience, future research should explore whether interventions of a longer duration, with higher contact frequency, or delivered in a different modality could produce the effects on resilience that were not observed here. The adaptation and testing of these interventions for other addictive behaviors, such as the potential ancillary benefit on alcohol use suggested by our secondary analysis, also represents a significant area for future inquiry.\u003c/p\u003e \u003cp\u003eIn conclusion, this randomized controlled trial demonstrates that participation in a structured smoking cessation program, whether involving specific resilience-enhancing interventions or referral to active quit services, is associated with significant reductions in smoking probability and nicotine dependence among low SES adult smokers. However, no single intervention arm proved statistically superior for direct smoking cessation outcomes, nor did they demonstrate a significant effect on enhancing internal psychological resilience (CD-RISC) or external social support (ENRICHD) compared to the active control. Furthermore, the study observed significant participant attrition, a finding consistent with the known difficulties of retaining socioeconomically disadvantaged populations in smoking cessation trials (40). This high attrition, combined with the lack of superior intervention efficacy, highlights the profound challenge of designing effective, low-intensity online interventions for this vulnerable population and underscores that more intensive or differently structured approaches may be necessary to impact both smoking behavior and its underlying psychosocial determinants. The study highlights the profound challenge of designing effective, low-intensity online interventions for this vulnerable population and underscores that more intensive or differently structured approaches may be necessary to impact both smoking behavior and its underlying psychosocial determinants. These findings contribute valuable evidence to the effort to address smoking-related health inequities by demonstrating the limitations of the tested online models.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eANZCTR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAustralian New Zealand Clinical Trials Registry\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eAUDIT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAlcohol Use Disorders Identification Test\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBACL\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBiener and Abrams Contemplation Ladder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBCW\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBehaviour Change Wheel\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCBT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCognitive Behavioural Therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCD-RISC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConnor-Davidson Resilience Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCOM-B\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCapability, Opportunity, Motivation-Behaviour model\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCTRL\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eENRICHD SSI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eENRICHD Social Support Inventory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eES-16\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEquanimity Scale-16\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eFTND\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFagerstrom Test for Nicotine Dependency\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eIRSD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIndex of Relative Social Disadvantage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMiCBT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMindfulness-integrated Cognitive Behavioural Therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMindfulness Training\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePSS-10\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePerceived Stress Scale-10\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eQALY\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eQuality Adjusted Life Year\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eRCT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRandomized Controlled Trial\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSACHREC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSouthern Adelaide Clinical Human Research Ethics Committee\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSEQ-12\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSmoking Self-Efficacy Questionnaire-12\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSES\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSocio-economic Status\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSPIRIT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard Protocol Items:Recommendations for Interventional Trials\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSRG\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSetting Realistic Goals\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eWSQ\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWeekly Smoking Questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eEthics approval and consent to participate: Informed consent was obtained from all participants. The trial was registered with the Australian New Zealand Clinical Trials Registry (ID: ACTRN12621000445875). Specific ethics committee approval details are as outlined in the original protocol publication \u003csup\u003e11\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003cbr\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study was primarily funded by an IDEAS Grant funding commencing in 2020 (Application ID: APP1182598). The principal investigator and research team members have also received funding from the National Health and Medical Research Council (NHMRC) and the Australian Research Council (ARC) for related work. Flinders University, particularly the College of Medicine and Public Health, the Flinders Centre for Innovation in Cancer, and the Southgate Institute for Health, Society and Equity, provided institutional support and resources. The Olivia Newton John Cancer Research Institute at La Trobe University was a collaborating institution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e PW was the Chief Investigator, conceived the study, led the proposal development, and has expertise in resilience, smoking cessation, and mixed methodologies. R DeZ was the corresponding author for the published protocol paper \u003csup\u003e11\u003c/sup\u003e. EM, GT, SL, CW, and RW were co-investigators involved in the study design, and methodology. RW performed all power and sample size calculations, statistical analysis and provided the first draft of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe research team acknowledges the participants who dedicated their time to this study, the peer mentors for their valuable contributions, and the funding bodies for their financial support. During the preparation of this work the author(s) used Google AI Studio in order to assist with the initial drafting of the manuscript and to refine language for clarity and readability. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the published article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO report on the global tobacco epidemic, 2023: protect people from tobacco smoke [Internet]. [cited 2025 Oct 17]. 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Arch Intern Med. 1998 Sept 14;158(16):1789–95.\u003c/li\u003e\n\u003cli\u003eAUDIT : the Alcohol Use Disorders Identification Test : guidelines for use in primary health care [Internet]. [cited 2025 May 25]. Available from: https://www.who.int/publications/i/item/WHO-MSD-MSB-01.6a\u003c/li\u003e\n\u003cli\u003eOikonomou MT, Arvanitis M, Sokolove RL. Mindfulness training for smoking cessation: A meta-analysis of randomized-controlled trials. J Health Psychol. 2017 Dec;22(14):1841–50.\u003c/li\u003e\n\u003cli\u003eCancer Council welcomes reforms that will bring Australia’s tobacco control into the 21st century [Internet]. [cited 2025 Aug 22]. Available from: https://www.cancer.org.au/media-releases/2022/cancer-council-welcomes-reforms-that-will-bring-australia-tobacco-control-into-the-21st-century\u003c/li\u003e\n\u003cli\u003eBelita E, Sidani S. Attrition in Smoking Cessation Intervention Studies: A Systematic Review. Can J Nurs Res Rev Can Rech En Sci Infirm. 2015 Dec;47(4):21–40.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Smoking Cessation, Socioeconomic Status, Resilience, Mindfulness, Cognitive Behavioural Therapy, Goal Setting, Randomized Controlled Trial, Health Equity.","lastPublishedDoi":"10.21203/rs.3.rs-8282925/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8282925/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSmoking rates remain disproportionately high among individuals of low socio-economic status (SES), contributing significantly to health inequities. Resilience-based interventions offer a potential strengths-focused approach to address this challenge. This study aimed to evaluate the efficacy of Mindfulness Training, Setting Realistic Goals, and Mindfulness-integrated Cognitive Behavioural Therapy (MiCBT) for promoting smoking cessation and enhancing resilience in low SES adult smokers.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA four-arm, parallel-group, 12-month online randomized controlled trial was conducted with 346 adult regular smokers in Australia classified as low SES. Participants were randomized to one of four conditions: Mindfulness Training, Setting Realistic Goals, MiCBT, or an active control group that received referrals to standard quit services. The active interventions consisted of eight 1-hour online group sessions over 6 months, followed by 6 months of online forum-based peer support. The primary outcome was self-reported 14-day smoking abstinence at 6 months. Secondary outcomes included internal resilience (Connor-Davidson Resilience Scale-25), external resilience (social support), nicotine dependence, self-efficacy, and stress. Data were analyzed using mixed-effects modelling.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll study groups achieved substantial self-reported quit rates at the 6-month primary endpoint, ranging from 29.9% in the control group to 36.4% in the Mindfulness Training group. Significant reductions in nicotine dependence were also observed across all groups over the 18-month study period. However, there were no statistically significant between-group differences for the primary outcome of smoking abstinence or for secondary outcomes, including internal resilience and social support, at any time point.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eParticipation in a structured smoking cessation trial was associated with reduced smoking behaviors among low SES adults. However, none of the online resilience-enhancing interventions demonstrated superior efficacy for smoking cessation or for enhancing internal resilience compared to an active control. These findings suggest that low-intensity online interventions may be insufficient for this population and highlight the need for more intensive or blended support models.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003eAustralian New Zealand Clinical Trials Registry ACTRN12621000445875. Registered 19 April 2021.\u003c/p\u003e","manuscriptTitle":"A Randomized Controlled Trial of Mindfulness, Goal Setting, and MiCBT for Smoking Cessation and Resilience in Low SES Smokers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-06 23:49:30","doi":"10.21203/rs.3.rs-8282925/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0aba386b-abb9-4430-b0f6-206e9e4fdb7c","owner":[],"postedDate":"January 6th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T08:42:14+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-06 23:49:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8282925","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8282925","identity":"rs-8282925","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}