Enhancing Quality in Protective Strategies

Risk Reduction Behavior Clinical Trial

— EQUIP  

Official title:

Examining Motivations for and Quality of Alcohol and Marijuana Protective Behavior Strategy Use: Improving Prevention of Hazardous Young Adult Substance Use

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT04978129
• Other study ID #: R34AA028730
• Secondary ID: 1R34AA028730-01A
• Status: Recruiting
• Phase: N/A
• Start date: August 15, 2023
• Est. completion date: March 1, 2025

Study information

• Verified date: May 2024
• Source: University of North Texas Health Science Center
• Contact: Melissa A Lewis, PhD
• Phone: 817-735-5136
• Email: Melissa.Lewis[@]unthsc.edu
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The most successful young adult alcohol or marijuana interventions involve the provision of accurate, nonjudgmental personalized feedback, but notably the inclusion and effectiveness of protective behavioral strategies (PBS) content is inconsistent. Moreover, active components of brief interventions are not well understood, and findings have been inconclusive regarding whether PBS mediates intervention efficacy of college student personalized feedback interventions (PFIs), with only some studies showing evidence of mediation. One possible reason for these findings is that investigators often do not know young adults' motivations for using (or not using) PBS or the quality of PBS use across individuals or across drinking occasions. The proposed study will provide an in-depth examination of which PBS young adults are motivated to use (including implementation quality) and reasons that young adults may or may not use PBS. Understanding why young adults are choosing not to use PBS on specific occasions or do not engage in effective or high-quality PBS use on certain occasions has significant clinical implications, whereby interventions may need to spend more time increasing motivations to use PBS in an effective manner or work on reducing perceived barriers (i.e., reasons individuals are not using PBS). Clinicians may then be better able to work with young adults in various settings to reduce or prevent excessive alcohol and marijuana use and related consequences. The proposed research has high potential for making a substantial impact on the field and public health (particularly as more states permit legal access to marijuana for those over 21) as it will address a problem of high importance (alcohol and marijuana use) by being the first to develop and refine a PBS intervention that specifically focuses on motivations for alcohol and marijuana PBS use and non-use as well as quality of use, which is an overlooked aspect of current PBS-related intervention approaches. The development of more efficacious interventions to reduce the proportion of young adults who engage in excessive alcohol use and who experience consequences is a key priority of the NIAAA. Related, development of more effective interventions to reduce risk from marijuana use is an area of great importance for the NIDA.

Description:

The majority of young adults who use both alcohol and marijuana do so simultaneously. Simultaneous Alcohol and Marijuana (SAM) use is defined as using alcohol and marijuana at the same time so that their effects overlap. Individuals who engage in Concurrent Alcohol and Marijuana (CAM) use are often characterized as those who report both alcohol and marijuana use within the same time period (e.g., past month, past week). An increasing body of literature has documented CAM and SAM use on a given day among young adults. Event-level findings show SAM use is associated with increased risk for consequences, compared to marijuana use alone or CAM use. Given that the investigators' focus in this application is on daily-level substance use behaviors, the investigators define CAM use as using both substances on the same day, but not so that their effects overlap. Interventions should focus on reducing drinking as well as drinking that occurs in conjunction with marijuana use to provide a more comprehensive evaluation of intervention efficacy. The proposed research in this application will develop and test a novel online and text message (TM) protective behavioral strategies (PBS) intervention to reduce alcohol, marijuana, CAM, and SAM use and related negative consequences among young adults. One way interventions could prevent or reduce alcohol- and marijuana-related consequences is by promoting the use of PBS, which are behaviors that individuals can use to limit consequences and/or reduce substance use. PBS are often incorporated into brief interventions or TM interventions in the form of skills training. Despite the empirical support for including PBS content in brief interventions, findings have been inconclusive regarding whether PBS mediate intervention efficacy among college students. One possible explanation is that skills-based PBS interventions prematurely focus on "how" to use PBS, but not "why" PBS might be used or used with high quality. Research is needed to determine motivations for when and why young adults may or may not decide to use PBS to reduce harm while using alcohol and/or marijuana, which can then enable investigators to better address these motivations in brief interventions. Research has yet to examine how alcohol and marijuana PBS use on a given day relates to an individual's use of alcohol alone or marijuana alone in comparison to CAM or SAM use. The proposed study will fill these critical gaps by identifying the extent to which motivations for PBS use and nonuse (marijuana or alcohol) and quality of PBS use (degree of effectiveness or degree of implementation) differ when using alcohol alone versus concurrently or simultaneously with marijuana. The overall goal of this research is to inform a pilot study of a newly developed alcohol and marijuana PBS intervention. The proposed research will (1) collect pilot data to establish feasibility and acceptability and test the interactive online and TM PBS intervention (baseline, 2-month) while also (2) collecting event-level data to examine daily-level associations among PBS motivation/quality, PBS use and non-use, alcohol and/or marijuana use, and negative consequences with a focus on how PBS may differ on CAM or SAM use days compared to alcohol-only days. Aim 1: Examine motivations for alcohol and marijuana PBS use (and non-use of PBS) as well as quality of PBS use among young adults (ages 18-24) who use both alcohol and marijuana. The present study will conduct online focus groups (10 groups, N=10 individuals per group) and cognitive interviews (N=10) to determine why young adults use or do not use specific PBS related to alcohol and/or marijuana use. Focus groups will address how PBS use or motivations to avoid consequences may differ by gender (male, female, non-binary). Focus groups and cognitive interviews will discuss the level of quality in which PBS are used and various contexts in which PBS may or may not be used. Discussions will consider use of either substance alone on a given day as well as SAM or CAM use on a given day and will include ways in which the motivations and quality of PBS could be incorporated into an online and TM PBS intervention, as well as elicit feedback on mock intervention material. Using an exploratory sequential mixed methods design, an iterative process of focus groups and cognitive interviews will inform the development and delivery of the intervention to be tested in the pilot study (Aim 2). Aim 1 is not a clinical trial. Aim 2: Conduct a pilot study with young adults (N=200; ages 18-24), who typically use alcohol and marijuana at least two days per week, to determine feasibility, acceptability, and preliminary effect sizes (to inform a future R01 application). Participants will be randomized to either the intervention or wait-list control. The intervention is a brief interactive online intervention focusing on self-selected alcohol and marijuana PBS messages and motives for using alcohol- and marijuana-related PBS and includes intervention content delivered via TMs three days a week (random day, Friday, Saturday) over eight consecutive weekends. All participants will report PBS use, motivations for PBS use (and non-use), quality of PBS use, readiness to change, and alcohol and marijuana use in morning surveys timed to occur the day after the intervention TMs for those in the intervention group. The proposed research in this application will provide an in-depth understanding of young adults' PBS use and has potential to develop a more efficacious intervention for these co-occurring or simultaneous alcohol and marijuana behaviors. Aim 2 is the clinical trial.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 200
• Est. completion date: March 1, 2025
• Est. primary completion date: March 1, 2025
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: All
• Age group: 18 Years to 24 Years

Eligibility

Inclusion Criteria:

1. Age 18-24

2. Live in Texas

3. Valid email address

4. Own a cell phone with text messaging capabilities

5. Okay with receiving messages

6. Typically drink at least 2 days a week

7. Typically use marijuana at least 2 days a week

8. Report having at least 1 alcohol-related and 1 marijuana-related consequence in the past month

9. Report being in contemplation or action stage based on readiness to change scale for alcohol or marijuana (i.e., not in precontemplation stage)

10. If female, not pregnant or trying to become pregnant

11. Not currently in treatment for alcohol or substance use

12. Willing to participate in either online focus group or online cognitive interview (Phase I) or pilot study with daily morning surveys (Phase II), and willing to receive study notifications on phone (e.g., survey reminders) [Phase II]

13. Their device must meet the system requirements to participate in the online focus group or cognitive interview (have iOS 8.0 or later, Android 4.0x, or later, or have another video-enabled device) [Phase I]

Exclusion Criteria:

1. Not meeting inclusion criteria

2. Unwillingness to participate

3. Failure to provide consent

4. Providing inconsistent responses (e.g., age), and

5. Having already participated in the study as identified by overlap or consistency in email addresses, contact information, and demographics.

Related Conditions & MeSH terms

• Health Risk Behaviors
• Risk Reduction Behavior

Intervention

Behavioral:
• Online and Text Messaging Intervention
The online and TM intervention, and its delivery, will be designed and adapted based on the results of the formative focus groups and cognitive interviews and is meant to be non-confrontational in tone, seeks to increase motivation to increase the quality use of PBS and decrease motivations for non-use of PBS.

Locations

Country	Name	City	State
United States	University of North Texas Health Science Center	Fort Worth	Texas

Sponsors (2)

Lead Sponsor	Collaborator
University of North Texas Health Science Center	National Institute on Alcohol Abuse and Alcoholism (NIAAA)

Country where clinical trial is conducted

United States, 

References & Publications (41)

Adamson SJ, Kay-Lambkin FJ, Baker AL, Lewin TJ, Thornton L, Kelly BJ, Sellman JD. An improved brief measure of cannabis misuse: the Cannabis Use Disorders Identification Test-Revised (CUDIT-R). Drug Alcohol Depend. 2010 Jul 1;110(1-2):137-43. doi: 10.1016/j.drugalcdep.2010.02.017. Epub 2010 Mar 26. — View Citation

Babor, T. F., Higgins-Biddle, J. C., Saunders, J. B., Monteiro, M. G. (2001). AUDIT- The alcohol use disorders identification test: guidelines for use in primary care (Research Report No. (WHO/MSD/MSB/01.6a). http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf

Bravo AJ, Pearson MR, Stevens LE, Henson JM. Weighing the Pros and Cons of Using Alcohol Protective Behavioral Strategies: A Qualitative Examination among College Students. Subst Use Misuse. 2018 Nov 10;53(13):2190-2198. doi: 10.1080/10826084.2018.1464026. Epub 2018 Apr 30. — View Citation

Brooke, J. (1996). SUS: A quick and dirty usability scale. In Jordan PW, Thomas B, Weerdmeester BA, McClelland IL (Eds.), Usability evaluation in industry (pp. 189-194). London, England: Taylor & Francis.

Brooke, J. (2013). SUS: A retrospective. Journal of Usability Studies, 8(2), 29-40.

Brown SA, Myers MG, Lippke L, Tapert SF, Stewart DG, Vik PW. Psychometric evaluation of the Customary Drinking and Drug Use Record (CDDR): a measure of adolescent alcohol and drug involvement. J Stud Alcohol. 1998 Jul;59(4):427-38. doi: 10.15288/jsa.1998.59.427. — View Citation

Cadigan JM, Martens MP, Dworkin ER, Sher KJ. The Efficacy of an Event-Specific, Text Message, Personalized Drinking Feedback Intervention. Prev Sci. 2019 Aug;20(6):873-883. doi: 10.1007/s11121-018-0939-9. — View Citation

Collins RL, Parks GA, Marlatt GA. Social determinants of alcohol consumption: the effects of social interaction and model status on the self-administration of alcohol. J Consult Clin Psychol. 1985 Apr;53(2):189-200. doi: 10.1037//0022-006x.53.2.189. No abstract available. — View Citation

Danielson CK, McCauley JL, Gros KS, Jones AM, Barr SC, Borkman AL, Bryant BG, Ruggiero KJ. SiHLEWeb.com: Development and usability testing of an evidence-based HIV prevention website for female African-American adolescents. Health Informatics J. 2016 Jun;22(2):194-208. doi: 10.1177/1460458214544048. Epub 2014 Aug 28. — View Citation

Egan KL, Cox MJ, Suerken CK, Reboussin BA, Song EY, Wagoner KG, Wolfson M. More drugs, more problems? Simultaneous use of alcohol and marijuana at parties among youth and young adults. Drug Alcohol Depend. 2019 Sep 1;202:69-75. doi: 10.1016/j.drugalcdep.2019.07.003. Epub 2019 Jul 6. — View Citation

Gaume J, McCambridge J, Bertholet N, Daeppen JB. Mechanisms of action of brief alcohol interventions remain largely unknown - a narrative review. Front Psychiatry. 2014 Aug 26;5:108. doi: 10.3389/fpsyt.2014.00108. eCollection 2014. — View Citation

Heather, N., & Hönekopp, J. (2008). A revised edition of the Readiness to Change Questionnaire [Treatment Version]. Addiction Research & Theory, 16(5), 421-433. https://doi.org/10.1080/16066350801900321

Johnston, L. D., O'Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2012). Monitoring the Future national results on adolescent drug use: Overview of key findings, 2011. Ann Arbor: Institute for Social Research, The University of Michigan.

Johnston, L. D., O'Malley, P. M., Miech, R. A., Bachman, J. G., & Schulenberg, J. E. (2015). Monitoring the Future national survey results on drug use: 1975-2014: Overview, key findings on adolescent drug use: 1975-2014 [PDF File]. Ann Arbor: Institute for Social Research, The University of Michigan. https://deepblue.lib.umich.edu/handle/2027.42/137913.

Lee CM, Kilmer JR, Neighbors C, Atkins DC, Zheng C, Walker DD, Larimer ME. Indicated prevention for college student marijuana use: a randomized controlled trial. J Consult Clin Psychol. 2013 Aug;81(4):702-9. doi: 10.1037/a0033285. Epub 2013 Jun 10. — View Citation

Lewis MA, Cadigan JM, Cronce JM, Kilmer JR, Suffoletto B, Walter T, Lee CM. Developing Text Messages to Reduce Community College Student Alcohol Use. Am J Health Behav. 2018 Jul 1;42(4):70-79. doi: 10.5993/AJHB.42.4.7. — View Citation

Lewis MA, Litt DM, King KM, Fairlie AM, Waldron KA, Garcia TA, LoParco C, Lee CM. Examining the ecological validity of the prototype willingness model for adolescent and young adult alcohol use. Psychol Addict Behav. 2020 Mar;34(2):293-302. doi: 10.1037/adb0000533. Epub 2019 Nov 21. — View Citation

Li, X., Lewis, M. A., Fairlie, A. M., & Mun, E. Y. (2019, June). Participants come back to see web-delivered personalized feedback aimed at reducing alcohol-related risky sexual behavior among young adults. Poster presented at the annual meeting of the Research Society on Alcoholism, Minneapolis, MN.

Linden-Carmichael AN, Van Doren N, Masters LD, Lanza ST. Simultaneous alcohol and marijuana use in daily life: Implications for level of use, subjective intoxication, and positive and negative consequences. Psychol Addict Behav. 2020 May;34(3):447-453. doi: 10.1037/adb0000556. Epub 2020 Jan 23. — View Citation

Lipperman-Kreda S, Gruenewald PJ, Grube JW, Bersamin M. Adolescents, alcohol, and marijuana: Context characteristics and problems associated with simultaneous use. Drug Alcohol Depend. 2017 Oct 1;179:55-60. doi: 10.1016/j.drugalcdep.2017.06.023. Epub 2017 Jul 20. — View Citation

Litt, D. M. & Lewis, M. A. (2016). An Examination of Protective Behavioral Strategies, Motivations for Strategy Selection, and Alcohol Use Among Young Adults. Poster presented at the Association for Behavioral and Cognitive Therapies, New York.

Martens MP, Taylor KK, Damann KM, Page JC, Mowry ES, Cimini MD. Protective behavioral strategies when drinking alcohol and their relationship to negative alcohol-related consequences in college students. Psychol Addict Behav. 2004 Dec;18(4):390-3. doi: 10.1037/0893-164X.18.4.390. — View Citation

Miller MB, Leffingwell T, Claborn K, Meier E, Walters S, Neighbors C. Personalized feedback interventions for college alcohol misuse: an update of Walters & Neighbors (2005). Psychol Addict Behav. 2013 Dec;27(4):909-20. doi: 10.1037/a0031174. Epub 2012 Dec 31. Erratum In: Psychol Addict Behav. 2013 Dec;27(4):1101. — View Citation

Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York, NY: Guilford Press.

Murphy JG, Dennhardt AA, Skidmore JR, Borsari B, Barnett NP, Colby SM, Martens MP. A randomized controlled trial of a behavioral economic supplement to brief motivational interventions for college drinking. J Consult Clin Psychol. 2012 Oct;80(5):876-86. doi: 10.1037/a0028763. Epub 2012 Jun 4. — View Citation

National Institute on Alcohol Abuse and Alcoholism (2019). Planning alcohol interventions using NIAAA's College Alcohol Intervention Matrix (CollegeAIM). Bethesda, MD: National Institutes of Health, (NIH Publication No. 19-AA-8017, Updated December 2019).

Pedersen ER, Huang W, Dvorak RD, Prince MA, Hummer JF; (The Marijuana Outcomes Study Team). The Protective Behavioral Strategies for Marijuana Scale: Further examination using item response theory. Psychol Addict Behav. 2017 Aug;31(5):548-559. doi: 10.1037/adb0000271. Epub 2017 Jul 13. — View Citation

Pedersen ER, Hummer JF, Rinker DV, Traylor ZK, Neighbors C. Measuring Protective Behavioral Strategies for Marijuana Use Among Young Adults. J Stud Alcohol Drugs. 2016 May;77(3):441-50. doi: 10.15288/jsad.2016.77.441. — View Citation

Read JP, Kahler CW, Strong DR, Colder CR. Development and preliminary validation of the young adult alcohol consequences questionnaire. J Stud Alcohol. 2006 Jan;67(1):169-77. doi: 10.15288/jsa.2006.67.169. — View Citation

Reid AE, Carey KB. Interventions to reduce college student drinking: State of the evidence for mechanisms of behavior change. Clin Psychol Rev. 2015 Aug;40:213-24. doi: 10.1016/j.cpr.2015.06.006. Epub 2015 Jun 24. — View Citation

Riggs NR, Conner BT, Parnes JE, Prince MA, Shillington AM, George MW. Marijuana eCHECKUPTO GO: Effects of a personalized feedback plus protective behavioral strategies intervention for heavy marijuana-using college students. Drug Alcohol Depend. 2018 Sep 1;190:13-19. doi: 10.1016/j.drugalcdep.2018.05.020. Epub 2018 Jun 23. — View Citation

Sauro, J. (2011). A practical guide to the system usability scale: Background, benchmarks, & best practices. Denver, CO: Measuring Usability LLC.

Schafer J, Brown SA. Marijuana and cocaine effect expectancies and drug use patterns. J Consult Clin Psychol. 1991 Aug;59(4):558-65. doi: 10.1037//0022-006x.59.4.558. — View Citation

Shrier LA, Burke PJ, Kells M, Scherer EA, Sarda V, Jonestrask C, Xuan Z, Harris SK. Pilot randomized trial of MOMENT, a motivational counseling-plus-ecological momentary intervention to reduce marijuana use in youth. Mhealth. 2018 Jul 30;4:29. doi: 10.21037/mhealth.2018.07.04. eCollection 2018. — View Citation

Simons JS, Dvorak RD, Merrill JE, Read JP. Dimensions and severity of marijuana consequences: development and validation of the Marijuana Consequences Questionnaire (MACQ). Addict Behav. 2012 May;37(5):613-21. doi: 10.1016/j.addbeh.2012.01.008. Epub 2012 Jan 14. — View Citation

Stephens RS, Roffman RA, Curtin L. Comparison of extended versus brief treatments for marijuana use. J Consult Clin Psychol. 2000 Oct;68(5):898-908. — View Citation

Stephens RS, Roffman RA, Fearer SA, Williams C, Picciano JF, Burke RS. The Marijuana Check-up: reaching users who are ambivalent about change. Addiction. 2004 Oct;99(10):1323-32. doi: 10.1111/j.1360-0443.2004.00832.x. — View Citation

Subbaraman MS, Kerr WC. Simultaneous versus concurrent use of alcohol and cannabis in the National Alcohol Survey. Alcohol Clin Exp Res. 2015 May;39(5):872-9. doi: 10.1111/acer.12698. — View Citation

Substance Abuse and Mental Health Services Administration. Enhancing Motivation for Change in Substance Use Disorder Treatment. Treatment Improvement Protocol (TIP) Series No. 35. SAMHSA Publication No. PEP19-02-01-003. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2019

Treloar H, Martens MP, McCarthy DM. The Protective Behavioral Strategies Scale-20: improved content validity of the Serious Harm Reduction subscale. Psychol Assess. 2015 Mar;27(1):340-6. doi: 10.1037/pas0000071. Epub 2015 Jan 5. — View Citation

White, H. R., Labouvie, E. W., Papadaratsakis, V. (2005). Changes in substance use during the transition to adulthood: A comparison of college students and their noncollege age peers. Journal of Drug Issues, 35(2), 281-306. doi:10.1177/002204260503500204

* Note: There are 41 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Change in Daily Drinking Questionnaire	The Daily Drinking Questionnaire (Collins, Parks, & Marlatt, 1985) measures the quantity and frequency of alcohol use by asking students to estimate the typical number of drinks consumed on each day of the week, averaged over the previous 3 months.	Change from Baseline measurement at 2 months
Primary	Change in Young Adult Alcohol Consequences Questionnaire	The Young Adult Alcohol Consequences Questionnaire (a=.79; Read et al., 2006) will asses consequences from drinking.	Change from Baseline measurement at 2 months
Primary	Change in Alcohol Protective Behavioral Strategies	Alcohol Protective Behavioral Strategies (i.e., tips and strategies used to reduce harm when drinking) will be assessed with the Protective Behavioral Strategies Survey-20 (PBSS-20; a=.63-.81; Treloar et al., 2015).	Change from Baseline measurement at 2 months
Primary	Change in Motivations for alcohol Protective Behavioral Strategies use and non-use	Motivations for alcohol Protective Behavioral Strategies use and non-use survey (i.e., tips and strategies used to reduce harm when drinking) will be used (a=.80; Litt & Lewis, 2016; Bravo et al., 2018).	Change from Baseline measurement at 2 months
Primary	Change in Daily Marijuana Use Questionnaire	A parallel Daily Drinking Questionnaire measure will be asked for marijuana assessing typical days used and typical number of hours high each day (a=.97, Lee et al., 2013).	Change from Baseline measurement at 2 months
Primary	Change in Marijuana Protective Behavioral Strategies	Marijuana Protective Behavioral Strategies (i.e., tips and strategies used to reduce harm when using marijuana) will be assessed using the Protective Behavioral Strategies for Marijuana Scale (PBSM-36; Pedersen et al., 2017; a=.93).	Change from Baseline measurement at 2 months
Primary	Change in Motivations for marijuana Protective Behavioral Strategies use and non-use	Motivations for marijuana Protective Behavioral Strategies use and non-use survey (i.e., tips and strategies used to reduce harm when using marijuana) will be assessed using parallel items to the alcohol protective behavioral strategies motivations measure (Litt & Lewis, 2016; Bravo et al., 2018).	Change from Baseline measurement at 2 months
Primary	Change in Rutgers Marijuana Problem Index	The Rutgers Marijuana Problem Index (White et al., 2005) will assess marijuana consequences, selecting acute items appropriate for daily-level measurement.	From date of randomization until study completion, up to 2 months. This measure will be administered using daily surveys sent on the day following intervention TMs, which are sent on Friday, Saturday, and a randomly chosen weekday for up to 8 weeks.
Primary	Change in Protective Behavioral Strategy use and quality the previous day	PBS use and quality the previous day will be assessed by having participants report which, if any, alcohol and/or marijuana PBS they used the previous day, and for those they report using, how well they implemented the PBS (i.e., quality) and how helpful they perceived the strategy to be.	From date of randomization until study completion, up to 2 months. This measure will be administered using daily surveys sent on the day following intervention TMs, which are sent on Friday, Saturday, and a randomly chosen weekday for up to 8 weeks.
Primary	Change in Simultaneous Alcohol and Marijuana Use	Questions regarding SAM use will be adapted from MTF (Johnston et al., 2015).	Change from date of randomization until study completion, up to 2 months. This measure will be administered using daily surveys sent the day after intervention TMs, which are sent on Friday, Saturday, and a randomly chosen weekday for up to 8 weeks.
Primary	Change in Concurrent Alcohol and Marijuana Use	Concurrent Alcohol and Marijuana Use: Concurrent Alcohol and Marijuana Use is determined from the alcohol and marijuana measures (i.e., endorsement of both alcohol and marijuana use within the same timeframe; Lee et al., 2013).	Change from date of randomization until study completion, up to 2 months. This measure will be administered using daily surveys sent the day after intervention TMs, which are sent on Friday, Saturday, and a randomly chosen weekday for up to 8 weeks.