Influences of Mood, Depression History, and Treatment Modality on Outcomes in Smoking Cessation

Neurobiological associations between smoking and internalizing disorders

People with severe mental disorders have a higher mortality rate due to preventable conditions like cardiovascular diseases and respiratory diseases. Nicotine addiction is a preventable risk factor, with tobacco use being twice as high in people with mental disorders. An integrative model that divides mental disorders into externalising, internalising, and thought disorders could be useful for identifying common causalities and risk factors. This review aims to examine the interface between smoking and internalising disorders, specifically schizophrenia, depressive disorders, and anxiety disorders. The review finds that there is a clear association between smoking behaviour and these disorders. Schizophrenia is associated with polymorphisms that result in an imbalance between glutamate and GABA release and abnormalities of dopaminergic pathways. Nicotine improves dopaminergic signalling and balances glutamatergic and GABAergic pathways, improving symptoms and increasing the risk of nicotine dependence. In depressive disorders, smoking is associated with functional changes in brain regions affected by smoking and self-medication. In anxiety disorders, there is a bidirectional relationship with smoking, involving the amygdala and changes in dopaminergic pathways and cortisol production. Smoking poses a threat to people living with psychiatric disorders and calls for further research to assess the interactions between nicotine dependence and internalising and thought disorders.

Antidepressants for smoking cessation

BACKGROUND

The pharmacological profiles and mechanisms of antidepressants are varied. However, there are common reasons why they might help people to stop smoking tobacco: nicotine withdrawal can produce short-term low mood that antidepressants may relieve; and some antidepressants may have a specific effect on neural pathways or receptors that underlie nicotine addiction.

OBJECTIVES

To assess the evidence for the efficacy, harms, and tolerability of medications with antidepressant properties in assisting long-term tobacco smoking cessation in people who smoke cigarettes.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, most recently on 29 April 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in people who smoked, comparing antidepressant medications with placebo or no pharmacological treatment, an alternative pharmacotherapy, or the same medication used differently. We excluded trials with fewer than six months of follow-up from efficacy analyses. We included trials with any follow-up length for our analyses of harms.

DATA COLLECTION AND ANALYSIS

We extracted data and assessed risk of bias using standard Cochrane methods. Our primary outcome measure was smoking cessation after at least six months' follow-up. We used the most rigorous definition of abstinence available in each trial, and biochemically validated rates if available. Our secondary outcomes were harms and tolerance outcomes, including adverse events (AEs), serious adverse events (SAEs), psychiatric AEs, seizures, overdoses, suicide attempts, death by suicide, all-cause mortality, and trial dropouts due to treatment. We carried out meta-analyses where appropriate.

MAIN RESULTS

We included a total of 124 studies (48,832 participants) in this review, with 10 new studies added to this update version. Most studies recruited adults from the community or from smoking cessation clinics; four studies focused on adolescents (with participants between 12 and 21 years old). We judged 34 studies to be at high risk of bias; however, restricting analyses only to studies at low or unclear risk of bias did not change clinical interpretation of the results.  There was high-certainty evidence that bupropion increased smoking cessation rates when compared to placebo or no pharmacological treatment (RR 1.60, 95% CI 1.49 to 1.72; I2 = 16%; 50 studies, 18,577 participants). There was moderate-certainty evidence that a combination of bupropion and varenicline may have resulted in superior quit rates to varenicline alone (RR 1.21, 95% CI 0.95 to 1.55; I2 = 15%; 3 studies, 1057 participants). However, there was insufficient evidence to establish whether a combination of bupropion and nicotine replacement therapy (NRT) resulted in superior quit rates to NRT alone (RR 1.17, 95% CI 0.95 to 1.44; I2 = 43%; 15 studies, 4117 participants; low-certainty evidence). There was moderate-certainty evidence that participants taking bupropion were more likely to report SAEs than those taking placebo or no pharmacological treatment. However, results were imprecise and the CI also encompassed no difference (RR 1.16, 95% CI 0.90 to 1.48; I2 = 0%; 23 studies, 10,958 participants). Results were also imprecise when comparing SAEs between people randomised to a combination of bupropion and NRT versus NRT alone (RR 1.52, 95% CI 0.26 to 8.89; I2 = 0%; 4 studies, 657 participants) and randomised to bupropion plus varenicline versus varenicline alone (RR 1.23, 95% CI 0.63 to 2.42; I2 = 0%; 5 studies, 1268 participants). In both cases, we judged evidence to be of low certainty. There was high-certainty evidence that bupropion resulted in more trial dropouts due to AEs than placebo or no pharmacological treatment (RR 1.44, 95% CI 1.27 to 1.65; I2 = 2%; 25 studies, 12,346 participants). However, there was insufficient evidence that bupropion combined with NRT versus NRT alone (RR 1.67, 95% CI 0.95 to 2.92; I2 = 0%; 3 studies, 737 participants) or bupropion combined with varenicline versus varenicline alone (RR 0.80, 95% CI 0.45 to 1.45; I2 = 0%; 4 studies, 1230 participants) had an impact on the number of dropouts due to treatment. In both cases, imprecision was substantial (we judged the evidence to be of low certainty for both comparisons). Bupropion resulted in inferior smoking cessation rates to varenicline (RR 0.73, 95% CI 0.67 to 0.80; I2 = 0%; 9 studies, 7564 participants), and to combination NRT (RR 0.74, 95% CI 0.55 to 0.98; I2 = 0%; 2 studies; 720 participants). However, there was no clear evidence of a difference in efficacy between bupropion and single-form NRT (RR 1.03, 95% CI 0.93 to 1.13; I2 = 0%; 10 studies, 7613 participants). We also found evidence that nortriptyline aided smoking cessation when compared with placebo (RR 2.03, 95% CI 1.48 to 2.78; I2 = 16%; 6 studies, 975 participants), and some evidence that bupropion resulted in superior quit rates to nortriptyline (RR 1.30, 95% CI 0.93 to 1.82; I2 = 0%; 3 studies, 417 participants), although this result was subject to imprecision. Findings were sparse and inconsistent as to whether antidepressants, primarily bupropion and nortriptyline, had a particular benefit for people with current or previous depression.

AUTHORS' CONCLUSIONS

There is high-certainty evidence that bupropion can aid long-term smoking cessation. However, bupropion may increase SAEs (moderate-certainty evidence when compared to placebo/no pharmacological treatment). There is high-certainty evidence that people taking bupropion are more likely to discontinue treatment compared with people receiving placebo or no pharmacological treatment. Nortriptyline also appears to have a beneficial effect on smoking quit rates relative to placebo, although bupropion may be more effective. Evidence also suggests that bupropion may be as successful as single-form NRT in helping people to quit smoking, but less effective than combination NRT and varenicline. In most cases, a paucity of data made it difficult to draw conclusions regarding harms and tolerability. Further studies investigating the efficacy of bupropion versus placebo are unlikely to change our interpretation of the effect, providing no clear justification for pursuing bupropion for smoking cessation over other licensed smoking cessation treatments; namely, NRT and varenicline. However, it is important that future studies of antidepressants for smoking cessation measure and report on harms and tolerability.

The effects of varenicline, bupropion, nicotine patch, and placebo on smoking cessation among smokers with major depression: A randomized clinical trial

IMPORTANCE

Improving treatment outcomes for smokers with major depressive disorder (MDD) can have significant public health implications.

OBJECTIVE

To evaluate the safety and efficacy of smoking cessation pharmacotherapy among smokers with MDD.

DESIGN

Secondary analysis of a randomized, double-blind, active- (nicotine patch) and placebo-controlled trial of 12 weeks of either varenicline or bupropion with a 12-week follow-up.

PARTICIPANTS

Community volunteers 18-75 years of age; smoke 10+ cigarettes/day; with clinically stable MDD (N = 2635) or no psychiatric disorder (N = 4028), from 140 sites in 16 countries.

INTERVENTION

Twelve weeks of pharmacotherapy (placebo [PLA], nicotine replacement therapy [NRT], bupropion [BUP], varenicline [VAR]) plus brief cessation counseling.

MEASURE(S)

Primary safety outcome: the occurrence of ≥1 treatment-emergent, moderate to severe neuropsychiatric adverse event (NPSAE). Primary efficacy outcome: biochemically confirmed continuous abstinence (CA) during the final 4 weeks of treatment (Weeks 9-12).

RESULTS

A total of 6653 participants (56% female; 39% MDD) ~47 years old. Risk of NPSAEs did not differ by medication for MDD. MDD had higher risk (p < .0001) for NPSAEs than the NPC. Efficacy (6653; intent-to-treat): CA rates for MDD versus NPC respectively were 31.2% versus 38.0% VAR; 23.0% versus 26.1% BUP; 22.6% versus 26.4% NRT; and 13.4% versus 13.7% PLA but no differential treatment effect was noted within the cohorts. All active treatments differed from PLA but VAR showed the largest effect.

CONCLUSIONS

Results suggest that for MDD smokers, inclusive of those with recurrent episode, varenicline plus counseling may be the best pharmacological option for the treatment of smoking given its greater efficacy effect size and similar risk of NPSAEs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01456936. https://clinicaltrials.gov/ct2/show/NCT01456936.

Association of depression symptom level with smoking urges, cigarette withdrawal, and smoking reinstatement: A preliminary laboratory study

BACKGROUND

Cigarette smoking urges, withdrawal, and smoking reinstatement may be especially relevant to people with elevated depression symptoms who smoke. This laboratory study aimed to assess relations between depression symptom level and smoking urges for reward and relief, cigarette withdrawal, and smoking reinstatement in people who smoke cigarettes daily during acute abstinence and while smoking as usual.

METHODS

Participants with low (n = 51) or elevated (n = 29) baseline depression symptoms underwent two counterbalanced laboratory sessions (i.e., abstinent, non-abstinent). At each session, they completed subjective measures of smoking urges for reward and relief, and withdrawal. They also completed a laboratory smoking reinstatement task measuring whether they would delay smoking and the number of cigarettes smoked.

RESULTS

The elevated depression symptom group reported significantly higher withdrawal (p = .01) and smoked more cigarettes than the low depression symptoms group during the smoking reinstatement task self-administration period at the abstinent session (p = .04). Smoking urges for reward and relief were not significantly different by depression symptom group. There were no significant interactions of depression and abstinence with any outcomes.

CONCLUSIONS

As outcomes were measured at both an abstinent and non-abstinent session, findings identify factors for people with elevated depression symptoms who smoke which may drive smoking behavior and impede smoking cessation efforts. This study provides evidence that people with elevated depression symptoms who smoke may need additional/more pharmacological or behavioral smoking cessation aids targeted at reducing withdrawal and number of cigarettes smoked.

Interventions for preventing weight gain after smoking cessation

BACKGROUND

Most people who stop smoking gain weight. This can discourage some people from making a quit attempt and risks offsetting some, but not all, of the health advantages of quitting. Interventions to prevent weight gain could improve health outcomes, but there is a concern that they may undermine quitting.

OBJECTIVES

To systematically review the effects of: (1) interventions targeting post-cessation weight gain on weight change and smoking cessation (referred to as 'Part 1') and (2) interventions designed to aid smoking cessation that plausibly affect post-cessation weight gain (referred to as 'Part 2').

SEARCH METHODS

Part 1 - We searched the Cochrane Tobacco Addiction Group's Specialized Register and CENTRAL; latest search 16 October 2020. Part 2 - We searched included studies in the following 'parent' Cochrane reviews: nicotine replacement therapy (NRT), antidepressants, nicotine receptor partial agonists, e-cigarettes, and exercise interventions for smoking cessation published in Issue 10, 2020 of the Cochrane Library. We updated register searches for the review of nicotine receptor partial agonists.

SELECTION CRITERIA

Part 1 - trials of interventions that targeted post-cessation weight gain and had measured weight at any follow-up point or smoking cessation, or both, six or more months after quit day. Part 2 - trials included in the selected parent Cochrane reviews reporting weight change at any time point.

DATA COLLECTION AND ANALYSIS

Screening and data extraction followed standard Cochrane methods. Change in weight was expressed as difference in weight change from baseline to follow-up between trial arms and was reported only in people abstinent from smoking. Abstinence from smoking was expressed as a risk ratio (RR). Where appropriate, we performed meta-analysis using the inverse variance method for weight, and Mantel-Haenszel method for smoking.

MAIN RESULTS

Part 1: We include 37 completed studies; 21 are new to this update. We judged five studies to be at low risk of bias, 17 to be at unclear risk and the remainder at high risk.  An intermittent very low calorie diet (VLCD) comprising full meal replacement provided free of charge and accompanied by intensive dietitian support significantly reduced weight gain at end of treatment compared with education on how to avoid weight gain (mean difference (MD) -3.70 kg, 95% confidence interval (CI) -4.82 to -2.58; 1 study, 121 participants), but there was no evidence of benefit at 12 months (MD -1.30 kg, 95% CI -3.49 to 0.89; 1 study, 62 participants). The VLCD increased the chances of abstinence at 12 months (RR 1.73, 95% CI 1.10 to 2.73; 1 study, 287 participants). However, a second study  found that no-one completed the VLCD intervention or achieved abstinence. Interventions aimed at increasing acceptance of weight gain reported mixed effects at end of treatment, 6 months and 12 months with confidence intervals including both increases and decreases in weight gain compared with no advice or health education. Due to high heterogeneity, we did not combine the data. These interventions increased quit rates at 6 months (RR 1.42, 95% CI 1.03 to 1.96; 4 studies, 619 participants; I² = 21%), but there was no evidence at 12 months (RR 1.25, 95% CI 0.76 to 2.06; 2 studies, 496 participants; I² = 26%). Some pharmacological interventions tested for limiting post-cessation weight gain (PCWG) reduced weight gain at the end of treatment (dexfenfluramine, phenylpropanolamine, naltrexone). The effects of ephedrine and caffeine combined, lorcaserin, and chromium were too imprecise to give useful estimates of treatment effects. There was very low-certainty evidence that personalized weight management support reduced weight gain at end of treatment (MD -1.11 kg, 95% CI -1.93 to -0.29; 3 studies, 121 participants; I² = 0%), but no evidence in the longer-term 12 months (MD -0.44 kg, 95% CI -2.34 to 1.46; 4 studies, 530 participants; I² = 41%). There was low to very low-certainty evidence that detailed weight management education without personalized assessment, planning and feedback did not reduce weight gain and may have reduced smoking cessation rates (12 months: MD -0.21 kg, 95% CI -2.28 to 1.86; 2 studies, 61 participants; I² = 0%; RR for smoking cessation 0.66, 95% CI 0.48 to 0.90; 2 studies, 522 participants; I² = 0%). Part 2: We include 83 completed studies, 27 of which are new to this update. There was low certainty that exercise interventions led to minimal or no weight reduction compared with standard care at end of treatment (MD -0.25 kg, 95% CI -0.78 to 0.29; 4 studies, 404 participants; I² = 0%). However, weight was reduced at 12 months (MD -2.07 kg, 95% CI -3.78 to -0.36; 3 studies, 182 participants; I² = 0%). Both bupropion and fluoxetine limited weight gain at end of treatment (bupropion MD -1.01 kg, 95% CI -1.35 to -0.67; 10 studies, 1098 participants; I² = 3%); (fluoxetine MD -1.01 kg, 95% CI -1.49 to -0.53; 2 studies, 144 participants; I² = 38%; low- and very low-certainty evidence, respectively). There was no evidence of benefit at 12 months for bupropion, but estimates were imprecise (bupropion MD -0.26 kg, 95% CI -1.31 to 0.78; 7 studies, 471 participants; I² = 0%). No studies of fluoxetine provided data at 12 months. There was moderate-certainty that NRT reduced weight at end of treatment (MD -0.52 kg, 95% CI -0.99 to -0.05; 21 studies, 2784 participants; I² = 81%) and moderate-certainty that the effect may be similar at 12 months (MD -0.37 kg, 95% CI -0.86 to 0.11; 17 studies, 1463 participants; I² = 0%), although the estimates are too imprecise to assess long-term benefit. There was mixed evidence of the effect of varenicline on weight, with high-certainty evidence that weight change was very modestly lower at the end of treatment (MD -0.23 kg, 95% CI -0.53 to 0.06; 14 studies, 2566 participants; I² = 32%); a low-certainty estimate gave an imprecise estimate of higher weight at 12 months (MD 1.05 kg, 95% CI -0.58 to 2.69; 3 studies, 237 participants; I² = 0%).

AUTHORS' CONCLUSIONS

Overall, there is no intervention for which there is moderate certainty of a clinically useful effect on long-term weight gain. There is also no moderate- or high-certainty evidence that interventions designed to limit weight gain reduce the chances of people achieving abstinence from smoking.

Antidepressants for smoking cessation

BACKGROUND

Whilst the pharmacological profiles and mechanisms of antidepressants are varied, there are common reasons why they might help people to stop smoking tobacco. Firstly, nicotine withdrawal may produce depressive symptoms and antidepressants may relieve these. Additionally, some antidepressants may have a specific effect on neural pathways or receptors that underlie nicotine addiction.

OBJECTIVES

To assess the evidence for the efficacy, safety and tolerability of medications with antidepressant properties in assisting long-term tobacco smoking cessation in people who smoke cigarettes.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Specialized Register, which includes reports of trials indexed in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO, clinicaltrials.gov, the ICTRP, and other reviews and meeting abstracts, in May 2019.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that recruited smokers, and compared antidepressant medications with placebo or no treatment, an alternative pharmacotherapy, or the same medication used in a different way. We excluded trials with less than six months follow-up from efficacy analyses. We included trials with any follow-up length in safety analyses.

DATA COLLECTION AND ANALYSIS

We extracted data and assessed risk of bias using standard Cochrane methods. We also used GRADE to assess the certainty of the evidence. The primary outcome measure was smoking cessation after at least six months follow-up, expressed as a risk ratio (RR) and 95% confidence intervals (CIs). We used the most rigorous definition of abstinence available in each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed-effect model. Similarly, we presented incidence of safety and tolerance outcomes, including adverse events (AEs), serious adverse events (SAEs), psychiatric AEs, seizures, overdoses, suicide attempts, death by suicide, all-cause mortality, and trial dropout due to drug, as RRs (95% CIs).

MAIN RESULTS

We included 115 studies (33 new to this update) in this review; most recruited adult participants from the community or from smoking cessation clinics. We judged 28 of the studies to be at high risk of bias; however, restricting analyses only to studies at low or unclear risk did not change clinical interpretation of the results. There was high-certainty evidence that bupropion increased long-term smoking cessation rates (RR 1.64, 95% CI 1.52 to 1.77; I² = 15%; 45 studies, 17,866 participants). There was insufficient evidence to establish whether participants taking bupropion were more likely to report SAEs compared to those taking placebo. Results were imprecise and CIs encompassed no difference (RR 1.16, 95% CI 0.90 to 1.48; I² = 0%; 21 studies, 10,625 participants; moderate-certainty evidence, downgraded one level due to imprecision). We found high-certainty evidence that use of bupropion resulted in more trial dropouts due to adverse events of the drug than placebo (RR 1.37, 95% CI 1.21 to 1.56; I² = 19%; 25 studies, 12,340 participants). Participants randomized to bupropion were also more likely to report psychiatric AEs compared with those randomized to placebo (RR 1.25, 95% CI 1.15 to 1.37; I² = 15%; 6 studies, 4439 participants). We also looked at the safety and efficacy of bupropion when combined with other non-antidepressant smoking cessation therapies. There was insufficient evidence to establish whether combination bupropion and nicotine replacement therapy (NRT) resulted in superior quit rates to NRT alone (RR 1.19, 95% CI 0.94 to 1.51; I² = 52%; 12 studies, 3487 participants), or whether combination bupropion and varenicline resulted in superior quit rates to varenicline alone (RR 1.21, 95% CI 0.95 to 1.55; I² = 15%; 3 studies, 1057 participants). We judged the certainty of evidence to be low and moderate, respectively; in both cases due to imprecision, and also due to inconsistency in the former. Safety data were sparse for these comparisons, making it difficult to draw clear conclusions. A meta-analysis of six studies provided evidence that bupropion resulted in inferior smoking cessation rates to varenicline (RR 0.71, 95% CI 0.64 to 0.79; I² = 0%; 6 studies, 6286 participants), whilst there was no evidence of a difference in efficacy between bupropion and NRT (RR 0.99, 95% CI 0.91 to 1.09; I² = 18%; 10 studies, 8230 participants). We also found some evidence that nortriptyline aided smoking cessation when compared with placebo (RR 2.03, 95% CI 1.48 to 2.78; I² = 16%; 6 studies, 975 participants), whilst there was insufficient evidence to determine whether bupropion or nortriptyline were more effective when compared with one another (RR 1.30 (favouring bupropion), 95% CI 0.93 to 1.82; I² = 0%; 3 studies, 417 participants). There was no evidence that any of the other antidepressants tested (including St John's Wort, selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs)) had a beneficial effect on smoking cessation. Findings were sparse and inconsistent as to whether antidepressants, primarily bupropion and nortriptyline, had a particular benefit for people with current or previous depression.

AUTHORS' CONCLUSIONS

There is high-certainty evidence that bupropion can aid long-term smoking cessation. However, bupropion also increases the number of adverse events, including psychiatric AEs, and there is high-certainty evidence that people taking bupropion are more likely to discontinue treatment compared with placebo. However, there is no clear evidence to suggest whether people taking bupropion experience more or fewer SAEs than those taking placebo (moderate certainty). Nortriptyline also appears to have a beneficial effect on smoking quit rates relative to placebo. Evidence suggests that bupropion may be as successful as NRT and nortriptyline in helping people to quit smoking, but that it is less effective than varenicline. There is insufficient evidence to determine whether the other antidepressants tested, such as SSRIs, aid smoking cessation, and when looking at safety and tolerance outcomes, in most cases, paucity of data made it difficult to draw conclusions. Due to the high-certainty evidence, further studies investigating the efficacy of bupropion versus placebo are unlikely to change our interpretation of the effect, providing no clear justification for pursuing bupropion for smoking cessation over front-line smoking cessation aids already available. However, it is important that where studies of antidepressants for smoking cessation are carried out they measure and report safety and tolerability clearly.

Depression as a moderator of the prospective relationship between mood and smoking

OBJECTIVE

Affective features of depression are uniquely involved in the depression-smoking relationship, and it follows that smokers with depression are likely to use cigarettes to alleviate negative affect. However, most ecological momentary assessment (EMA) studies demonstrate no relationship between mood and smoking, in general. Conversely, a small number of experimental studies suggest there is an association between mood and smoking and that the relationship is dependent on levels of depression. Researchers have yet to examine the impact of depression on the relationship between mood and smoking using EMA methodology. Accordingly, the aim of this study was to explore the relationship between depression, mood, and ad lib smoking among adults in "real time."

METHOD

Participants included 96 adult daily smokers (53% female, 67% non-Hispanic Black; age, M = 40.76, SD = 12.42) who completed baseline ratings of depressive symptoms and 7 consecutive days of in vivo data collection focused on cigarette smoking and associated mood and craving ratings.

RESULTS

Results indicated that depression moderates the prospective relationship between mood and smoking (even when controlling for craving), such that participants with higher levels of depressive symptoms smoke more cigarettes in response to an improvement in mood (relative to their average mood), whereas participants with lower levels of depressive symptoms smoke more in response to worsening mood states (relative to their average mood).

CONCLUSIONS

Attempting to maintain better mood may be a motivating factor for smoking among depressed individuals. These findings may be helpful in tailoring smoking cessation treatment programs for people exhibiting depressive symptoms. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Positive psychotherapy for smoking cessation enhanced with text messaging: Protocol for a randomized controlled trial

BACKGROUND

Despite reductions in cigarette smoking in the U.S., improvements in the efficacy of smoking cessation treatments are needed, as rates of sustained abstinence remain disappointingly low. Both low positive affect and high negative affect contribute to smoking relapse and constitute viable targets for smoking cessation interventions. Although some clinical trials have evaluated interventions to address depression as a smoking relapse risk factor, very few have focused on positive affect. Recently, we developed and conducted a preliminary clinical trial of a smoking cessation treatment that targets positive affect and cognitions by incorporating interventions rooted in positive psychology. The current randomized controlled trial will expand upon this preliminary trial to test whether this positive psychology-informed approach results in higher smoking cessation rates compared to a time-matched standard smoking cessation treatment control.

METHODS

Three hundred and forty adult daily smokers will be randomly assigned to either positive psychotherapy for smoking cessation or standard behavioral smoking cessation counseling. Participants will meet weekly with a study counselor for 6 weeks and will receive transdermal nicotine patch and text messaging smoking cessation support. Additionally, text messaging in the positive psychotherapy condition will encourage engagement in positive psychology-specific strategies for boosting mood and staying smoke free. Smoking cessation outcomes will be measured at 12, 26, and 52 weeks following target quit date.

CONCLUSION

Results from this study will provide evidence on whether incorporating positive psychology interventions into smoking cessation treatment can improve smoking cessation outcomes relative to standard behavioral counseling with nicotine patch and text messaging.

Effectiveness of pharmacological or psychological interventions for smoking cessation in smokers with major depression or depressive symptoms: A systematic review of the literature

BACKGROUND

Smokers with major depressive disorder (MDD) or depressive symptoms (DS) represent a subgroup in need of attention, since they have specific clinical features and prognosis.

METHODS

A systematic review of the literature (Cochrane, MEDLINE, ScienceDirect, Web of Science databases from inception to June 2017) of randomized clinical trials assessing the effectiveness of pharmacological, psychological, or combined interventions for smoking cessation in subjects with current or past MDD/DS without medical or comorbid psychiatric disorder(s) was run following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Twenty-seven studies met the inclusion criteria. Nicotine, varenicline, and staged-care intervention were more effective in smokers with current MDD; nicotine and fluoxetine plus nicotine were more effective in smokers with DS; naltrexone and nicotine plus fluoxetine were more effective in smokers with severe current DS. Cognitive-behavioral therapy and cognitive and behavioral cessation and relapse prevention skills training were superior to placebo in smokers with past MDD.

CONCLUSIONS

More research is needed into effectively addressing smoking in people with concurrent mental disorder. Data currently available need to be confirmed in randomized trials aimed at replicating the results and disentangling the effects of each therapeutic ingredient when a combination therapy is proposed. Studies on tolerability of treatments are warranted, as well as those aimed at identifying factors of vulnerability to adverse effects.

Substance use comorbidity in bipolar disorder: A qualitative review of treatment strategies and outcomes

BACKGROUND AND OBJECTIVES

Substance use disorders (SUDs) are present in up to 70% of patients with bipolar disorder (BD) and contribute to high rates of disability, morbidity, and treatment non-adherence. Despite this prevalence, few trials have investigated targeted psychosocial interventions for comorbid BD and SUDs.

METHODS

Using PubMed and PsycINFO, we conducted a search of the literature up to January 2018 for psychosocial interventions targeted to patients with comorbid BD and SUDs. We identified eight total trials. Of these studies, four randomized and two open trials targeted the types of substance use (alcohol and illicit drugs) of primary concern to mood stability; the remaining two studies, both open trials, targeted smoking cessation.

RESULTS

None of the randomized trials provided consistent evidence for management of both mood symptoms and substance use though integrated group therapy (IGT) demonstrated consistent beneficial effects on substance use outcomes. Other treatments showed benefit for mood symptoms without benefits for alcohol or illicit substance use. Small pilot studies of combined treatments for smoking cessation provided some initial promise.

CONCLUSIONS

At present, IGT is the most-well validated and efficacious approach if substance use is targeted in an initial treatment phase. For a subsequent phase, additional psychosocial BD treatments may be needed for mood and functioning benefits.

SCIENTIFIC SIGNIFICANCE

This review synthesizes the psychosocial interventions that have been conducted in comorbid BD and SUDs while also providing a perspective on which intervention elements are helpful for addressing substance use versus mood symptoms in patients with these co-occurring conditions. (Am J Addict 2018;27:188-201).

Predictors of Smoking Cessation and Relapse in Cancer Patients and Effect on Psychological Variables: an 18-Month Observational Study

BACKGROUND

Although cancer patients are generally strongly advised to quit smoking in order to improve treatment efficacy and survival, up to 68 % of patients who were smokers at the time of cancer diagnosis continue smoking. Psychological factors such as depression and anxiety are likely to be associated with smoking behavior following a cancer diagnosis, but the empirical evidence is scarce.

PURPOSE

This observational study aimed at estimating smoking cessation rates and assessing the effect of smoking cessation on psychological symptoms, as well as the predictive role of the same psychological variables on smoking cessation and smoking relapse following cancer surgery.

METHODS

As part of a larger prospective, epidemiological study, smokers (n = 175) with a first diagnosis of nonmetastatic cancer completed the Hospital Anxiety and Depression Scale, the Insomnia Severity Index, and the Fear of Cancer Recurrence Inventory. Quitters (n = 55) and pair-matched nonquitters (n = 55) were compared on each symptom at pre-quitting, post-quitting, and at a 4-month follow-up. Predictors of smoking cessation and smoking relapse, including psychological variables, were also investigated.

RESULTS

Fifty-five patients (31.4 %) stopped smoking at least on one occasion during the study. Of the 55 quitters, 27 (49.1 %) experienced a relapse. At pre-quitting, quitters had significantly higher levels of anxiety (p = .03) and fear of cancer recurrence (p = .01) than nonquitters, symptoms that significantly diminished at post-quitting and 4 months later in this subgroup of patients. Having breast cancer significantly predicted smoking cessation (relative risk [RR] = 3.08), while depressive symptoms were a significant predictor of smoking relapse (RR = 1.07).

CONCLUSIONS

This study highlights the importance of psychological symptoms in predicting tobacco cessation and relapse among individuals with cancer. Our findings suggest that breast cancer patients are more inclined to stop smoking than patients with other cancers, but future studies should attempt to delineate the effect on smoking cessation of gender and other demographics that characterize this subgroup. This study also suggests that a particular attention should be paid to the early management of depressive symptoms in order to prevent smoking relapse.

Review of smoking cessation treatments for people with mental illness

This article reviews the current literature regarding treatments for smoking cessation in both the general population and in those with mental health problems. The gold-standard treatment for the general population is pharmacotherapy (nicotine replacement therapy, bupropion or varenicline) coupled with individual or group psychological support. This is also effective in helping people with mental illness to reduce or quit smoking, but care must be taken to avoid adverse medication interactions and to monitor antipsychotic medication in particular as cigarette consumption reduces.

Smoking Cessation for Pregnant Smokers: Development and Pilot Test of an Emotion Regulation Treatment Supplement to Standard Smoking Cessation for Negative Affect Smokers

INTRODUCTION

Negative affect has been identified as a factor influencing continued smoking during pregnancy. In this study, a multi-component emotion regulation intervention was developed to address negative emotional smoking triggers and pilot-tested among low-income pregnant smokers. Treatment feasibility and acceptability, cotinine-verified rates of smoking cessation, and self-report of mean cigarettes smoked were assessed.

METHODS

Pregnant smokers who self-reported smoking in response to negative affect (N = 70) were randomly assigned to receive one of two 8-session interventions: (1) emotion regulation treatment combined with standard cognitive-behavioral smoking cessation (ERT + CBT) or (2) a health and lifestyle plus standard smoking cessation active control (HLS + CBT). Outcomes for the 4-month period following the quit date are reported.

RESULTS

Treatment attendance and subjective ratings provide evidence for the feasibility and acceptability of the ERT + CBT intervention. Compared with the HLS + CBT control condition, the ERT + CBT condition demonstrated higher abstinence rates at 2 months (ERT + CBT = 23% vs. HLS + CBT = 0%, OR = 13.51; 95% CI = 0.70-261.59) and 4 months (ERT = 18% vs. HLS = 5%; OR = 2.98; 95% CI = 0.39-22.72) post-quit. Mean number of cigarettes per day was significantly lower in ERT + CBT at 2 months (ERT + CBT = 2.73 (3.35) vs. HLS + CBT = 5.84 (6.24); p = .05) but not at 4 months (ERT + CBT = 2.15 (3.17) vs. HLS + CBT = 5.18 (2.88); p = .06) post-quit.

CONCLUSIONS

The development and initial test of the ERT + CBT intervention supports its feasibility and acceptability in this difficult-to-treat population. Further development and testing in a Stage II randomized clinical trial are warranted.

IMPLICATIONS

Negative affect has been identified as a motivator for continued smoking during pregnancy. To date, smoking cessation interventions for pregnant smokers have not specifically addressed the role of negative affect as a smoking trigger. This treatment development pilot study provides support for the feasibility and acceptability of a multi-component ERT + CBT for low-income pregnant smokers who self-report smoking in response to negative affect. Study findings support further testing in a fully-powered Stage II efficacy trial powered to assess mediators and moderators of treatment effects.

Cigarette smoking and depression comorbidity: systematic review and proposed theoretical model

BACKGROUND AND AIMS

Despite decades of research on co-occurring smoking and depression, cessation rates remain consistently lower for depressed smokers than for smokers in the general population, highlighting the need for theory-driven models of smoking and depression. This paper provides a systematic review with a particular focus upon psychological states that disproportionately motivate smoking in depression, and frame an incentive learning theory account of smoking-depression co-occurrence.

METHODS

We searched PubMed, Scopus, PsychINFO and CINAHL to December 2014, which yielded 852 papers. Using pre-established eligibility criteria, we identified papers focused on clinical issues and motivational mechanisms underlying smoking in established, adult smokers (i.e. maintenance, quit attempts and cessation/relapse) with elevated symptoms of depression. Two reviewers determined independently whether papers met review criteria. We included 297 papers in qualitative synthesis.

RESULTS

Our review identified three primary mechanisms that underlie persistent smoking among depressed smokers: low positive affect, high negative affect and cognitive impairment. We propose a novel application of incentive learning theory which posits that depressed smokers experience greater increases in the expected value of smoking in the face of these three motivational states, which promotes goal-directed choice of smoking behavior over alternative actions.

CONCLUSIONS

The incentive learning theory accounts for current evidence on how depression primes smoking behavior and provides a unique framework for conceptualizing psychological mechanisms of smoking maintenance among depressed smokers. Treatment should focus upon correcting adverse internal states and beliefs about the high value of smoking in those states to improve cessation outcomes for depressed smokers.

A Review of Impact of Tobacco Use on Patients with Co-occurring Psychiatric Disorders

Consumption of tobacco has been a worldwide problem over the past few decades due to the highly prevalent tobacco-attributable complications. Tobacco use has also been found to be more prevalent in patients with psychiatric disorders. Therefore, we conducted this review about the impact of tobacco use on co-occurring psychiatric disorders. Various facets of this interaction between tobacco use among those with co-occurring psychiatric disorders have been explored. It has been found that people with psychiatric disorders have a higher chance of currently smoking tobacco and lesser chance of cessation. Tobacco use and mental disorders continue to share a complex relationship that has been further evolving after the change in the pattern of tobacco use and also the advent of newer modalities of treatment. However, at the same time, it is believed that cessation of smoking may lead to improvement in the symptoms of mental illness.

Understanding Inequalities of Maternal Smoking--Bridging the Gap with Adapted Intervention Strategies

Women who are generally part of socially disadvantaged and economically marginalized groups are especially susceptible to smoking during pregnancy but smoking rates are underreported in both research and interventions. While there is evidence to support the short-term efficacy of nicotine replacement therapy (NRT) use in pregnancy, long-term abstinence rates are modest. Current health strategies and interventions designed to diminish smoking in pregnancy have adopted a simplified approach to maternal smoking-one that suggests that they have a similar degree of choice to non-pregnant smokers regarding the avoidance of risk factors, and overlooks individual predictors of non-adherence. As a result, interventions have been ineffective among this high-risk group. For this reason, this paper addresses the multiple and interacting determinants that must be considered when developing and implementing effective strategies that lead to successful smoking cessation: socioeconomic status (SES), nicotine dependence, social support, culture, mental health, and health services. Based on our review of the literature, we conclude that tailoring cessation programs for pregnant smokers may ultimately optimize NRT efficacy and reduce the prevalence of maternal smoking.

Individualized Treatment for Tobacco Dependence in Addictions Treatment Settings: The Role of Current Depressive Symptoms on Outcomes at 3 and 6 Months

INTRODUCTION

Individuals with concurrent tobacco dependence and other addictions often report symptoms of low mood and depression and as such may have more difficulty quitting smoking. We hypothesized that current symptoms of depression would be a significant predictor of quit success among a group of smokers receiving individualized treatment for tobacco dependence within addiction treatment settings.

METHODS

Individuals in treatment for other addictions were enrolled in a smoking cessation program involving brief behavioral counseling and individualized dosing of nicotine replacement therapy. The baseline assessment included the Patient Health Questionnaire (PHQ9) for depression. Smoking cessation outcomes were measured at 3 and 6 months post-enrollment. Bivariate associations between cessation outcomes and PHQ9 score were analyzed.

RESULTS

Of the 1,196 subjects enrolled to date, 1,171 (98%) completed the PHQ9. Moderate to severe depression (score >9) was reported by 28% of the sample, and another 29% reported mild depression (score between 5 and 9). Contrary to the extant literature and other findings by our own group, there was no association between current depression and cessation outcome at either 3 months (n = 1,171) (17.0% in those with PHQ9 > 9 vs. 19.8% in those with PHQ9 < 5, p = .32) or 6 months (n = 834) (17.8% vs. 18.9%, p = .74).

CONCLUSIONS

Contrary to our hypothesis, depression severity as measured by the PHQ9 did not predict cessation outcome in this clinical population. A possible explanation may be the individualized treatment and supportive environment of an addictions treatment setting. These data indicate that patients in an addictions treatment setting can successfully quit smoking regardless of current depressive symptoms.

Smoking cessation and depressive symptoms at 1-, 3-, 6-, and 12-months follow-up

BACKGROUND

The relationship between tobacco and depressive symptoms has been examined. However, there is little information on the evolution of these symptoms when an individual quits. The aim of this study was to analyze the evolution of depressive symptoms over time (pre-, post-treatment, 1-, 3-, 6-, and 12-months follow-up) in relation to smoking status 12 months after having received a psychological treatment for smoking cessation.

METHOD

The sample was made up of 242 adults who received cognitive-behavioral treatment for smoking cessation (64.4% women; mean age=41.71 years). The BDI-II was used to assess depressive symptomatology. Participants were classified into three groups according to smoking status at 12-months follow-up (abstainers, relapsers, and smokers).

RESULTS

There were no significant differences in depressive symptoms among the three groups at pretreatment. At the end of treatment, abstainers and relapsers presented less depressive symptomatology than smokers. At follow-up, abstainers continued to present less depressive symptomatology than smokers, whereas in relapsers, symptoms began to increase as the relapses occurred. Regarding the evolution of depressive symptomatology, the abstainer and relapser groups showed a significant reduction at the end of treatment. Only in the group of abstainers did the decrease continue during 12 months follow-up.

LIMITATIONS

The decrease of the initial sample size from 562 to 242 participants. Variables such as self-esteem and self-efficacy were not assessed.

CONCLUSIONS

Smoking cessation is associated with a decrease in depressive symptomatology, that is maintained over time. In contrast, relapse is associated with an increase of such symptoms. These findings signify the potential importance of addressing depressive symptomatology in smoking cessation treatment.

Cigarette smoking and the onset and persistence of depression among adults in the United States: 1994-2005

BACKGROUND

The present study investigated the relationship between daily cigarette smoking and risk of onset and persistence of major depressive disorder (MDD) over a 10-year period among adults in the United States and whether successful smoking cessation reduced the risk for MDD.

METHOD

Data were drawn from the Midlife Development in the United States Survey (MIDUS; n=2101) Waves I and II. Logistic regressions were used to investigate the relations between smoking and the onset and persistence of MDD, adjusting for demographic characteristics and substance use problems.

RESULTS

Daily smoking in 1994 [OR=1.9 (1.2-3.2)] and persistent daily smoking (in 1994 and 2005) [OR=2.2 (1.3-3.7)] were both associated with a significantly increased likelihood of MDD in 2005. Additionally, abstinence, compared to daily smoking, for more than 10years significantly reduced the risk of MDD in 2005 [OR=0.5 (0.3-0.87)] and persistent MDD in 1994 and 2005; [OR=0.5 (0.3-0.87)].

CONCLUSIONS

Findings from this study provide new insights into the role of smoking in the onset and persistence of MDD. Namely, among those in mid-adulthood, smoking is associated with greater MDD risk and quitting may help to reduce such risk. These results suggest that there may be merit in targeting smoking to reduce the risk of MDD and the mental health benefits of quitting smoking in the form of reduced risk of MDD could usefully be added to common information listed as reasons to quit.

Depression and anxiety symptoms moderate the relation between negative reinforcement smoking outcome expectancies and nicotine dependence

OBJECTIVE

Smoking reinforcement expectancies-expectations that smoking modulates mood-can be powerful motivators to smoke, resulting in increased nicotine dependence. The impact of smoking reinforcement expectancies on nicotine dependence may be particularly strong in individuals with increased mood or anxiety symptoms because they may be more likely to act on expectancies with smoking behavior in order to offset their affective symptoms. This study examined levels of emotional symptom dimensions as moderators of the relation between positive and negative smoking reinforcement expectancies and nicotine dependence severity in a community sample.

METHOD

In a cross-sectional design, 317 daily cigarette smokers (215 men) completed self-report measures of smoking reinforcement expectancies, mood and anxiety symptoms, and nicotine dependence.

RESULTS

Increasing levels of negative affect and anxiety symptoms strengthened associations between negative reinforcement smoking expectancies and nicotine dependence severity (moderation effects; (βs > .13; ps < .03) but did not moderate relations between positive reinforcement expectancies and dependence. Anhedonia did not moderate relations involving either positive or negative reinforcement smoking expectancies.

CONCLUSIONS

Distinct components of anxiety and depressive symptoms interact differently with smoking reinforcement expectancies. Emotional symptoms characterized by excesses in aversive (but not deficits in appetitive) functioning may amplify tendencies to compulsively act on negative reinforcement expectancies by smoking. Cessation treatments that target negative reinforcement expectancies may be particularly salient for emotionally distressed smokers.

Depression status as a predictor of quit success in a real-world effectiveness study of nicotine replacement therapy

To provide population-level evidence of the role of current depression on smoking cessation treatment success, we conducted a secondary analysis of data obtained from a large cessation study conducted in over 13,000 smokers. On the basis of self-reported history of depression diagnoses at baseline, participants were divided into four mutually exclusive groups: current/recent depression, recurrent depression, past depression and no depression history. Cessation outcomes were compared among the four groups at 6-month follow-up. Of the 6261 individuals who were consented and attempted to be contacted for follow-up, 4648 (74.2%) had no diagnostic history of depression, 591 (9.4%) had a past history of depression, 759 (12.1%) had a current/recent depression diagnoses, and 263 (4.2%) had recurrent depression (both current and history). Those with recurrent depression were significantly less likely to quit smoking compared to those with no history of depression. In unadjusted analyses, recurrent depression was associated with significantly lower odds of quitting compared to those with either no history or a past history of depression. Current/recent depression was also associated with poorer quit outcomes compared to those with no history of depression. Depressed smokers may benefit from more individualized, in-person approaches to smoking cessation.

Positive Psychotherapy for Smoking Cessation: A Pilot Randomized Controlled Trial

OBJECTIVE

Greater depressive symptoms and low positive affect (PA) are associated with poor smoking cessation outcomes. Smoking cessation approaches that incorporate a focus on PA may benefit smokers trying to quit. The purpose of this study was to conduct a pilot randomized clinical trial to compare standard smoking cessation treatment (ST) with smoking cessation treatment that targets positive affect, termed positive psychotherapy for smoking cessation (PPT-S).

METHOD

Smokers who were seeking smoking cessation treatment were assigned by urn randomization to receive, along with 8 weeks of nicotine replacement therapy, either ST (n = 31) or PPT-S (n = 35). Seven-day point prevalence smoking abstinence was biochemically confirmed at 8, 16, and 26 weeks.

RESULTS

Compared to ST, a greater percentage of participants in PPT-S were abstinent at 8 weeks, 16 weeks, and 26 weeks, but these differences were nonsignificant. In a more statistically powerful longitudinal model, participants in PPT-S had a significantly higher odds of abstinence (adjusted odds ratio [AOR] = 2.75; 95% CI = 1.02, 7.42; p = .046) across follow-ups compared to those in ST. The positive effect of PPT-S was stronger for those higher in PA (OR = 6.69, 95% CI = 1.16, 38.47, p = .03). Greater use of PPT-S strategies during the initial 8 weeks of quitting was associated with a less steep decline in smoking abstinence rates over time (OR = 2.64, 95% CI = 1.06, 6.56, p =.04).

CONCLUSION

This trial suggests substantial promise for incorporating PPT into smoking cessation treatment.

Smoking processes, panic, and depressive symptoms among treatment-seeking smokers

OBJECTIVES

The present study evaluated the relative contribution of panic and depressive symptoms in relation to past cessation difficulties and smoking motives among treatment-seeking daily smokers.

METHODS

The sample included 392 treatment-seeking daily smokers (47.07% female; Mage = 35.48; SD = 13.56), who reported smoking an average of 10 or more cigarettes daily for at least one year.

RESULTS

Findings indicated that panic and depressive symptoms were significantly associated with quit problems as well as addictive and negative affect motives for smoking. However, depressive symptoms were not associated with habitual smoking motives.

CONCLUSIONS

Differential patterns of associations with smoking-based processes imply that although panic and depression are related, there are important distinctions. Such data highlight the need for additional research to examine the putative role of panic and depressive symptoms in relation to smoking behaviors to further elucidate the mechanisms through which panic, depression, and smoking impact one another.

The Role of Depression in the Uptake and Maintenance of Cigarette Smoking

Cigarette smoking and depression both account for significant morbidity, mortality, and economic burden. The prevalence of both smoking and depression increase across mid-to-late adolescence and show high rates of comorbidity. While little is known about why smoking is disproportionately higher among depressed adolescents than adolescents without depression, emerging research has begun to offer some initial insights. The high rates of comorbidity between depression and smoking emphasize the importance of identifying intervention targets to inform smoking prevention efforts for this high-risk group. Interventions during adolescence may lessen the prevalence of depression-prone adult smokers. Depression is over-represented among adult smokers and contributes to lower smoking cessation rates. Negative mood management and pharmacotherapy have been the central focus of smoking cessation interventions for depression-prone populations to date. Converging lines of research highlight novel smoking cessation targets such as the maintenance of positive mood and reward regulation. Smoking cessation research in depression-prone smokers is critical to identify efficacious treatments that will ultimately decrease the excess smoking burden for this population.

Reward and affective regulation in depression-prone smokers

BACKGROUND

There is a disproportionately high smoking prevalence among individuals who are prone to depression. While depression has been conceptualized as a disorder of dysregulated positive affect and disrupted reward processing, little research has been conducted to determine the role of smoking in these processes among depression-prone smokers.

METHODS

Depression-prone smokers (DP+; n = 34) and smokers not depression-prone (DP-; n = 49) underwent two laboratory sessions, one while smoking abstinent and one while smoking ad libitum, to assess the relative reinforcing value of smoking and reward sensitivity. Using experience sampling methods, participants completed self-report measures of subjective reward, positive affect, and negative affect across 3 days while smoking as usual and 3 days while smoking abstinent.

RESULTS

DP+ were two times more likely to work for cigarette puffs versus money in a progressive ratio, choice task (odds ratio 2.05; 95% confidence interval 1.04 to 4.06, p = .039) compared with DP-. Reward sensitivity as measured by the signal detection task did not yield any significant findings. Mixed models regressions revealed a three-way interaction (depression group, smoking phase, and time) for subjective reward, negative affect, and positive affect. For all three of these outcomes, the slopes for DP- and DP+ differed significantly from each other (ps < .05) and the effect of smoking (versus abstinence) over time was greater for DP+ than DP- smokers (ps < .05).

CONCLUSIONS

These findings indicate that the effects of smoking on reward and positive affect regulation are specific to DP+ smokers and highlight novel targets for smoking cessation treatment in this population.

Effects of sequential fluoxetine and gender on prequit depressive symptoms, affect, craving, and quit day abstinence in smokers with elevated depressive symptoms: a growth curve modeling approach

Although the important roles of postquit affect and withdrawal symptoms in the process of smoking cessation have been well established, little is known about the relations between prequit affective trajectories and cessation outcome on the target quit date (TQD). This study examined whether a 16-week course of fluoxetine initiated 8 weeks prequit ("sequential" fluoxetine) improved TQD abstinence relative to placebo through its effects on prequit depressive symptoms, affect (withdrawal-relevant negative affect, general negative affect, and positive affect), and craving to smoke among 206 smokers with elevated depressed symptoms. The moderating effects of gender were also examined. In total, 83 smokers (40%) failed to achieve abstinence on TQD, with no difference between treatment conditions or gender. Overall structural equation models showed that fluoxetine had significant indirect effects on TQD abstinence through changes in prequit withdrawal-relevant negative affect and craving, but not depressive symptoms. However, multigroup analyses revealed gender differences. Sequential fluoxetine reduced prequit depressive symptoms, withdrawal-relevant negative affect, and craving only among women. Reduction in prequit depressive symptoms and craving among women, and withdrawal-relevant negative affect among men was associated with TQD abstinence. Moreover, exploratory analysis showed negative trend-level indirect effects of fluoxetine on TQD abstinence via increased side effects, regardless of gender. This study demonstrated the importance of considering gender when examining treatment efficacy. Identifying ways to further reduce prequit depressive symptoms and craving for women and withdrawal-relevant negative affect for men whereas alleviating side effects may help smokers with elevated depressed symptoms achieve the first smoking cessation milestone.

Tobacco smoking and mental illness: important considerations

Tobacco smoking is a contributory factor in the death of 50% of individuals who are regular or heavy smokers (The Office of Tobacco Control Ireland defines a regular smoker as someone who smokes 11-20 per day and a heavy smoker as someone who smokes 21 or more cigarettes per day). The World Health Organisation (WHO) regards tobacco smoking as the leading preventable cause of death worldwide. In Ireland, approximately 750,000 people smoke tobacco regularly (23.5% of the population) with 7,000 Irish people dying annually from smoking-related causes. Although there are no exact figures for prevalence rates of smoking in individuals with mental illness in Ireland, international studies unequivocally state that the prevalence of smoking is significantly higher in those with mental illness, with greater nicotine intake and increased prevalence of nicotine dependence also reported. Furthermore people with mental illness experience greater withdrawal symptoms and have lower cessation rates when attempting to stop smoking compared to the general population.

Smoking cessation behaviors among persons with psychiatric diagnoses: results from a population-level state survey

BACKGROUND

Persons with psychiatric illnesses are disproportionally affected by tobacco use, smoking at rates at least twice that of other adults. Intentions to quit are known to be high in this population, but population-level cessation behaviors and attitudes by mental health (MH) diagnosis are not well known.

METHODS

A population-level survey was conducted in 2008 to examine state-level tobacco attitudes and behaviors in Colorado. Respondents were eligible for the study if they had non-missing values for smoking status (n=14,118). Weighted descriptive and multivariate analyses were conducted of smoking prevalence, cessation behaviors, and attitudes toward cessation by MH status and specific diagnosis.

RESULTS

Among respondents with MH diagnoses, smoking was twice as prevalent as among respondents without an MH diagnosis, adjusted for demographic characteristics (adjusted odds ratio 2.2, 95% confidence interval 1.6-3.1). Compared to smokers without an MH diagnosis, those with MH diagnoses were more likely to attempt quitting (58.7% vs. 44.4%, p<0.05), use nicotine replacement therapy more often, and succeed in quitting at similar rates. Smokers with anxiety/PTSD were less likely to quit successfully compared those with other MH diagnoses (0.7% vs. 11.9%, p=0.03).

CONCLUSIONS

This population-level analysis found that smokers with mental illness are more likely than those without mental illness to attempt quitting and to use cessation treatment at similar rates, but those with anxiety are less likely to achieve short-term abstinence. Additional approaches are needed for smokers with mental illness in order to reach and sustain long-term abstinence from smoking.

Antidepressants for smoking cessation

BACKGROUND

There are at least three reasons to believe antidepressants might help in smoking cessation. Firstly, nicotine withdrawal may produce depressive symptoms or precipitate a major depressive episode and antidepressants may relieve these. Secondly, nicotine may have antidepressant effects that maintain smoking, and antidepressants may substitute for this effect. Finally, some antidepressants may have a specific effect on neural pathways (e.g. inhibiting monoamine oxidase) or receptors (e.g. blockade of nicotinic-cholinergic receptors) underlying nicotine addiction.

OBJECTIVES

The aim of this review is to assess the effect and safety of antidepressant medications to aid long-term smoking cessation. The medications include bupropion; doxepin; fluoxetine; imipramine; lazabemide; moclobemide; nortriptyline; paroxetine; S-Adenosyl-L-Methionine (SAMe); selegiline; sertraline; St. John's wort; tryptophan; venlafaxine; and zimeledine.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register which includes reports of trials indexed in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PsycINFO, and other reviews and meeting abstracts, in July 2013.

SELECTION CRITERIA

We considered randomized trials comparing antidepressant medications to placebo or an alternative pharmacotherapy for smoking cessation. We also included trials comparing different doses, using pharmacotherapy to prevent relapse or re-initiate smoking cessation or to help smokers reduce cigarette consumption. We excluded trials with less than six months follow-up.

DATA COLLECTION AND ANALYSIS

We extracted data and assessed risk of bias using standard methodological procedures expected by the Cochrane Collaboration.The main outcome measure was abstinence from smoking after at least six months follow-up in patients smoking at baseline, expressed as a risk ratio (RR). We used the most rigorous definition of abstinence available in each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed-effect model.

MAIN RESULTS

Twenty-four new trials were identified since the 2009 update, bringing the total number of included trials to 90. There were 65 trials of bupropion and ten trials of nortriptyline, with the majority at low or unclear risk of bias. There was high quality evidence that, when used as the sole pharmacotherapy, bupropion significantly increased long-term cessation (44 trials, N = 13,728, risk ratio [RR] 1.62, 95% confidence interval [CI] 1.49 to 1.76). There was moderate quality evidence, limited by a relatively small number of trials and participants, that nortriptyline also significantly increased long-term cessation when used as the sole pharmacotherapy (six trials, N = 975, RR 2.03, 95% CI 1.48 to 2.78). There is insufficient evidence that adding bupropion (12 trials, N = 3487, RR 1.9, 95% CI 0.94 to 1.51) or nortriptyline (4 trials, N = 1644, RR 1.21, 95% CI 0.94 to 1.55) to nicotine replacement therapy (NRT) provides an additional long-term benefit. Based on a limited amount of data from direct comparisons, bupropion and nortriptyline appear to be equally effective and of similar efficacy to NRT (bupropion versus nortriptyline 3 trials, N = 417, RR 1.30, 95% CI 0.93 to 1.82; bupropion versus NRT 8 trials, N = 4096, RR 0.96, 95% CI 0.85 to 1.09; no direct comparisons between nortriptyline and NRT). Pooled results from four trials comparing bupropion to varenicline showed significantly lower quitting with bupropion than with varenicline (N = 1810, RR 0.68, 95% CI 0.56 to 0.83). Meta-analyses did not detect a significant increase in the rate of serious adverse events amongst participants taking bupropion, though the confidence interval only narrowly missed statistical significance (33 trials, N = 9631, RR 1.30, 95% CI 1.00 to 1.69). There is a risk of about 1 in 1000 of seizures associated with bupropion use. Bupropion has been associated with suicide risk, but whether this is causal is unclear. Nortriptyline has the potential for serious side-effects, but none have been seen in the few small trials for smoking cessation.There was no evidence of a significant effect for selective serotonin reuptake inhibitors on their own (RR 0.93, 95% CI 0.71 to 1.22, N = 1594; 2 trials fluoxetine, 1 paroxetine, 1 sertraline) or as an adjunct to NRT (3 trials of fluoxetine, N = 466, RR 0.70, 95% CI 0.64 to 1.82). Significant effects were also not detected for monoamine oxidase inhibitors (RR 1.29, 95% CI 0.93 to 1.79, N = 827; 1 trial moclobemide, 5 selegiline), the atypical antidepressant venlafaxine (1 trial, N = 147, RR 1.22, 95% CI 0.64 to 2.32), the herbal therapy St John's wort (hypericum) (2 trials, N = 261, RR 0.81, 95% CI 0.26 to 2.53), or the dietary supplement SAMe (1 trial, N = 120, RR 0.70, 95% CI 0.24 to 2.07).

AUTHORS' CONCLUSIONS

The antidepressants bupropion and nortriptyline aid long-term smoking cessation. Adverse events with either medication appear to rarely be serious or lead to stopping medication. Evidence suggests that the mode of action of bupropion and nortriptyline is independent of their antidepressant effect and that they are of similar efficacy to nicotine replacement. Evidence also suggests that bupropion is less effective than varenicline, but further research is needed to confirm this finding. Evidence suggests that neither selective serotonin reuptake inhibitors (e.g. fluoxetine) nor monoamine oxidase inhibitors aid cessation.

Positive Psychotherapy for Smoking Cessation: Treatment Development, Feasibility and Preliminary Results

Low positive and high negative affect predict low rates of smoking abstinence among smokers making a quit attempt. Positive Psychotherapy can both increase positive affect and decrease negative affect and therefore may be a useful adjunct to behavioral smoking counseling. The purpose of the present study was to assess the feasibility and acceptability of a Positive Psychotherapy for Smoking Cessation (PPT-S) intervention that integrates standard smoking cessation counseling with nicotine patch and a package of positive psychology interventions. We delivered PPT-S to 19 smokers who were low in positive affect at baseline. Rates of session attendance and satisfaction with treatment were high, and most participants reported using and benefiting from the positive psychology interventions. Almost one-third of participants (31.6%) sustained smoking abstinence for 6 months after their quit date. Future studies to assess the relative efficacy of PPT-S compared to standard smoking cessation treatment are warranted.

Anhedonia, depressed mood, and smoking cessation outcome

OBJECTIVE

Although the relation between lifetime depression and smoking cessation outcome has been well studied, the proposition that different symptomatic expressions of depression exert disparate predictive effects on risk of smoking cessation failure has largely gone uninvestigated. This study analyzed the individual contributions of depression's 2 hallmark affective symptoms, anhedonia (i.e., diminished interest in normally enjoyable activities) and depressed mood (i.e., elevated sadness), to the prediction of smoking cessation outcome.

METHOD

Participants were adult daily smokers (N = 1,469; mean age = 45 years, 58% female, 84% White) enrolled in a smoking cessation treatment study. Lifetime history of anhedonia and depressed mood were classified via structured interview prior to quit day. Seven-day point prevalence smoking abstinence was assessed at 8 weeks and 6 months postquit.

RESULTS

When examined separately, both lifetime anhedonia, OR (95% CI) = 1.42 (1.16, 1.73), p = .004, and depressed mood, OR (95% CI) = 1.35 (1.11, 1.63), p = .002, predicted increased odds of relapse. These relations remained after adjusting for covariates, including lifetime depressive disorder, which did not predict outcome. After controlling for the covariation between lifetime anhedonia and depressed mood, anhedonia predicted cessation outcome, OR (95% CI) = 1.31 (1.05, 1.62), p = .02, while depressed mood did not (p = .19). Symptom duration (>2 weeks), treatment, and substance use disorder did not modify relations of lifetime anhedonia and depressed mood with cessation outcome.

CONCLUSIONS

Results suggest that (1) symptoms of affective disturbance capture depression-relevant risk of cessation failure, which is not adequately demarcated by the lifetime depressive disorder diagnosis, and (2) anhedonia is a more sensitive index of this affective disturbance than depressed mood per se. Clinical attention to anhedonia may facilitate smoking cessation.

Smoking behaviour and mental health disorders--mutual influences and implications for therapy

Tobacco use is strongly associated with a variety of psychiatric disorders. Smokers are more likely than non-smokers to meet current criteria for mental health conditions, such as mood disorders, anxiety disorders and psychosis. Evidence also suggest that smokers with psychiatric disorders may have more difficulty quitting, offering at least a partial explanation for why smoking rates are higher in this population. The mechanisms linking mental health conditions and cigarette smoking are complex and likely differ across each of the various disorders. The most commonly held view is that patients with mental health conditions smoke in an effort to regulate the symptoms associated with their disorder. However some recent evidence suggests that quitting smoking may actually improve mental health symptoms. This is particularly true if the tobacco cessation intervention is integrated into the context of ongoing mental health treatment. In this paper we reviewed and summarized the most relevant knowledge about the relationship between tobacco use and dependence and psychiatric disorders. We also reviewed the most effective smoking cessation strategies available for patients with psychiatric comorbidity and the impact of smoking behavior on psychiatric medication.

Efficacy of sequential use of fluoxetine for smoking cessation in elevated depressive symptom smokers

INTRODUCTION

Fluoxetine, a selective serotonin reuptake inhibitor, was examined in the treatment of smokers with elevated depressive symptoms. Specifically, this randomized, open-label clinical trial was designed to evaluate the efficacy of three logical, real-world alternatives for providing smoking cessation treatment to smokers with elevated depressive symptoms.

METHODS

In a sample of 216 smokers (mean Center for Epidemiological Studies Depression Scale score = 11.41), participants were randomly assigned to (a) transdermal nicotine patch (TNP), beginning on quit date and continuing for 8 weeks thereafter; (b) standard administration of antidepressant pharmacotherapy with fluoxetine (20mg), beginning 2 weeks before quit date and continuing for 8 weeks following quit date + TNP (ST-FLUOX); or (c) sequential administration of fluoxetine (20mg), beginning 8 weeks before quit date and continuing for 8 weeks following quit date + TNP (SEQ-FLUOX). All participants received 5 sessions of brief behavioral smoking cessation treatment.

RESULTS

Findings indicate that SEQ-FLUOX resulted in significantly higher point prevalence abstinence than ST-FLUOX at 6-month follow-up (OR = 2.35; 95% CI = 1.10-5.02, p < .03), a difference that was reduced at the 12-month assessment. Furthermore, sequential fluoxetine treatment, compared with standard fluoxetine treatment, resulted in significantly lower levels of depressive symptoms throughout smoking cessation treatment (p < .025) and significantly lower nicotine withdrawal-related negative affect (p < .004) immediately after quitting.

CONCLUSIONS

Findings suggest that if one is going to prescribe fluoxetine for smoking cessation in smokers with elevated depressive symptoms, it is best to begin prescribing fluoxetine well before the target quit date.

Social support and smoking abstinence among incarcerated adults in the United States: a longitudinal study

BACKGROUND

In the United States, tobacco use among prisoners is nearly three times that of the general population. While many American prisons and jails are now tobacco-free, nearly all inmates return to smoking as soon as they are released back into the community.

METHODS

To better understand the role that personal relationships may play in enabling return to smoking, we enrolled former-smokers who were inmates in a tobacco-free prison. Baseline assessments were conducted six weeks prior to inmates' scheduled release and included measures of smoking prior to incarceration, motivation, confidence and plans for remaining quit after release. We also assessed global social support (ISEL) and a measure of social support specific to quitting smoking (SSQ). Smoking status was assessed three weeks after prison release and included 7-day point-prevalence abstinence validated by urine cotinine, days to first cigarette and smoking rate.

RESULTS

A diverse sample comprised of 35% women, 20% Hispanic, and 29% racial minorities (average age 35.5 years) provided baseline data (n = 247). Over 90% of participants provided follow up data at 3-weeks post-release. Prior to incarceration participants had smoked an average of 21.5 (SD = 11.7) cigarettes per day. Only 29.2% had definite plans to remain smoking-abstinent after release. Approximately half of all participants reported that "most" or "all" of their family (42.2%) and friends (68%) smoked, and 58.8% reported their spouse or romantic partner smoked.SSQ scores were not significantly predictive of smoking outcomes at three weeks, however, social support from family and friends were each significantly and positively correlated with motivation, confidence, and plans for remaining abstinent (all p values <0.05). These smoking-related attitudinal variables were significantly predictive of smoking outcomes (all p values <0.01). General social support (ISEL) was not associated with smoking-related attitudinal variables or smoking outcomes.

CONCLUSIONS

Inmates of smoke-free prisons have a head-start on being smoke-free for life. They have been abstinent well past the duration of nicotine withdrawal and have great financial incentive not to begin smoking again. However, this advantage may be offset by a lack of non-smoking role models among their family and friends, and perceived lack of support for remaining smoke-free.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01684995.

Anhedonia and anxiety sensitivity: prospective relationships to nicotine withdrawal symptoms during smoking cessation

OBJECTIVE

The aim of the present investigation was to explore the main and interactive effects of anhedonic depressive symptoms and anxiety sensitivity in terms of the individual components of nicotine withdrawal symptoms experienced on quit day as well as throughout the initial 14 days of cessation.

METHOD

Participants included 65 daily cigarette smokers (38 women; Mage = 46.08 years, SD = 9.12) undergoing psychosocial-pharmacological cessation treatment.

RESULTS

Results indicated that, after controlling for the effects of participant sex and nicotine dependence, anhedonic depression symptoms, but not anxiety sensitivity, significantly predicted quit day levels of mood-based nicotine withdrawal symptoms. Conversely, anxiety sensitivity, but not anhedonic depression symptoms, was significantly related to the change in most nicotine withdrawal symptoms over time. Finally, our results revealed a significant interaction between anxiety sensitivity and anhedonic depression symptoms related to the slope of certain withdrawal symptoms over time. Specifically, among participants with higher levels of anxiety sensitivity, greater levels of anhedonic depression symptoms were related to greater increases in withdrawal symptoms over time for two of the nine anxiety-relevant components of nicotine withdrawal (restlessness and frustration).

CONCLUSIONS

Among high anxiety-sensitivity persons, compared with those low in anxiety sensitivity, anhedonic depression symptoms may be more relevant to the experience of some withdrawal symptoms being more intense and persistent during the early phases of quitting.

Two decades of smoking cessation treatment research on smokers with depression: 1990-2010

INTRODUCTION

Adults with depression smoke at higher rates than other adults leaving a large segment of this population, who already incur increased health-related risks, vulnerable to the enormous harmful consequences of smoking. Yet, the impact that depression has on smoking cessation is not clear due to the mixed results of past research. The primary aims of this review were to synthesize the research examining the relationship of depression to smoking cessation outcomes over a 20-year period, to examine the gender and racial composition of these studies, and to identify directions for future research.

METHODS

Potential articles published between January 1, 1990 and December 31, 2010 were identified through a MEDLINE search of the terms "clinical trial," "depression," and "smoking cessation." 68 studies used all three terms and met the inclusion criteria.

RESULTS

The majority of studies examined either a past diagnosis of major depression or current depression symptoms. Within the few studies that examined the interaction of gender and depression on smoking cessation, depression had a greater impact on treatment outcomes for women than men. No study reported examining the interactive impact of race and depression on treatment outcomes.

CONCLUSIONS

Although attention to the relationship of depression and smoking cessation outcomes has increased over the past 20 years, little information exists to inform a treatment approach for smokers with Current Major Depressive Disorder, Dysthymia, and Minor Depression and few studies report gender and racial differences in the relationship of depression and smoking cessation outcomes, thus suggesting major areas for targeted research.

Tobacco use and nicotine dependence among conflict-affected men in the Republic of Georgia

Background: There is very little evidence globally on tobacco use and nicotine dependence among civilian populations affected by armed conflict, despite key vulnerability factors related to elevated mental disorders and socio-economic stressors. The study aim was to describe patterns of smoking and nicotine dependence among conflict-affected civilian men in the Republic of Georgia and associations with mental disorders. Methods: A cross-sectional household survey using multistage random sampling was conducted in late 2011 among conflict-affected populations in Georgia. Respondents included in this paper were 1,248 men aged ≥18 years who were internally displaced persons (IDPs) and former IDPs who had returned in their home areas. Outcomes of current tobacco use, heavy use (≥20 cigarettes per day), and nicotine dependence (using the Fagerström Test for Nicotine Dependence) were used. PTSD, depression, anxiety and hazardous alcohol use were also measured, along with exposure to traumatic events and a range of demographic and socio-economic characteristics. Results: Of 1,248 men, 592 (47.4%) smoked and 70.9% of current smokers were heavy smokers. The mean nicotine dependence score was 5.0 and the proportion with high nicotine dependence (≥6) was 41.4%. In multivariate regression analyses, nicotine dependence was significantly associated with PTSD (β 0.74) and depression (β 0.85), along with older age (except 65+ years), and being a returnee (compared to IDPs). Conclusions: The study reveals very high levels of heavy smoking and nicotine dependence among conflict-affected persons in Georgia. The associations between nicotine dependence, PTSD and depression suggest interventions could yield synergistic benefits.

Past major depression and smoking cessation outcome: a systematic review and meta-analysis update

AIMS

To update our prior meta-analysis that showed past major depression (MD+) to be unrelated to smoking cessation outcome.

METHODS

Eligible trials included 14 from our original review and 28 identified through an updated systematic review (2000-2009). We coded for assessment of past MD, exclusion for recent MD episode (MDE; ≤6 months versus no exclusion), duration/modality of cognitive behavioral treatment (CBT; face-to-face versus self-help) and other factors. To minimize influence of experimental treatments that may selectively benefit MD+ smokers we analyzed placebo/lowest intensity control arms only. Study-specific ORs for the effect of past MD on short-term (≤3 months) and long-term (≥6 months) abstinence were estimated and combined using random effects. Two-way interaction models of past MD with study methodology and treatment factors were used to evaluate hypothesized moderators of the past MD-abstinence association.

RESULTS

MD+ smokers had 17% lower odds of short-term abstinence (n = 35, OR = 0.83, 95% CI = 0.72-0.95, P = 0.009) and 19% lower odds of long-term abstinence (n = 38, OR = 0.81, 95% CI = 0.67-0.97, P = 0.023) than MD- smokers after excluding the sole study of varenicline because of its antidepressant properties. The association between past MD and abstinence was affected by methodological (recent MDE exclusion, type of MD assessment) and treatment (CBT modality) factors.

CONCLUSIONS

Past major depression has a modest adverse effect on abstinence during and after smoking cessation treatment. An increased focus on the identification of effective treatments or treatment adaptations that eliminate this disparity in smoking cessation for MD+ smokers is needed.

Smoking cessation in pregnant women with mental disorders: a cohort and nested qualitative study

OBJECTIVE

To investigate whether 1) pregnant smokers with mental disorders are less likely to accept referrals to smoking cessation services compared with pregnant smokers without disorders; 2) they experience specific barriers to smoking cessation.

DESIGN

Cohort study supplemented by cross-sectional survey and nested qualitative study.

SETTING

Three maternity services, London, UK.

POPULATION

Pregnant smokers with and without mental disorders.

METHODS

Case notes were examined on a cohort of 400 consecutive pregnant smokers; data were triangulated with routinely collected data on 845 pregnant smokers at two other sites; 27 pregnant smokers were interviewed using qualitative methods.

MAIN OUTCOME MEASURES

Acceptance of referral to smoking cessation services; perceived barriers to quitting.

RESULTS

Pregnant smokers with a mental disorder recorded by midwives were one-quarter of the cohort (97, 23%), were more likely to accept referral to smoking cessation services (69% versus 56%, adjusted odds ratio 1.70, 95% confidence interval 1.03-2.79), but more likely to still smoke at delivery (69% versus 56%, adjusted odds ratio 2.63, 95% confidence interval 1.41-4.92). Discussion about smoking was documented in 7.7% of subsequent antenatal visits in women with or without mental disorders. Pregnant smokers with diagnosed mental disorders reported that they and health practitioners did not prioritise smoking advice because of concern about adversely impacting mental health.

CONCLUSIONS

Pregnant women with mental disorders appear more motivated, yet find it more difficult, to stop smoking. Prioritisation of mental health over smoking may therefore lead to increasing health inequality for this group. Research into effective smoking cessation interventions is required for those with mental disorders.

Interventions for tobacco smoking

Around 19% of US adults smoke cigarettes, and smoking remains the leading avoidable cause of death in this country. Without treatment only ~5% of smokers who try to quit achieve long-term abstinence, but evidence-based cessation treatment increases this figure to 10% to 30%. The process of smoking cessation comprises different pragmatically defined phases, and these can help guide smoking treatment development and evaluation. This review evaluates the effectiveness of smoking interventions for smokers who are unwilling to make a quit attempt (motivation phase), who are willing to make a quit attempt (cessation phase), who have recently quit (maintenance phase), and who have recently relapsed (relapse recovery phase). Multiple effective treatments exist for some phases (cessation), but not others (relapse recovery). A chronic care approach to treating smoking requires effective interventions for every phase, especially interventions that exert complementary effects both within and across phases and that can be disseminated broadly and cost-effectively.

The relationship of major depressive disorder and gender to changes in smoking for current and former smokers: longitudinal evaluation in the US population

AIMS

Although depression and smoking are correlated highly, the relationship of major depressive disorder (MDD) to smoking cessation and relapse remains unclear. This study compared changes in smoking for current and former smokers with and without current and life-time MDD over a 3-year period.

DESIGN

Analysis of two waves of longitudinal data from the National Institute on Alcohol Abuse and Alcoholism's National Epidemiologic Survey on Alcohol and Related Conditions (wave 1, 2001-02; wave 2, 2004-05).

SETTING

Data were collected through face-to-face interviews from non-institutionalized United States civilians, aged 18 years and older, in 50 states and the District of Columbia.

PARTICIPANTS

A total of 11 973 adults (54% male) classified as current or former daily smokers at wave 1 and completed wave 2.

MEASUREMENTS

Classification as current or former smokers at wave 1 and wave 2.

FINDINGS

Smoking status remained stable for most participants. Wave 1 current daily smokers with current MDD [odds ratio (OR) = 1.38, 95% confidence interval (CI): 1.03, 1.85] and life-time MDD (OR = 1.52, 95% CI: 1.15, 2.01) were more likely than those without the respective diagnosis to report continued smoking at wave 2. Wave 1 former daily smokers with current MDD (OR = 0.44, 95% CI: 0.26, 0.76) were less likely to report continued abstinence at wave 2. None of the gender × MDD diagnosis interactions were significant. Patterns of results remained similar when analyses were limited to smokers with nicotine dependence.

CONCLUSIONS

Current and life-time major depressive disorders are associated with a lower likelihood of quitting smoking and current major depressive disorder is associated with greater likelihood of smoking relapse.

Isolating the role of psychological dysfunction in smoking cessation: relations of personality and psychopathology to attaining cessation milestones

Research exploring psychological dysfunction as a predictor of smoking cessation success may be limited by nonoptimal predictor variables (i.e., categorical psychodiagnostic measures vs. continuous personality-based manifestations of dysfunction) and imprecise outcomes (i.e., summative point-prevalence abstinence vs. constituent cessation milestone measures). Accordingly, this study evaluated the unique and overlapping relations of broad-spectrum personality traits (positive emotionality, negative emotionality, and constraint) and past-year psychopathology (anxiety, mood, and substance use disorder) to point-prevalence abstinence and three smoking cessation milestones: (a) initiating abstinence, (b) first lapse, and (c) transition from lapse to relapse. Participants were daily smokers (N = 1365) enrolled in a smoking cessation treatment study. In single-predictor regression models, each manifestation of internalizing dysfunction (lower positive emotionality, higher negative emotionality, and anxiety and mood disorder) predicted failure at one or more cessation milestone(s). In simultaneous predictor models, lower positive and higher negative emotionality significantly predicted failure to achieve milestones after controlling for psychopathology. Psychopathology did not predict any outcome when controlling for personality. Negative emotionality showed the most robust and consistent effects, significantly predicting failure to initiate abstinence, earlier lapse, and lower point-prevalence abstinence rates. Substance use disorder and constraint did not predict cessation outcomes, and no single variable predicted lapse-to-relapse transition. These findings suggest that personality-related manifestations of internalizing dysfunction are more accurate markers of affective sources of relapse risk than mood and anxiety disorders. Further, individuals with high trait-negative emotionality may require intensive intervention to promote the initiation and early maintenance of abstinence.

Smoking cessation interventions for patients with depression: a systematic review and meta-analysis

OBJECTIVES

We conducted a systematic literature review of smoking cessation interventions for patients with histories of depressive disorders or current significant depressive symptoms. We examined the comparative effectiveness of smoking cessation strategies on abstinence rates, differential effects of cessation strategies by depression status (i.e., history positive vs. current depression), and differential effects by gender.

DATA SOURCES

Peer-reviewed literature in MEDLINE, Embase, PsycINFO, and Cochrane Library.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

Randomized controlled trials or secondary analysis of RCT data comparing two or more smoking cessation interventions or intervention to control, and reporting cessation outcomes in adults with depression.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two trained researchers screened articles for inclusion. When possible, we estimated pooled risk ratios with 95% confidence intervals by using a random effects model with the Mantel-Haenszel method. We synthesized other studies qualitatively. We classified each intervention as antidepressants, nicotine replacement therapy (NRT), brief smoking cessation counseling, smoking cessation behavioral counseling, or behavioral mood management.

RESULTS

We identified 16 unique RCTs, of which, only three trials recruited participants with current depression. Meta-analysis demonstrated a small, positive effect of adding behavioral mood management (RR = 1.41, 95% CI 1.01-1.96). All included antidepressant trials showed small, positive effects, but risk ratio summary was not significant (RR = 1.31, 95% CI 0.73-2.34). Three NRT trials demonstrated small, positive effects on smoking cessation rates. We found insufficient evidence to examine gender and depression status moderator effects.

LIMITATIONS

Few RCTs exist that test smoking cessation interventions among adults with depression. To make meaningful comparisons, we created broad intervention categories that contained heterogeneity.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Few trials enrolled smokers with current depression. Most of data identified were from subgroup analyses of patients history-positive for depression. However, several promising interventions exist. Healthcare providers should consider encouraging their patients with significant depressive symptoms or depression histories to seek smoking cessation services that include NRT and behavioral mood management.