Effect of depressive symptoms on smoking abstinence and treatment adherence among smokers with a history of alcohol dependence

Validation of the food craving Acceptance and action questionnaire (FAAQ) in a weight loss-seeking sample

OBJECTIVE

The Food Craving Acceptance and Action Questionnaire (FAAQ) was developed to measure psychological flexibility around food-related internal experiences (e.g., thoughts, feelings, urges) and has two subscales, acceptance and willingness. However, the FAAQ factor structure has not yet been systematically validated with a clinically relevant sample.

METHODS

Two weight-loss treatment seeking samples (total N = 462; 80.4% female) ages 18 to 70 (M = 52.6, SD = 9.8) completed the FAAQ before and after group-based treatment of overweight or obesity.

RESULTS

Confirmatory factor analysis on the FAAQ's previously observed two-factor model produced poor model fit. An alternative 7-item model removing specific items that contributed to poor fit and were conceptually relevant to remove provided good model fit. The resulting revised 7-item FAAQ (items 1,3,6 removed) had adequate internal consistency and significant predictive validity for the Total score and subscales, and showed initial construct validity for the Total score.

CONCLUSIONS

Results from this study suggest researchers and clinicians should now use the 7-item FAAQ-II, which retains the Willingness and Acceptance subscales. Future research is needed with other relevant samples to confirm the FAAQ-II's factor structure and psychometric properties.

Psychological interventions for co-occurring depression and substance use disorders

BACKGROUND

Comorbid depression and substance use disorders are common and have poorer outcomes than either disorder alone. While effective psychological treatments for depression or substance use disorders are available, relatively few randomised controlled trials (RCTs) have examined the efficacy of these treatments in people with these comorbid disorders.

OBJECTIVES

To assess the efficacy of psychological interventions delivered alone or in combination with pharmacotherapy for people diagnosed with comorbid depression and substance use disorders.

SEARCH METHODS

We searched the following databases up to February 2019: Cochrane Central Register of Controlled Trials, PubMed, Embase, CINAHL, Google Scholar and clinical trials registers. All systematic reviews identified, were handsearched for relevant articles.

SELECTION CRITERIA

The review includes data from RCTs of psychological treatments for people diagnosed with comorbid depression and substance use disorders, using structured clinical interviews. Studies were included if some of the sample were experiencing another mental health disorder (e.g. anxiety); however, studies which required a third disorder as part of their inclusion criteria were not included. Studies were included if psychological interventions (with or without pharmacotherapy) were compared with no treatment, delayed treatment, treatment as usual or other psychological treatments.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Seven RCTs of psychological treatments with a total of 608 participants met inclusion criteria. All studies were published in the USA and predominately consisted of Caucasian samples. All studies compared different types of psychological treatments. Two studies compared Integrated Cognitive Behavioural Therapy (ICBT) with Twelve Step Facilitation (TSF), another two studies compared Interpersonal Psychotherapy for Depression (IPT-D) with other treatment (Brief Supportive Therapy (BST) or Psychoeducation). The other three studies compared different types or combinations of psychological treatments. No studies compared psychological interventions with no treatment or treatment as usual control conditions. The studies included a diverse range of participants (e.g. veterans, prisoners, community adults and adolescents). All studies were at high risk of performance bias, other main sources were selection, outcome detection and attrition bias. Due to heterogeneity between studies only two meta-analyses were conducted. The first meta-analysis focused on two studies (296 participants) comparing ICBT to TSF. Very low-quality evidence revealed that while the TSF group had lower depression scores than the ICBT group at post-treatment (mean difference (MD) 4.05, 95% confidence interval (CI) 1.43 to 6.66; 212 participants), there was no difference between groups in depression symptoms (MD 1.53, 95% CI -1.73 to 4.79; 181 participants) at six- to 12-month follow-up. At post-treatment there was no difference between groups in proportion of days abstinent (MD -2.84, 95% CI -8.04 to 2.35; 220 participants), however, the ICBT group had a greater proportion of days abstinent than the TSF group at the six- to 12-month follow-up (MD 10.76, 95% CI 3.10 to 18.42; 189 participants). There were no differences between the groups in treatment attendance (MD -1.27, 95% CI -6.10 to 3.56; 270 participants) or treatment retention (RR 0.95, 95% CI 0.72 to 1.25; 296 participants). The second meta-analysis was conducted with two studies (64 participants) comparing IPT-D with other treatment (Brief Supportive Psychotherapy/Psychoeducation). Very low-quality evidence indicated IPT-D resulted in significantly lower depressive symptoms at post-treatment (MD -0.54, 95% CI -1.04 to -0.04; 64 participants), but this effect was not maintained at three-month follow-up (MD 3.80, 95% CI -3.83 to 11.43) in the one study reporting follow-up outcomes (38 participants; IPT-D versus Psychoeducation). Substance use was examined separately in each study, due to heterogeneity in outcomes. Both studies found very low-quality evidence of no significant differences in substance use outcomes at post-treatment (percentage of days abstinent, IPD versus Brief Supportive Psychotherapy; MD -2.70, 95% CI -28.74 to 23.34; 26 participants) or at three-month follow-up (relative risk of relapse, IPT-D versus Psychoeducation; RR 0.67, 95% CI 0.30 to 1.50; 38 participants). There was also very low-quality evidence for no significant differences between groups in treatment retention (RR 1.00, 95% CI 0.81 to 1.23; 64 participants). No adverse events were reported in any study.

AUTHORS' CONCLUSIONS

The conclusions of this review are limited due to the low number and very poor quality of included studies. No conclusions can be made about the efficacy of psychological interventions (delivered alone or in combination with pharmacotherapy) for the treatment of comorbid depression and substance use disorders, as they are yet to be compared with no treatment or treatment as usual in this population. In terms of differences between psychotherapies, although some significant effects were found, the effects were too inconsistent and small, and the evidence of too poor quality, to be of relevance to practice.

Predictors of reduced smoking quantity among recovering alcohol dependent men in a smoking cessation trial

INTRODUCTION

Adults with alcohol dependence (AD) have exceptionally high smoking rates and poor smoking cessation outcomes. Discovery of factors that predict reduced smoking among AD smokers may help improve treatment. This study examined baseline predictors of smoking quantity among AD smokers in a pharmacotherapy trial for smoking cessation.

METHODS

The sample includes male, AD smokers (N = 129) with 1-32 months of alcohol abstinence who participated in a 12-week trial of medication (topiramate vs. placebo) and adjunct counseling with 6 months of follow-up. Baseline measures of nicotine dependence, AD severity, psychopathology, motivation to quit smoking, and smoking-related cognitions were used to predict smoking quantity (cigarettes per day) at post-treatment and follow-up.

RESULTS

Overall, the sample had statistically significant reductions in smoking quantity. Greater nicotine dependence (Incidence rate ratios (IRRs) = 0.82-0.90), motivation to quit (IRRs = 0.65-0.85), and intrinsic reasons for quitting (IRRs = 0.96-0.98) predicted fewer cigarettes/day. Conversely, greater lifetime AD severity (IRR = 1.02), depression severity (IRRs = 1.05-1.07), impulsivity (IRRs = 1.01-1.03), weight-control expectancies (IRRs = 1.10-1.15), and childhood sexual abuse (IRRs = 1.03-1.07) predicted more cigarettes/day.

CONCLUSIONS

Smokers with AD can achieve large reductions in smoking quantity during treatment, and factors that predict smoking outcomes in the general population also predict greater smoking reductions in AD smokers. Treatment providers can use severity of nicotine dependence and AD, motivation to quit, smoking-related cognitions, and severity of depression to guide treatment and improve outcomes among AD smokers.

Assessment of factors related to smokers' adherence to a short-term support group for smoking cessation: a longitudinal study in a developing country

Objective:

The aim of this study was to determine which individual characteristics of smokers are associated with their adherence to a support group for smoking cessation.

Methods:

Smokers from Porto Alegre, Brazil, were invited to participate in a support group for smoking cessation consisting of four weekly sessions. Demographic data, smoking history, presence of tobacco-related diseases, severity of nicotine dependence, stage of motivation, and symptoms of anxiety and depression were evaluated at baseline. Adherence was defined as attendance at group sessions and was measured at the second and fourth sessions of the program.

Results:

The study recruited 167 smokers who attended the first meeting and met criteria for admission to the study. One hundred and two of the participants returned to the second session and only 55 of those who attended the first meeting completed the four-week program. For immediate adherence (second session), adult smokers over the age of 35 were more likely to adhere to the treatment (p = 0.004), whereas smoking higher numbers of cigarettes per day was associated with lower adherence to attendance at group meetings (p = 0.031). For final adherence (fourth session), only minimal level symptoms of anxiety were associated with a higher likelihood of adherence (p = 0.02).

Conclusions:

Older smokers, those who smoked fewer cigarettes per day, and those with lower levels of anxiety exhibited higher rates of adherence to a smoking cessation support group.

Group behaviour therapy programmes for smoking cessation

BACKGROUND

Group therapy offers individuals the opportunity to learn behavioural techniques for smoking cessation, and to provide each other with mutual support.

OBJECTIVES

To determine the effect of group-delivered behavioural interventions in achieving long-term smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register, using the terms 'behavior therapy', 'cognitive therapy', 'psychotherapy' or 'group therapy', in May 2016.

SELECTION CRITERIA

Randomized trials that compared group therapy with self-help, individual counselling, another intervention or no intervention (including usual care or a waiting-list control). We also considered trials that compared more than one group programme. We included those trials with a minimum of two group meetings, and follow-up of smoking status at least six months after the start of the programme. We excluded trials in which group therapy was provided to both active therapy and placebo arms of trials of pharmacotherapies, unless they had a factorial design.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data in duplicate on the participants, the interventions provided to the groups and the controls, including programme length, intensity and main components, the outcome measures, method of randomization, and completeness of follow-up. The main outcome measure was abstinence from smoking after at least six months follow-up in participants smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically-validated rates where available. We analysed participants lost to follow-up as continuing smokers. We expressed effects as a risk ratio for cessation. Where possible, we performed meta-analysis using a fixed-effect (Mantel-Haenszel) model. We assessed the quality of evidence within each study and comparison, using the Cochrane 'Risk of bias' tool and GRADE criteria.

MAIN RESULTS

Sixty-six trials met our inclusion criteria for one or more of the comparisons in the review. Thirteen trials compared a group programme with a self-help programme; there was an increase in cessation with the use of a group programme (N = 4395, risk ratio (RR) 1.88, 95% confidence interval (CI) 1.52 to 2.33, I2 = 0%). We judged the GRADE quality of evidence to be moderate, downgraded due to there being few studies at low risk of bias. Fourteen trials compared a group programme with brief support from a health care provider. There was a small increase in cessation (N = 7286, RR 1.22, 95% CI 1.03 to 1.43, I2 = 59%). We judged the GRADE quality of evidence to be low, downgraded due to inconsistency in addition to risk of bias. There was also low quality evidence of benefit of a group programme compared to no-intervention controls, (9 trials, N = 1098, RR 2.60, 95% CI 1.80 to 3.76 I2 = 55%). We did not detect evidence that group therapy was more effective than a similar intensity of individual counselling (6 trials, N = 980, RR 0.99, 95% CI 0.76 to 1.28, I2 = 9%). Programmes which included components for increasing cognitive and behavioural skills were not shown to be more effective than same-length or shorter programmes without these components.

AUTHORS' CONCLUSIONS

Group therapy is better for helping people stop smoking than self-help, and other less intensive interventions. There is not enough evidence to evaluate whether groups are more effective, or cost-effective, than intensive individual counselling. There is not enough evidence to support the use of particular psychological components in a programme beyond the support and skills training normally included.

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.

A new look at the science of weight control: how acceptance and commitment strategies can address the challenge of self-regulation

The current manuscript proposes an acceptance-based, self-regulation framework for understanding the challenge of weight maintenance and describes how this framework can be integrated into the behavioral treatment of obesity. According to this framework, intrinsic drives to consume palatable, high-calorie food interact with a modern environment in which high calorie foods are easily accessible. This combination produces a chronic desire to eat unhealthy foods that exists in opposition to individuals' weight control goals. Similarly, low energy expenditure requirements reduce physical activity. We suggest that individuals vary in their responsivity to cues that motivate overeating and sedentary behavior, and that those higher in responsivity need specialized self-regulatory skills to maintain healthy eating and exercise behaviors. These skills include an ability to tolerate uncomfortable internal reactions to triggers and a reduction of pleasure, behavioral commitment to clearly-defined values, and metacognitive awareness of decision-making processes. So-called "acceptance-based" interventions based on these skills have so far proven efficacious for weight control, especially for those who are the most susceptible to eating in response to internal and external cues (as predicted by the model). Despite the current empirical support for the postulated model, much remains to be learned including whether acceptance-based interventions will prove efficacious in the longer-term.

Measuring the Ability to Tolerate Activity-Related Discomfort: Initial Validation of the Physical Activity Acceptance Questionnaire (PAAQ)

BACKGROUND

Physical activity (PA) is essential for health, but many adults find PA adherence challenging. Acceptance of discomfort related to PA may influence an individual's ability to begin and sustain a program of exercise. The aim of this study was to evaluate the psychometric properties of the Physical Activity Acceptance Questionnaire (PAAQ).

METHODS

The PAAQ was administered to 3 distinct samples (N = 418). Each sample completed additional self-report measures; 1 sample also wore accelerometers for 7 days (at baseline and 6 months later).

RESULTS

The PAAQ demonstrated high internal validity for its total score (α = .89) and 2 subscales (Cognitive Acceptance α = .86, Behavioral Commitment α = .85). The PAAQ also showed convergent validity with measures of mindfulness, self-reported physical activity levels, and accelerometer-verified levels of moderate-to-vigorous PA (MVPA; P-values < .05). The Cognitive Acceptance subscale showed predictive validity for objectively-verified PA levels among individuals attempting to increase PA over 6 months (P = .05). Test-retest reliability for a subset of participants (n = 46) demonstrated high consistency over 1 week (P < .0001).

CONCLUSIONS

The PAAQ demonstrates sound psychometric properties, and shows promise for improving the current understanding of PA facilitators and barriers among adults.

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.

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.

Mood management intervention for college smokers with elevated depressive symptoms: a pilot study

OBJECTIVE

This pilot study examined smoking reduction and cessation among college smokers with elevated depressive symptomatology participating in a group-based behavioral counseling, mood management, and motivational enhancement combined intervention (CBT).

PARTICIPANTS AND METHODS

Fifty-eight smokers (smoked 6 days in the past 30) were randomized to 6 sessions of CBT (n = 29) or a nutrition-focused attention-matched control group (CG; n = 29).

RESULTS

Relative to CG participants, significantly more CBT participants reduced smoking intensity by 50% (χ(2)[1, N = 58] = 4.86, p = .028) at end of treatment. Although CBT participants maintained smoking reductions at 3- and 6-month follow-up, group differences were no longer significant. No group differences in cessation emerged. Finally, participants in both groups evidenced increased motivation to reduce smoking at end of treatment (F[1, 44] = 11.717, p = .001, η(p)(2) = .207).

CONCLUSIONS

Findings demonstrate the utility of this intervention for smoking reduction and maintenance of reductions over time among a population of college students with elevated depressive symptomatology.

The development and validation of the food craving acceptance and action questionnaire (FAAQ)

Research has suggested that mindfulness and acceptance may be important factors in the development, maintenance and treatment of both obesity and eating disorders. However, very few scales exist that apply constructs of acceptance and mindfulness to eating behavior. A measure of acceptance about food related thoughts would be especially beneficial in investigating links between acceptance and problematic eating, and in better understanding mechanisms of action of effective treatments for obesity and eating disorders. The Food Acceptance and Awareness Questionnaire (FAAQ) was developed to measure acceptance of urges and cravings to eat or the extent to which individuals might try to control or change these thoughts. The FAAQ is a self-report questionnaire made up of ten items each rated on a seven-point Likert scale (1=very seldom true to 6=always true). Higher scores indicate greater acceptance of motivations to eat. The FAAQ was given to a sample of 463 undergraduate students along with several other measures of eating behavior and other psychological variables. Concurrent associations with variables theorized to be closely linked (Eating Attitudes Test, EAT; the Dutch Eating Behavior Questionnaire, DEBQ; body mass index, BMI) and not very closely linked (the Depression Anxiety Stress Scale, DASS) were evaluated in order to indicate the new scale's convergent and divergent validity. These results demonstrated highly significant correlations with these measures in the expected direction, with stronger correlations for the theoretically-consistent variables than the theoretically-inconsistent variables. Exploratory factor analyses confirmed a structural two-factor model. Factor 1 seems to measure one's ability to regulate eating despite urges and cravings, and Factor 2 seems to measure desire to maintain internal control over eating thoughts. The FAAQ was also administered to a separate sample of 29 overweight or obese women enrolled in a weight loss program, and found to be predictive of weight loss. Taken together, results suggest that the FAAQ is a psychometrically sound instrument which might be a valuable tool for assessing acceptance of food related thoughts and urges.

Depression vulnerability moderates the effects of cognitive behavior therapy in a randomized controlled trial for smoking cessation

Several clinical trials have tested the hypothesis that smoking cessation treatments with a mood management component derived from cognitive behavior therapy (CBT) for depression would be specifically effective for depression-vulnerable smokers, with mixed results. This trial addressed methodological concerns with some of the previous studies to clarify whether depression vulnerability does in fact moderate CBT smoking cessation outcome. The study compared 8-session group CBT with a time-matched comparison group condition in a sample of 100 cigarette smokers randomized to treatment condition. Each treatment group was led by one of 7 American University clinical psychology graduate students; therapists were crossed with treatment conditions. Outcome (7-day point prevalence abstinence) was evaluated 1 month and 3 months after quit date. Baseline self-reported depression vulnerability (sample median split on the Depression Proneness Inventory) moderated treatment response, such that more depression-prone smokers fared better in CBT whereas less depression-prone smokers fared better in the comparison condition. These results may have implications for determining when to use CBT components in smoking cessation programs.

Addressing tobacco use disorder in smokers in early remission from alcohol dependence: the case for integrating smoking cessation services in substance use disorder treatment programs

Despite the declining overall rate of cigarette smoking in the general population in the United States, the prevalence of smoking is estimated to be as high as 80% among treatment-seeking alcoholics. The serious adverse health effects of tobacco and heavy alcohol use are synergistic and recent evidence suggests that smoking slows the process of cognitive recovery following alcohol abstinence. In addition, substantial evidence shows that treatment for tobacco dependence does not jeopardize alcohol abstinence. In this paper, we focus on the impact and treatment implications of tobacco dependence among treatment-seeking alcoholics through a review of five areas of research. We begin with brief reviews of two areas of research: studies investigating the genetic and neurobiological vulnerability of comorbid tobacco and alcohol dependence and studies investigating the consequences of comorbid dependence on neurobiological and cognitive functioning. We then review literature on the effects of smoking cessation on drinking urges and alcohol use and the effectiveness of smoking cessation interventions with alcoholic smokers. Finally, we offer recommendations for research with an emphasis on clinical research for enhancing smoking cessation outcomes in this population.

Effects of an intensive depression-focused intervention for smoking cessation in pregnancy

OBJECTIVE

The objective of this study was to evaluate a depression-focused treatment for smoking cessation in pregnant women versus a time and contact health education control. We hypothesized that the depression-focused treatment would lead to improved abstinence and reduced depressive symptoms among women with high levels of depressive symptomatology. No significant main effects of treatment were hypothesized.

METHOD

Pregnant smokers (N = 257) were randomly assigned to a 10-week, intensive, depression-focused intervention (cognitive behavioral analysis system of psychotherapy; CBASP) or to a time and contact control focused on health and wellness (HW); both included equivalent amounts of behavioral and motivational smoking cessation counseling. Of the sample, 54% were African American, and 37% met criteria for major depression. Mean age was 25 years (SD = 5.9), and women averaged 19.5 weeks (SD = 8.5) gestation at study entry. We measured symptoms of depression using the Center for Epidemiological Studies-Depression Scale (Radloff, 1977).

RESULTS

At 6 months posttreatment, women with higher levels of baseline depressive symptoms treated with CBASP were abstinent significantly more often, F(1, 253) = 5.61, p = .02, and had less depression, F(1, 2620) = 10.49, p = .001, than those treated with HW; those with low baseline depression fared better in HW. Differences in abstinence were not retained at 6 months postpartum.

CONCLUSIONS

The results suggest that pregnant women with high levels of depressive symptoms may benefit from a depression-focused treatment in terms of improved abstinence and depressive symptoms, both of which could have a combined positive effect on maternal and child health.

A comment on analyzing addictive behaviors over time

INTRODUCTION

If not handled appropriately, missing data can result in biased estimates and, quite possibly, incorrect conclusions about treatment efficacy. This article aimed to demonstrate how ordinary use of generalized estimating equations (GEE) can be problematic if the assumption of missing completely at random (MCAR) is not met.

METHODS

We tested whether results differed for different analytic methods depending on whether the MCAR assumption was violated. This example used data from a published randomized controlled trial examining whether varying the timing of a weight management intervention, in concert with smoking cessation, improved cessation rates for adult female smokers. Participants were 284 women with at least one report of smoking status during Visits 4-16. Smoking status was assessed at each visit via self-report and biologically verified using expired carbon monoxide.

RESULTS

Results showed that while the GEE analysis found differences in smoking status between conditions, tests of the MCAR assumption demonstrated that it was not valid for this dataset. Additional analyses using tests that do not require the MCAR assumption found no differences between conditions. Thus, GEE is not an appropriate choice for this analysis.

DISCUSSION

While GEE is an appropriate technique for analyzing dichotomous data when the MCAR assumption is not violated, weighted GEE or mixed-effects logistic regression are more appropriate when the missing data mechanism is not MCAR.

Depressive symptoms, drinking problems, and smoking cessation in older smokers

This study modeled the predictive association between depressive symptoms and smoking cessation in a sample of 442 late-middle-aged smokers; assessments occurred at four time-points across a 10-year period. In addition, the study examined the role of baseline drinking problems in moderating the relationship between depressive symptoms and smoking cessation. Findings supported hypotheses. More depressive symptoms prospectively predicted a lower likelihood of smoking cessation. In addition, the presence of baseline drinking problems strengthened the relationship between depressive symptoms and a lower likelihood of smoking cessation. Understanding the mechanisms underlying depression and cigarette smoking among older adults is applicable to secondary prevention and treatment and suggests additional public health benefits from treating depression in older persons.

The impact of depressive symptoms on alcohol and cigarette consumption following treatment for alcohol and nicotine dependence

BACKGROUND

Although depression is common among alcohol and tobacco dependent patients, its impact on treatment outcomes is not well established. The purpose of this study was to examine the impact of depressive symptoms on abstinence from tobacco and alcohol after treatment for alcohol dependence and nicotine dependence.

METHODS

The Timing of Alcohol and Smoking Cessation Study (TASC) randomized adults receiving intensive alcohol dependence treatment, who were also smokers, to concurrent or delayed smoking cessation treatment. The sample consisted of 462 adults who completed depression and substance use (alcohol and smoking) assessments at treatment entry and 6, 12, and 18 months posttreatment. Longitudinal regression models were used to examine the relationships between depression and subsequent abstinence from alcohol and tobacco after baseline characteristics, including alcohol and smoking histories, were considered.

RESULTS

Depressive symptoms were prospectively related to nonabstinence from alcohol. Depressive symptoms at the previous assessment increased the odds of drinking at the subsequent time point by a factor of 1.67 (95% CI 1.14, 2.43), p < 0.01. Depressive symptoms were not significantly related to subsequent abstinence from cigarettes.

CONCLUSIONS

Depression is an important negative predictor of the ability to maintain abstinence from alcohol within the context of intensive alcoholism and smoking treatment. It may be important to include depression-specific interventions for alcohol and tobacco dependent individuals to facilitate successful drinking treatment outcomes.

Integrated cognitive behavioral therapy versus twelve-step facilitation therapy for substance-dependent adults with depressive disorders

In a randomized trial, this study compared the longitudinal outcome patterns of veterans (N = 66) with substance use disorders and major depressive disorder receiving standard pharmacotherapy and either 12-Step Facilitation Therapy (TSF) or disorder-specific Integrated Cognitive Behavioral Treatment (ICBT). Depression and substance use were assessed at intake, during and after treatment using the Hamilton Depression Rating Scale and the Time Line Follow Back. Reductions in depression during treatment were comparable between the two treatment groups; however, their posttreatment patterns were distinct. While ICBT participants evidenced a steady linear decline in depression through six months posttreatment, a quadratic trend characterized TSF participants, for whom depression declined during treatment, but increased throughout posttreatment follow-up. During treatment, TSF participants used substances less frequently relative to those in ICBT; however, reductions in substance use were more stable through six months posttreatment among those in ICBT relative toTSF. While both interventions produced improvement in depression and substance use during treatment, ICBT may yield more stable clinical outcomes once treatment ceases.

Group behaviour therapy programmes for smoking cessation

BACKGROUND

Group therapy offers individuals the opportunity to learn behavioural techniques for smoking cessation, and to provide each other with mutual support.

OBJECTIVES

We aimed to determine the effects of smoking cessation programmes delivered in a group format compared to self-help materials, or to no intervention; to compare the effectiveness of group therapy and individual counselling; and to determine the effect of adding group therapy to advice from a health professional or to nicotine replacement. We also aimed to determine whether specific components increased the effectiveness of group therapy. We aimed to determine the rate at which offers of group therapy are taken up.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Trials Register, with additional searches of MEDLINE and PsycINFO, including the terms behavior therapy, cognitive therapy, psychotherapy or group therapy, in January 2005.

SELECTION CRITERIA

We considered randomized trials that compared group therapy with self help, individual counselling, another intervention or no intervention (including usual care or a waiting list control). We also considered trials that compared more than one group programme. We included those trials with a minimum of two group meetings, and follow up of smoking status at least six months after the start of the programme. We excluded trials in which group therapy was provided to both active therapy and placebo arms of trials of pharmacotherapies, unless they had a factorial design.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the participants, the interventions provided to the groups and the controls, including programme length, intensity and main components, the outcome measures, method of randomization, and completeness of follow up. The main outcome measure was abstinence from smoking after at least six months follow up in patients smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Subjects lost to follow up were analyzed as continuing smokers. Where possible, we performed meta-analysis using a fixed-effects (Mantel-Haenszel) model.

MAIN RESULTS

A total of 55 trials met inclusion criteria for one or more of the comparisons in the review. Sixteen studies compared a group programme with a self-help programme. There was an increase in cessation with the use of a group programme (N = 4395, odds ratio (OR) 2.04, 95% confidence interval (CI) 1.60 to 2.60). Group programmes were more effective than no intervention controls (seven trials, N = 815, OR 2.17, 95% CI 1.37 to 3.45). There was no evidence that group therapy was more effective than a similar intensity of individual counselling. There was limited evidence that the addition of group therapy to other forms of treatment, such as advice from a health professional or nicotine replacement, produced extra benefit. There was variation in the extent to which those offered group therapy accepted the treatment. There was limited evidence that programmes which included components for increasing cognitive and behavioural skills and avoiding relapse were more effective than same length or shorter programmes without these components. This analysis was sensitive to the way in which one study with multiple conditions was included. We did not find an effect of manipulating the social interactions between participants in a group programme on outcome.

AUTHORS' CONCLUSIONS

Group therapy is better for helping people stop smoking than self help, and other less intensive interventions. There is not enough evidence to evaluate whether groups are more effective, or cost-effective, than intensive individual counselling. There is not enough evidence to support the use of particular psychological components in a programme beyond the support and skills training normally included.

Integrating smoking cessation treatment into primary care: an effectiveness study

BACKGROUND

Lack of interest has been cited as a reason not to offer cessation assistance to smokers, but research suggests that smokers accept treatments offered proactively. This study assessed acceptability, utilization, and effectiveness of free smoking cessation treatment among diverse primary care patients.

METHOD

Medical assistants invited 4174 adult smokers to participate. Enrollees (1869) self-selected or were assigned to receive free nicotine patch therapy alone or in combination with the Committed Quitters(R) program, and for some, individual counseling.

RESULTS

In nearly 68% of cases, patients accepted a treatment invitation; 77% of eligible smokers enrolled; 85% of these picked up free patches. Given a choice of treatments, 75% of participants elected a psychosocial treatment in addition to patch therapy. Thirteen percent of treatment initiators achieved biochemically confirmed 7-day point-prevalence abstinence at 1 year, with no significant treatment effects. Minority patients showed greater initial interest but less utilization did than White patients.

CONCLUSIONS

Free, readily accessible smoking cessation treatment offered in primary care settings was accepted and used by the majority of unselected smokers of diverse racial/ethnic origins. Psychosocial treatment components did not significantly increase abstinence rates. Barriers, rather than lack of interest, may keep minority smokers from using cessation treatments.