Smoking cessation and depression: current knowledge and future directions

Impact of self-control and time perception on intertemporal choices in gain and loss situations

Individuals frequently encounter dilemmas in which they must choose between smaller, immediate gains and larger, delayed rewards; this phenomenon is known as intertemporal choice. The present study analyzed the interplay of trait and state self-control and time perception tendencies (time overestimation vs. time underestimation) and how it influences the rates of selecting immediate options in both gain and loss situations by conducting an intertemporal choice task. Experiment 1 was used to explore the impact of trait self-control and time perception on intertemporal choices within gain and loss situations. In Experiment 2, the e-crossing task was used to induce self-control resource depletion in participants and to investigate the impact of self-control resources and time perception on intertemporal choices in gain and loss situations. The results indicate that (1) compared with the high-self-control group, the low-self-control group exhibited a greater tendency to choose immediate options. Additionally, the high time estimation group was more likely to opt for immediate choices than the low time estimation group was. Furthermore, participants were more likely to select immediate options in the loss situation than in the gain situation. (2) In the gain situation, the high time estimation group was more likely to choose immediate options than was the low time estimation group. However, in the loss situation, the difference between the two groups was nonsignificant. (3) Time perception and gain-loss situations exerted a moderating mediating effect on the impact of self-control resources on intertemporal choices. These findings shed light on the influence of both self-control abilities and self-control resources on intertemporal choices. They provide valuable insights into intertemporal decision behaviors across diverse contexts and indicate the need for rational analysis based on one's current state to mitigate cognitive biases to ensure individuals can maximize benefits in their daily lives.

Efficacy and safety of combination behavioral activation for smoking cessation and varenicline for treating tobacco dependence among individuals with current or past major depressive disorder: A 2 × 2 factorial, randomized, placebo-controlled trial

BACKGROUND AND AIMS

Treatment of depression-related psychological factors related to smoking behavior may improve rates of cessation among adults with major depressive disorder (MDD). This study measured the efficacy and safety of 12 weeks of behavioral activation for smoking cessation (BASC), varenicline and their combination.

DESIGN, SETTING, PARTICIPANTS

This study used a randomized, placebo-controlled, 2 × 2 factorial design comparing BASC versus standard behavioral treatment (ST) and varenicline versus placebo, taking place in research clinics at two urban universities in the United States. Participants comprised 300 hundred adult smokers with current or past MDD.

INTERVENTIONS

BASC integrated behavioral activation therapy and ST to increase engagement in rewarding activities by reducing avoidance, withdrawal and inactivity associated with depression. ST was based on the 2008 PHS Clinical Practice Guideline. Both treatments consisted of eight 45-min sessions delivered between weeks 1 and 12. Varenicline and placebo were administered for 12 weeks between weeks 2 and 14.

MEASUREMENTS

Primary outcomes were bioverified intent-to-treat (ITT) 7-day point-prevalence abstinence at 27 weeks and adverse events (AEs).

FINDINGS

No significant interaction was detected between behavioral treatment and pharmacotherapy at 27 weeks (χ2 (1)  = 0.19, P = 0.67). BASC and ST did not differ (χ2 (1)  = 0.43, P = 0.51). Significant differences in ITT abstinence rates (χ2 (1)  = 4.84, P = 0.03) emerged among pharmacotherapy arms (16.2% for varenicline, 7.5% for placebo), with results favoring varenicline over placebo (rate ratio = 2.16, 95% confidence interval = 1.08, 4.30). All significant differences in AE rates after start of medication were higher for placebo than varenicline.

CONCLUSION

A randomized trial in smokers with major depressive disorder found that varenicline improved smoking abstinence versus placebo at 27 weeks without elevating rates of adverse events. Behavioral activation for smoking cessation did not outperform standard behavioral treatment, with or without adjunctive varenicline therapy.

Effects of an 80% cigarette price increase on quit attempts, successful quitting and smoking intensity among Korean adult smokers: results from nationally representative longitudinal panel data

OBJECTIVES

South Korea implemented an unprecedented cigarette tax increase in 2015, raising its cigarette price by 80%. This study evaluated the extent to which the 2015 cigarette tax increase affected Korean adult smokers in terms of quit attempts, successful quitting and smoking intensity.

METHODS

Data were drawn from a nationally representative longitudinal study, the Korean Welfare Panel Study (waves 9-12, 2014-2017). Korean adults who smoked before the 2015 cigarette tax increase comprised the sample (n=2114). We used the multiple logistic regressions to examine factors of quit attempts and successful quitting and the generalised estimating equations to estimate changes in smoking intensity among continued smokers.

RESULTS

After the cigarette tax increase, 60.9% (n=1334) of baseline smokers attempted to quit and 34.7% of the attempters succeeded in quitting. The smokers aged ≥ 65 years and light smokers both attempted more (p<0.01) and succeeded more (p<0.05) in quitting than smokers aged 35-44 years and heavy smokers, respectively. The successful quitting was not significantly associated with income levels. Depressive symptoms, first cigarette use before age 19 and smoking a pack or more a day at baseline were associated with failures in quitting. Smoking intensity among continued smokers decreased after the cigarette tax increase (p<0.001), but such a decrease was not observed in light smokers, young smokers and high-income smokers.

CONCLUSION

The current study findings imply that the Korean government may consider implementing periodic increases in cigarette tax which should reflect the rate of inflation and income growth. Smoking cessation programmes need to address depressive symptoms.

Outdoor smoking in Nigeria: prevalence, correlates and predictors

BACKGROUND

There is a lack of data on smoking in outdoor-open bars in Nigeria that may translate into effective legislation on public smoking.

METHOD

This study determined the prevalence, demographic and clinical correlates as well as predictors of smoking among a community sample of 1119 patrons of open place bars in Ibadan, Nigeria. Data on current smoking was obtained using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), while smoking intensity was calculated using the Pack-Year. Prevalence of alcohol use was determined using the Alcohol Use Disorders Identification Test (AUDIT), while depression was diagnosed using the Mini International Neuropsychiatry Interview (MINI). Analysis was carried out by SPSS version 20.0 software using Chi square statistics, t test and ANOVA, and was set at 95% confidence interval.

RESULTS

Prevalence of current smoking was 63.8% and the mean pack years of smoking of all respondents was 19.38 ± 17.16 years. Predictors of outdoor smoking were depression OR = 1.41, 95% CI (1.09-1.83) and alcohol use OR = 2.12, 95% CI (1.44-3.13). Predictors of high pack years were depression OR = 1.47, 95% CI (1.08-2.01), being married, OR = 1.78, 95% CI (1.29-2.45), high income, OR = 1.95, 95% CI (1.42-2.68) and alcohol use OR = 2.82, 95% CI (1.51-5.27). There was no significant relationship between stage of readiness to quit smoking and mean pack years of smoking, F = 0.3, p = 0.5.

CONCLUSION

The high prevalence of outdoor smoking in the sample calls for urgent public health initiatives for intervention. Thus, outdoor bars are potential tobacco use intervention sites to minimize the health consequences of smoking.

Longitudinal associations between number of cigarettes per day and depressive symptoms in adult smokers with type 2 diabetes: A path analysis approach

OBJECTIVE

Three theoretical models describe the direction of the association between depressive symptoms and cigarettes per day (CPD) in smokers: 1) CPD predicts subsequent depressive symptoms, 2) depressive symptoms predict CPD, and 3) there is a bidirectional relation between CPD and depressive symptoms. The objective of the study was to compare the fit of these three theoretical models to data from a community-based sample of adults with type 2 diabetes (T2D) who smoke cigarettes.

METHODS

Data were from adults with T2D who participated in the Evaluation of Diabetes Treatment Study. At baseline, 296 participants reported being a current smoker and were included in the analyses. Measures of CPD and depressive symptoms were collected annually over four years. Path models corresponding to the three directionality hypotheses were estimated. Model fit was compared, and the best fitting model was selected on the basis of Akaike's Information Criterion (AIC).

RESULTS

The path model depicting a unidirectional association from CPD to subsequent depressive symptoms had the lowest AIC value (7110.94) and was thus identified as the best fitting model. Although some paths within the model did not meet conventional levels of statistical significance, in general, more CPD predicted higher levels of depressive symptoms at subsequent follow-up points.

CONCLUSION

Amongst smokers with T2D, a primary smoking model, in which smoking precedes depressive symptoms, may best explain the longitudinal association between CPD and depressive symptoms. These findings further justify the need for early smoking cessation in diabetes care.

Effects of Delay Discounting and Other Predictors on Smoking Relapse

Despite the substantial decrease in the prevalence of tobacco smoking and the availability of effective smoking cessation treatments, smoking relapse after formal treatments remains extremely high. Evidence regarding clinical predictors of relapse after quitting is essential to promote long-term abstinence among those who successfully quit. This study aimed to explore whether baseline delay discounting (DD) rates and other sociodemographic, psychological, and smoking-related variables predicted relapse to smoking at six-month follow-up. Participants were 188 adult smokers (mean age = 42.9, SD = 12.9; 64.4% females) who received one of three treatment conditions: 6-weeks of cognitive–behavioral treatment (CBT) alone; or combined with contingency management (CBT + CM); or combined with cue exposure treatment (CBT+CET). Smoking status was biochemically verified. Logistic regression was conducted to examine prospective predictors of smoking relapse at six months after an initial period of abstinence. Greater DD rates (OR: 0.18; 95% CI [0.03, 0.93]), being younger (OR: 0.96; 95% CI [0.94, 0.99]), high nicotine dependence (OR: 1.34; 95% CI [1.13, 1.60]), and a higher number of previous quit attempts (OR: 4.47; 95% CI [1.14, 17.44]) increased the likelihood of smoking relapse at six-month follow-up. Besides sociodemographic and smoking-related characteristics, greater DD predisposes successful quitters to relapse back to smoking. These results stress the relevance of incorporating specific treatment components for reducing impulsivity.

The association between lifetime polytobacco use and intention to quit among HIV-positive cigarette smokers

BACKGROUND

This secondary analysis aims to describe, over time, the relationship between HIV disease progression and intention to quit cigarette smoking among current monocigarette users with and without a lifetime history of polytobacco use.

METHODS

Participants completed a baseline assessment at the time of HIV care initiation and four follow-up assessments (3, 6, 9, and 12-months). Assessments included biochemically verified smoking status and audio computer-assisted self-interviews assessing psychosocial, substance use, and clinical variables known to influence smoking behaviors. Using linear and generalized linear fixed-effects models, we modeled the covariance structure for the repeated outcome measures (intention to quit and 7-day point prevalence smoking abstinence) across the study time points and included a three-way interaction term to examine the effects of disease stage and tobacco product use.

RESULTS

Participants (N = 357) were 73.1% male, 67.3% black/African American, and had a mean (SD) age of 38.7 (10.6) years. At baseline, lifetime polytobacco users reported significantly worse HIV-related symptoms and burdens, illness perception, social support, and nicotine dependence. Intention to quit, but not smoking abstinence, was predicted by a three-way interaction between time from HIV care initiation, disease progression, and tobacco product use (p = .04). Overall, progressive HIV was associated with greater intention to quit smoking cigarettes. However, the relationship differed over time between the two tobacco product groups.

CONCLUSION

Future studies should consider tailoring the timing of cessation interventions upon disease stage and lifetime history of polytobacco use.

Tobacco use does not influence the response to non-pharmacologic depression treatment: A secondary analysis of the Regassa randomized controlled trial

Behavioural interventions show promising results among patients with mild- to moderate depression. However, whether tobacco use moderates the effects of these interventions is not known. In the present study, we examined whether patients suffering from mild-to-moderate depression differed in their response to prescribed physical exercise or internet-based cognitive behavioural therapy (ICBT) according to their current tobacco use. We conducted a secondary analysis of data from 740 participants in a multicentre randomised controlled trial comparing physical exercise, internet-based cognitive behavioural therapy and treatment as usual (Regassa study). Information on current daily tobacco use was self-reported at baseline. Linear and logistic regression were used to examine the treatments' effect (reduction in depression score) in the subgroups of tobacco users (n=154) and non-users (n=586). We found that baseline tobacco use did not significantly moderate the association between treatment type and post-treatment depression severity. Both interventions (exercise and ICBT) resulted in a reduction of depression scores that was similar among non-users and users of tobacco, albeit formally statistically significant only among non-users. Physical exercise on prescription and ICBT can be used in the clinical management of depressed patients, with similar prognostic advantage among tobacco users and non-users.

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.

Behavioral Medecine Review: The Lifestyle Factor

Martinsen and Raglin provide a persuasive, evidence-based rationale for lifestyle approaches to the management of anxiety, depressive disorders, and their comorbidities. Yet, their review prompts discussion of the complexities navigating this terrain, including barriers to the identification and management of these common psychological problems in medical settings, the potential of these disorders to complicate health care, and challenges to the implementation of lifestyle interventions for depression and anxiety-related concerns.

Smoking status and psychosocial factors in binge eating disorder and bulimia nervosa

OBJECTIVE

To examine eating-disorder psychopathology and depressive symptoms by smoking status (never, former, or current smoker) in persons with binge eating disorder (BED) and bulimia nervosa (BN).

METHODS

Participants were 575 adult volunteers from the community (mean age=36.0±12years and BMI=32.9±9.5kg/m(2); 80% white; 88% female) who were classified with BED (n=410) or BN (n=165). Participants completed a battery of questionnaires, including items about current and historical cigarette smoking, the Eating Disorder Examination -Questionnaire, and the Beck Depression Inventory.

RESULTS

Among those with BED, depressive symptoms were significantly higher in current smokers than former or never smokers (p=.001). There were no significant differences in depressive symptoms by smoking status in participants with BN and no differences in eating-disorder psychopathology by smoking status in either the BED or BN groups.

DISCUSSION

In this non-clinical group of community volunteers, we found that smoking history or status was not associated with eating disorder psychopathology in participants classified with BED and BN but was significantly associated with depressive symptoms in participants with BED.

Age-varying associations between substance use behaviors and depressive symptoms during adolescence and young adulthood

BACKGROUND

Substance use and depression often co-occur, complicating treatment of both substance use and depression. Despite research documenting age-related trends in both substance use and depression, little research has examined how the associations between substance use behaviors and depression changes across the lifespan.

METHODS

This study examines how the associations between substance use behaviors (daily smoking, regular heavy episodic drinking (HED), and marijuana use) and depressive symptoms vary from adolescence into young adulthood (ages 12-31), and how these associations differ by gender. Using data from the National Longitudinal Study of Adolescent to Adult Health (Add Health), we implemented time-varying effect models (TVEM), an analytic approach that estimates how the associations between predictors (e.g., substance use measures) and an outcome (e.g., depressive symptoms) vary across age.

RESULTS

Marijuana use and daily smoking were significantly associated with depressive symptoms at most ages from 12 to 31. Regular HED was significantly associated with depressive symptoms during adolescence only. In bivariate analyses, the association with depressive symptoms for each substance use behavior was significantly stronger for females at certain ages; when adjusting for concurrent substance use in a multivariate analysis, no gender differences were observed.

CONCLUSIONS

While the associations between depressive symptoms and both marijuana and daily smoking were relatively stable across ages 12-31, regular HED was only significantly associated with depressive symptoms during adolescence. Understanding age and gender trends in these associations can help tailor prevention efforts and joint treatment methods in order to maximize public health benefit.

Depressive symptoms affect changes in nicotine withdrawal and smoking urges throughout smoking cessation treatment: Preliminary results

BACKGROUND

Individuals who report more depressive symptoms consistently demonstrate higher rates of nicotine dependence and less successful smoking cessation than do individuals who report fewer depressive symptoms. Nicotine withdrawal and smoking urges are two potential factors that may account for the differences observed between these two groups. This study assessed whether elevated depression symptoms among nicotine dependent smokers are associated with changes in withdrawal and urges to smoke when undergoing smoking cessation treatment.

METHOD

Data on 81 nicotine dependent smokers were collected as part of a smoking cessation randomized trial that compared standard and contingency management treatment across one baseline week and four treatment weeks. Linear mixed model analyses were conducted with high and low depression scores predicting changes in withdrawal and urge ratings from a baseline week and four treatment weeks.

RESULTS

Participants with elevated depression symptoms reported more intense nicotine withdrawal and smoking urges throughout treatment. Further, participants with greater depressive symptoms exhibited an increase in smoking urges at the start of treatment, compared with a gradual decline in urges among participants with fewer depressive symptoms.

CONCLUSIONS

Smokers with elevated depressive symptoms experience significantly elevated discomfort during smoking cessation efforts in the form of increased withdrawal and craving. This discomfort has the potential to make quitting smoking more difficult. Clinical Trial Identifier: NCT00865254.

The Association of Panic Disorder, Posttraumatic Stress Disorder, and Major Depression With Smoking in American Indians

INTRODUCTION

Rates of cigarette smoking are disproportionately high among American Indian populations, although regional differences exist in smoking prevalence. Previous research has noted that anxiety and depression are associated with higher rates of cigarette use. We asked whether lifetime panic disorder, posttraumatic stress disorder, and major depression were related to lifetime cigarette smoking in two geographically distinct American Indian tribes.

METHODS

Data were collected in 1997-1999 from 1506 Northern Plains and 1268 Southwest tribal members; data were analyzed in 2009. Regression analyses examined the association between lifetime anxiety and depressive disorders and odds of lifetime smoking status after controlling for sociodemographic variables and alcohol use disorders. Institutional and tribal approvals were obtained for all study procedures, and all participants provided informed consent.

RESULTS

Odds of smoking were two times higher in Southwest participants with panic disorder and major depression, and 1.7 times higher in those with posttraumatic stress disorder, after controlling for sociodemographic variables. After accounting for alcohol use disorders, only major depression remained significantly associated with smoking. In the Northern Plains, psychiatric disorders were not associated with smoking. Increasing psychiatric comorbidity was significantly linked to increased smoking odds in both tribes, especially in the Southwest.

CONCLUSIONS

This study is the first to examine the association between psychiatric conditions and lifetime smoking in two large, geographically diverse community samples of American Indians. While the direction of the relationship between nicotine use and psychiatric disorders cannot be determined, understanding unique social, environmental, and cultural differences that contribute to the tobacco-psychiatric disorder relationship may help guide tribe-specific commercial tobacco control strategies.

Anxiety, depression, and cigarette smoking: a transdiagnostic vulnerability framework to understanding emotion-smoking comorbidity

Research into the comorbidity between emotional psychopathology and cigarette smoking has often focused upon anxiety and depression's manifest symptoms and syndromes, with limited theoretical and clinical advancement. This article presents a novel framework to understanding emotion-smoking comorbidity. We propose that transdiagnostic emotional vulnerabilities-core biobehavioral traits reflecting maladaptive responses to emotional states that underpin multiple types of emotional psychopathology-link various anxiety and depressive psychopathologies to smoking. This framework is applied in a review and synthesis of the empirical literature on 3 transdiagnostic emotional vulnerabilities implicated in smoking: (a) anhedonia (Anh; diminished pleasure/interest in response to rewards), (b) anxiety sensitivity (AS; fear of anxiety-related sensations), and (c) distress tolerance (DT; ability to withstand distressing states). We conclude that Anh, AS, and DT collectively (a) underpin multiple emotional psychopathologies, (b) amplify smoking's anticipated and actual affect-enhancing properties and other mechanisms underlying smoking, (c) promote progression across the smoking trajectory (i.e., initiation, escalation/progression, maintenance, cessation/relapse), and (d) are promising targets for smoking intervention. After existing gaps are identified, an integrative model of transdiagnostic processes linking emotional psychopathology to smoking is proposed. The model's key premise is that Anh amplifies smoking's anticipated and actual pleasure-enhancing effects, AS amplifies smoking's anxiolytic effects, and poor DT amplifies smoking's distress terminating effects. Collectively, these processes augment the reinforcing properties of smoking for individuals with emotional psychopathology to heighten risk of smoking initiation, progression, maintenance, cessation avoidance, and relapse. We conclude by drawing clinical and scientific implications from this framework that may generalize to other comorbidities.

Assessing the longitudinal associations and stability of smoking and depression syndrome over a 4-year period in a community sample with type 2 diabetes 24

BACKGROUND

The aim of the present study was to investigate the stability and longitudinal association between depression and smoking status within a community sample with type 2 diabetes (T2D) while controlling for sociodemographic and disease-related variables.

METHODS

Adults with T2D were recruited and agreed to be followed-up via random digit dialing for the Montreal Diabetes Health Study. At baseline, 1614 individuals were classified as never (n = 592), former (n = 690), light (≤10 cigarettes a day; n = 128) and moderate-heavy (11+ cigarettes a day; n = 204) smokers. Depression was assessed using the Patient Health Questionnaire-9 and individuals were classified as either "none" or having depression syndrome. Generalized estimating equations were used to test the association between depression syndrome and current smoking status while controlling for other demographic and health-related variables.

RESULTS

Prevalence rates of smoking and depression showed mild to substantial agreement over time. Depression syndrome was significantly associated with moderate-heavy smoking in the fully adjusted model using cross-sectional (all four waves; odds ratio [OR] 1.46; 95% confidence interval [CI] 1.08-1.99; P < 0.05) and longitudinal (controlling for depression at baseline; OR 1.54; 95% CI 1.02-2.31; P < 0.05) data.

CONCLUSIONS

Smoking and depression prevalence rates appear to be stable over time in our community sample with T2D. Moderate-heavy smoking is strongly associated with elevated depression, both in cross-sectional and longitudinal models. Persistent moderate-heavy smokers may be at increased risk of both physical and mental health complications. This burden is even greater for those with T2D.

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.

Smoking cessation in women at the time of an invasive cardiovascular procedure and 3 months later

BACKGROUND

Female smokers with coronary heart disease (CHD) are at an increased risk for negative health effects. The time of invasive cardiovascular (CV) interventions is a critical opportunity to make lifestyle changes to reduce future CV interventions.

OBJECTIVE

The purpose of this study guided by the Health Belief Model was to determine which factors predict smoking cessation (SC) in women after an invasive CV procedure.

METHODS

A correlational, prospective design was used. Data were collected from female smokers at the time of an invasive CV intervention (baseline) and 3 months later. Instruments measured commitment to stop smoking, perceived threat of CHD and future interventions, cessation self-efficacy, barriers to SC, benefits of SC, cues to action, and motivation. Analyses included χ2 and t tests and multiple, hierarchical, and logistic regression.

RESULTS

On average, women (N = 76) were middle aged (mean [SD] age, 55.9 [8.0] years), smoked 15.3 (9.8) cigarettes per day, and on average smoked for 33.6 (10.2) years. At baseline, fewer perceived barriers to SC, high cessation self-efficacy, and being more autonomously motivated to quit smoking explained 67% of variance in commitment to stop smoking (P < .001). At 3 months, of 54 women responding, only 8 had quit smoking. Women reported smoking fewer cigarettes per day at 3 months compared with baseline (paired t51 = 3.43, P < .01). Higher baseline cessation self-efficacy and lower CHD threat were predictors of SC at 3 months (χ2(4) = 18.67, n = 54; P = .001).

CONCLUSIONS

Although commitment, motivation, and self-efficacy to stop smoking were high, perceived threat of CHD and future invasive CV interventions were high, and perceived barriers to SC were low, most women continued to smoke after their heart catheterization. Referrals for assistance from healthcare providers to decrease anxiety and nicotine dependence and to address ongoing challenges to SC are needed.

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.

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.

Girls' Tobacco and Alcohol Use During Early Adolescence: Prediction from Trajectories of Depressive Symptoms Across Two Studies

Associations between trajectories of depressive symptoms and subsequent tobacco and alcohol use were examined in two samples of girls assessed at age 11.5 (T1), 12.5 (T2), and 13.5 (T3). Two samples were examined to ascertain if there was generalizability of processes across risk levels and cultures. Study 1 comprised a United States-based sample of 100 girls in foster care; Study 2 comprised 264 girls in a United Kingdom community-based sample. Controlling for T1 aggression and T1 substance use, individual variation in intercept and slope of depressive symptoms was associated with tobacco use at T3 in both samples: greater intercept and increases in depressive symptoms increased the risk for T3 tobacco use. A similar pattern of associations was found for alcohol use in Study 1. The replicability of findings for the prediction of tobacco use from trajectories of depressive symptoms suggests potential benefit in identifying girls with elevated depressive symptoms for tobacco use prevention programs prior to the transition to secondary school.

Smoking cue reactivity in adult smokers with and without depression: a pilot study

Little is known about the relationship between Major Depressive Disorder (MDD) and smoking-related behaviors such as cue-induced urges to smoke. The purpose of this pilot study was to examine: (1) differences in smoking cue reactivity by MDD history and (2) the association of a diagnosis of MDD, current depressive symptoms, and smoking variables to cue-induced urges to smoke. Participants (N = 52) were n = 31 smokers with no MDD history and n = 21 smokers with past MDD. Participants completed a 2-hour laboratory session during which they were exposed to neutral (eg, pencils) and smoking cues (eg, cigarettes) after smoking one of their preferred brand cigarettes (Satiated Condition) and when it had been 1 hour since they smoked (Brief Deprivation Condition). Cue-induced urges increased with exposure to smoking cues and this increase did not significantly differ by diagnosis group. Current symptoms of depression, but not a diagnosis of MDD, were significantly and positively related to cue-induced cravings in satiated adult smokers. The association between depression symptoms and smoking urges was not significant in the Brief Deprivation Condition. Smoking cue reactivity may be a useful procedure for studying aspects of smoking behavior in adults with depression.

Types of smokers in a community sample of individuals with Type 2 diabetes: a latent class analysis

AIMS

Despite the detrimental effects of smoking on their health, a high number of adults with Type 2 diabetes continue to smoke. Identifying distinct types of smokers within this population could help tailor and target intervention programmes. This study examined whether smokers with Type 2 diabetes could be classified into different profiles based on smoking habits, socio-economic characteristics and lifestyle factors.

METHODS

A sample of adults with self-reported diabetes was selected from random-digit dialing. Analyses included 383 participants with Type 2 diabetes who were current smokers. Information related to smoking, socio-economic status, health and lifestyle was collected by phone interview at baseline and 1 year later. Latent class analysis was used to identify subgroups of smokers.

RESULTS

We uncovered three meaningful classes of smokers: class 1, long-time smokers with long-standing diabetes (n = 105); class 2, heavy smokers with deprived socio-economic status, poor health and unhealthy lifestyle characteristics (n = 105); class 3, working and active smokers who were more recently diagnosed with diabetes (n = 173). Members of class 2 were significantly more likely to be disabled and depressed at baseline and 1 year later compared with other classes.

CONCLUSIONS

Different profiles of smokers exist among adults with Type 2 diabetes, each suggesting different cessation treatment needs. Distinguishing between these types of smokers may enable clinicians to tailor their approach to smoking cessation.

Gender Differences in Smoking Behaviour and Cessation

This article reviews the literature to compare differential outcomes among men and women after smoking cessation, assess barriers they may face during cessation and provide recommendation to address gender-specific challenges in smoking cessation interventions. There is some evidence that women achieve lower abstinence rates than men after a quit attempt with nicotine replacement therapy, as well as without pharmacotherapy, and several underlying mechanisms were discussed to account for these findings. These include: (a) women have specific genetic variants that affect pharmacokinetics and pharmacodynamics of the medication, (b) hormonal influences increase nicotine metabolism and withdrawal symptoms, (c) women are more responsive to nonpharmacological aspects of smoking than men, (d) women are more vulnerable to depression and negative mood than men, (e) weight concerns are greater barriers for women than for men and (g) women receive less effective social support than men during a quit attempt. Gender-specific counselling that accounts for these factors and addresses the different needs of men and women may be a promising approach to improve long-term abstinence rates. However, more research is required to identify gender-related underlying mechanisms of differential smoking cessation outcomes, develop tailored interventions that account for gender differences and study the implementation and outcomes of gender-responsive treatment approaches.

Smokeless tobacco use and its relation to panic disorder, major depression, and posttraumatic stress disorder in American Indians

INTRODUCTION

Rates of nicotine use are high in American Indians. Anxiety and depression tend to be associated with cigarette use, but the association of anxiety and depression with smokeless tobacco (ST) is less clear. We asked if panic disorder, major depression, and posttraumatic stress disorder (PTSD) are related to lifetime ST use in 2 American Indian tribes.

METHODS

Logistic regression analyses examined the association between lifetime panic disorder, major depression, and PTSD and the odds of lifetime ST use status after controlling for sociodemographic characteristics, smoking status, and alcohol use disorders in 1,506 Northern Plains and 1,268 Southwest tribal members.

RESULTS

Odds of lifetime ST use was 1.6 times higher in Northern Plains tribal members with a lifetime history of PTSD after controlling for sociodemographic variables and smoking (95% CI: 1.1, 2.3; p = .01). This association remained significant after further adjustment for panic disorder and major depression (odds ratio [OR] = 1.5; 95% CI: 1.0, 2.2; p = .04) but was diminished after accounting for alcohol use (OR = 1.3; 95% CI: 0.9, 1.9; p = .23). In the Southwest, lifetime psychiatric disorders were not associated with lifetime ST use status. Increasing psychiatric comorbidity was significantly linked to increased odds of ST use in both tribes.

CONCLUSIONS

This study is the first to examine psychiatric conditions and lifetime ST use in a large, geographically diverse American Indian community sample. Although approximately 30% of tribal members were lifetime users of ST, the association with lifetime psychiatric disorders was not as strong as those observed with cigarette smoking. Understanding shared mechanisms between all forms of tobacco use with anxiety and depressive disorders remains an important area for investigation.

Examining antidepressant drug response by smoking status: why is it important and how often is it done?

Despite an increasingly recognized relationship between depression and smoking, little is known about the degree to which treatment studies for depression consider the impact of smoking on outcomes. The aim of this study is to examine the extent to which smoking is considered in current antidepressant treatment research. We conducted a MEDLINE search of recent randomized clinical trials of pharmacotherapy for depression published between 1 January and 31 December 2007, and a search of current pharmacological intervention studies for depression using www.ClinicalTrials.gov. Only 5% of the 107 pharmacological trials for depression published in 2007 reported the smoking status of their samples. Two studies (1.9%) controlled for smoking in the analyses and no studies analyzed outcomes by smoking status. Excluding the eight studies of combined treatment for depression and nicotine dependence, no other study on www.ClinicalTrials.gov (total n = 920) reported an intention to analyze outcomes by smoking status. Emerging data link smoking and depression, however, little attention has been directed toward the effects of smoking on antidepressant treatment outcomes. Conducting research to understand how nicotine and smoking affect responsiveness to antidepressants would advance our understanding of the neurobiology of depression and the development of new and targeted treatments.

A randomized trial of a multicomponent cessation strategy for emergency department smokers

OBJECTIVES

The objective was to determine the efficacy of an emergency department (ED)-based smoking cessation intervention.

METHODS

This study was a randomized trial conducted from January 2006 to September 2007 at an urban ED that treats 90,000 adults per year. Discharged adults who smoked at least 10 cigarettes per day were randomized to 1) usual care, receiving a smoking cessation brochure; or 2) enhanced care, receiving the brochure, a motivational interview (MI), nicotine patches, and a phone call at 3 days. Interventions were performed by a peer educator trained in tobacco treatment. Blinded follow-up was performed at 3 months.

RESULTS

A total of 338 subjects were enrolled, mean (±SD) age was 40.2 (±12.0) years, 51.8% were female, and 56.5% were either self-pay or Medicaid. Demographic and clinical variables were comparable between groups. Enhanced and usual care arms showed similar cessation rates at 3 months (14.7% vs. 13.2%, respectively). The proportion of subjects making a quit attempt (69.2% vs. 66.5%) and decrease in daily cigarette use (five vs. one; all p > 0.05) were also similar. In logistic modeling, factors associated with quitting included any tobacco-related International Classification of Diseases, ninth revision (ICD-9), code for the ED visit (odds ratio [OR]= 3.42, 95% confidence interval [CI] = 1.61 to 7.26) or subject belief that the ED visit was tobacco-related (OR = 2.47, 95% CI = 1.17 to 5.21). Conversely, subjects who reported having a preexisting tobacco-related illness were less likely to quit (OR = 0.22, 95% CI = 0.10 to 0.50).

CONCLUSIONS

The primary endpoint was negative, reflecting a higher-than-expected quit rate in the control group. Subjects whose ED visit was tobacco-related, based either on physician diagnosis or subject perception, were more than twice as likely to quit. These data suggest that even low-intensity screening and referral may prompt substantial numbers of ED smokers to quit or attempt to quit.

Differences in smoking expectancies in smokers with and without a history of major depression

Adults with depression evidence higher rates of smoking and lower quit rates than adults without depression. Little is known about the relationship between depression and smoking beliefs which are associated with both smoking and smoking cessation behavior. The primary aim of this study was to examine whether adult smokers with and without a history of major depressive disorder (MDD) differ in their endorsement of smoking expectancies. The secondary aim of the study was to examine whether there were interactions of depression and gender on the endorsement of expectancies. Adult cigarette smokers participating in a clinical trial of Selegiline hydrochloride for smoking cessation were classified as having a history of depression (MDD+, n=26) or no history of depression (MDD-, n=75). History of depression and smoking expectancies were assessed prior to randomization into the clinical trial. There was a main effect of depression on 7 out of 10 of the assessed beliefs. MDD+ smokers, compared to MDD- smokers, more strongly endorsed beliefs that smoking reduces negative affect, boredom, and cravings; smoking increases stimulation and social facilitation; smoking helps to manage cravings and weight; and that the taste is enjoyable. The main effect of gender and the interactive effect of depression and gender were not significant. Incorporating expectancies into cognitive-behavioral treatments for smoking cessation may be useful for smokers with a history of depression.

Anxiety, Health Risk Factors, and Chronic Disease

Anxiety disorders are the most common mental health condition and frequently co-occur with a variety of health risk factors, such as physical inactivity, cigarette smoking, and alcohol consumption. As such, untreated anxiety and increased risk for engagement in these health risk habits can further increase risk for later-onset chronic disease and complications in disease management. Contemporary studies have identified unique temporal relationships between the onset of specific anxiety disorders with smoking and alcohol use disorders. Incorporating exercise with evidence-based treatments for anxiety is emerging and promising in enhancing treatments for anxiety-related conditions. Likewise, substance use treatment programs may benefit from the detection and management of anxiety. Collaborative care models for anxiety may provide the needed systems-based approach for treating anxiety more effectively in primary and specialty care medical settings. Based on a qualitative review of the literature, this article summarizes the current research on the associations between anxiety, health risk factors, and the risk for chronic diseases. The authors also offer suggestions for future research that would help in better understanding the complex relationships between the role anxiety plays in the vulnerability for and management of physical inactivity and substance use.

Smoking cessation advantage among adult initiators: does it apply to black women?

INTRODUCTION

Smokers who initiate as adults are more likely to quit than those who initiate as adolescents. Black women are more likely than White women to initiate smoking in adulthood and are less likely to quit. There is a paucity of research examining whether the smoking cessation advantage among adult initiators applies to Black women. The study objective is to examine race differences in the effect of developmental stage of smoking initiation on number of years until cessation among Black and White women.

METHODS

Data were extracted from the National Longitudinal Survey of Young Women, a national cohort of women between the ages of 49 and 61 years in 2003. The analytic sample comprised 1,008 White women and 271 Black women with a history of smoking. Survival analysis procedures were utilized to address the study objective.

RESULTS

Racial disparities in smoking cessation were most evident among women who initiated smoking as adults. White young adult initiators had a 31% increased hazard of smoking cessation advantage (adjusted hazards ratio [HR]: 1.31, 95% CI: 1.04-1.65) over adolescent initiators, whereas Black young adult initiators had no smoking cessation advantage (adjusted HR: 0.85, CI: 95% 0.55-1.30) over adolescent initiators.

CONCLUSIONS

Prior observations that smoking initiation in adulthood is associated with high rates of cessation do not apply to black women. To contribute to the reduction of disparities in women's cessation efforts to prevent initiation should target young adult women, particularly Black young adult women.

Local Determinants of Tobacco Use in Pakistan and the Importance of Context

Introduction:The tobacco epidemic is surging in developing countries. While the determinants of tobacco use are well known, it is less certain whether they are similar in developed and developing countries. This has important ramifications for the implementation of interventions locally. This qualitative study explored the determinants and importance of context on tobacco use in Pakistan.Methods:Focus group discussions were conducted in two districts with doctors, nurses and patients from local tuberculosis clinics.Results:Peer influence, social acceptability, affordability and visibility of tobacco, public understanding and personal perception of risks influence tobacco use. Individual factors, such as personal curiosity, adversity and stress, also affected tobacco uptake and use. Patients were willing to pay for effective cessation treatment provided the costs were comparable to their expenditure on tobacco.Discussion:Factors such as peer and social influences are similar to those reported elsewhere. However, local variations exist in the degree of sociocultural acceptability, visibility of tobacco use, public understanding of risks and individual situational factors that influence tobacco use. Patients are prepared to pay for treatment, but there are gender differences in what can be afforded. For tobacco cessation interventions to be effective, local adaptations are essential to ensure cultural and contextual appropriateness.

Effectiveness of a mood management component as an adjunct to a telephone counselling smoking cessation intervention for smokers with a past major depression: a pragmatic randomized controlled trial

AIMS

To assess whether the addition of a mood management component to telephone counselling produces higher abstinence rates in smokers with past major depression and helps to prevent recurrence of depressive symptoms.

DESIGN

Pragmatic randomized controlled trial with two conditions, with follow-up at 6 and 12 months. The control intervention consisted of eight sessions of proactive telephone counselling. The mood management intervention was an integration of the control intervention with a mood management component. This component consisted of a self-help mood management manual, two more preparatory proactive telephone counselling sessions and supplementary homework assignments and advice.

SETTING

Dutch national smoking cessation quitline.

PARTICIPANTS

A total of 485 daily smokers with past major depression, according to the DSM-IV.

MEASUREMENTS

The primary outcome measure was prolonged abstinence and secondary outcome measures were 7-day point prevalence abstinence and depressive symptoms.

FINDINGS

The mood management intervention resulted in significantly higher prolonged abstinence rates at 6- and 12-month follow-up (30.5% and 23.9% in experimental condition, 22.3% and 14.0% in the control condition). The odds ratios were 1.60 (95% CI 1.06-2.42) and 1.96 (95% CI 1.22-3.14) for both follow-ups. The mood management intervention did not seem to prevent recurrence of depressive symptoms.

CONCLUSIONS

Adding a mood management component to telephone counselling for smoking cessation in smokers with a past major depression increases cessation rates without necessarily reducing depressive symptoms.

Personality disorders and premature dropout from psychological treatment for smoking cessation

The relation between personality disorders and premature dropout (attending half of the sessions or fewer) from a psychological treatment for giving up smoking was examined in a sample of 202 smokers. Percent of premature dropout was significantly higher for smokers with personality disorder in general, specifically for smokers with dependent personality disorder and with Cluster C personality disorder, than in smokers without such psychopathology.

Nicotinic acetylcholine receptors and depression: a review of the preclinical and clinical literature

Many patients with depression fail to derive sufficient benefit from available treatment options, with up to a third never reaching remission despite multiple trials of appropriate treatment. Novel antidepressant agents are needed, and drugs targeting nicotinic acetylcholine receptors (nAChRs) appear to hold promise in this regard. nAChRs are involved in a variety of neurobiological systems implicated in the pathophysiology of depression. In addition to their role in cholinergic neurotransmission, they modulate dopamine function and influence inflammation and hypothalamic-pituitary-adrenal axis activity. Preclinical studies have suggested antidepressant-like effects of drugs targeting nAChRs, with the most consistent results observed with alpha4beta2 nAChR modulators such as varenicline and nonspecific nAChR antagonists such as mecamylamine. These agents appear to offer the most potential antidepressant-like efficacy when used in conjunction with other established antidepressant treatments. nAChR modulators also influence neural processes that appear to mediate the behavioral effects of antidepressants, such as hippocampal cell proliferation. Clinical evidence, while limited, shows preliminary efficacy for mecamylamine and varenicline. Taken together, the preclinical and clinical evidence suggests that drugs targeting nAChRs may represent an important new approach to the treatment of depression.

Smoking Cessation: Case Study of a Client with Probable Borderline Personality Disorder

This report concerns the case of a female client with a probable borderline personality disorder who requested psychological treatment for the cessation of smoking. After six sessions, this client gave up smoking and remained abstinent at follow-up after 1, 3, 6, and 12 months. The presence of a probable borderline personality disorder did not interfere in the cessation of tobacco use or in the maintenance of abstinence.

Communication about smoking between depressed adolescents and their parents

INTRODUCTION

Better understanding of effective parent-adolescent communication regarding tobacco use could inform smoking cessation intervention.

METHODS

Semistructured interviews related to communication about smoking were conducted with 15 depressed adolescent smokers and their parents, primarily from urban areas. This study, conducted in 2006-2008, was funded by the Pennsylvania Department of Health. Interview transcripts (N = 30) were coded in QSR N6.

RESULTS

Quality of communication, rather than content, seemed to determine whether parental communication was effective. Parents reactivity to, or avoidance of, adolescent smoking presented a barrier to effective communication. In this sample, parents and adolescents were more concerned about problems, such as depression, than smoking.

DISCUSSION

Involving parents in adolescent smoking cessation programs may be promising. Parental involvement may include teaching parent-child communication skills, building stronger relational bonds, or helping parents quit simultaneously. Further research is needed to explore whether coupling smoking cessation with depression treatment increases parent and adolescent treatment engagement and effectiveness.

Varenicline augmentation in depressed smokers: an 8-week, open-label study

OBJECTIVE

To assess possible antidepressant effects of varenicline augmentation in outpatients with treatment-resistant depressive disorders and nicotine dependence.

BACKGROUND

Varenicline is a nicotinic acetylcholine receptor alpha4beta2 partial agonist and alpha7 full agonist approved for smoking cessation. Studies of similar compounds have suggested evidence of antidepressant effects.

METHOD

Eighteen patients (aged 18 to 65 years) were recruited from a general psychiatric outpatient clinic. Inclusion criteria were (1) primary Axis I depressive disorder (DSM-IV-TR criteria), (2) a stable antidepressant or mood stabilizer regimen, (3) persistent depressive symptoms despite adequate treatment, and (4) current cigarette smoking with nicotine dependence. Patients received varenicline (started at 0.5 mg daily and titrated to 1 mg twice daily) in addition to stable doses of their regular psychotropic medications. Depression symptoms, side effects, clinical global impressions, anhedonia, daily cigarette consumption, and vital signs were assessed every 2 weeks for 8 weeks. Baseline and endpoint ratings were compared, and the relationship between mood improvement and smoking cessation was examined. The primary outcome variable was mean change score in depressive symptoms as assessed by the 16-item Quick Inventory of Depressive Symptomatology-Self-Report. The study was conducted between September 2007 and March 2008.

RESULTS

Fourteen patients (78%) completed the study; 4 discontinued due to side effects, including gastrointestinal effects (n = 3) and worsened mood/irritability (n = 1). Patients demonstrated significant improvement in depression at end point (p < .001), with significant improvement as early as week 2. Eight patients (44%) met criteria for categorical response, and 6 (33%) reached remission criteria; the overall effect size was large. All patients were interested in smoking cessation: 8 (44%) achieved abstinence and 9 (50%) had some reduction in smoking. Improvement in depressive symptoms was correlated with smoking cessation. There was no evidence of treatment-emergent suicidality.

CONCLUSION

Open-label varenicline augmentation was associated with significant improvement in mood in a small sample of outpatient smokers with persistent depressive symptoms. Larger, double-blind studies are needed to investigate potential antidepressant effects of varenicline augmentation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00525837.

Treatment of tobacco dependence in mental health and addictive disorders

People with mental health and addictive (MHA) disorders smoke at high rates and require tobacco treatment as a part of their comprehensive psychiatric care. Psychiatric care providers often do not address tobacco use among people with mental illness, possibly owing to the belief that their patients will not be able to quit successfully or that even short-term abstinence will adversely influence psychiatric status. Progress in the development of treatments has been slow in part because smokers with current MHA disorders have been excluded from most smoking cessation trials. There are several smoking cessation treatment options, including psychological and pharmacological interventions, that should be offered to people with an MHA disorder who smoke. Building motivation and readiness to quit smoking is a major challenge, and therefore motivational interventions are essential. We review the treatment options for people with tobacco dependence and MHA disorders, offer recommendations on tobacco assessment and tailored treatment strategies, and provide suggestions for future research. Treatment efficacy could be enhanced through promoting smoking reduction as an initial treatment goal, extending duration of treatment, and delivering it within an integrated care model that also aims to reduce the availability of tobacco in MHA treatment settings and in the community.

Postpartum depressive symptoms and smoking relapse

BACKGROUND

Smokers with depressive symptoms are more likely to relapse after attempting to quit than those without depressive symptoms. Little is known about the relationship between depressive symptoms and relapse during the postpartum period; thus the aim of the present study is to assess the relationship between postpartum smoking relapse and depressive symptoms.

METHODS

Analysis of 2004 Pregnancy Risk Assessment Monitoring System (PRAMS) data from women in 16 states who reported smoking 3 months before pregnancy and reported abstinence from smoking during the last 3 months of pregnancy (n=2566). For women experiencing postpartum depressive symptoms, chi-square tests were computed for homogeneity of distribution between two groups (sustained abstinence versus relapsed) and an OR for relapsing during the postpartum period. Potential confounders, including demographic characteristics, intensity of smoking before pregnancy, and time since delivery, were computed.

RESULTS

Compared to women who did not experience postpartum depressive symptoms, women who did were 1.86 (95% CI=1.31, 2.65) times as likely to relapse during the postpartum period. After adjusting for demographic characteristics, intensity of smoking, and time since delivery, the association decreased slightly (adjusted OR=1.77, 95% CI=1.21, 2.59).

CONCLUSIONS

Women who quit smoking during pregnancy may be more likely to relapse if they experience depressive symptoms. Further research is needed into the screening and treatment of postpartum depressive symptoms as a possible method for preventing postpartum smoking relapse.

High frequency of adverse health behaviors in multiple sclerosis

Background

Health behaviors influence chronic disease risks in the general population, and may influence health outcomes independently of comorbid diseases. Health behaviors receive less attention in multiple sclerosis (MS) than in the general population. We assessed health behaviors among participants in the North American Research Committee on Multiple Sclerosis (NARCOMS) Registry and the demographic characteristics associated with particular health behaviors.

Methods

In October 2006, we surveyed NARCOMS participants regarding smoking using questions from the Behavioral Risk Factor Surveillance Survey; physical activity using questions from the PEPI study, alcohol use using the AUDIT-C; and height and weight. To determine the independent demographic predictors of health behaviors, we used multivariable logistic regression, either binary or polytomous as appropriate.

Results

Of 8983 responders, 4867 (54.2%) ever smoked; 1542 (17.3%) currently smoked. On the basis of the AUDIT-C, 1632 (18.2%) were at risk for alcohol abuse or dependence. A quarter of participants were obese ( n = 2269), and 2780 (31.3%) were overweight. Fewer than 25% of participants reported moderate or heavy leisure-time physical activity. Generally, lower socioeconomic status was associated with a higher frequency of adverse health behaviors accounting for other demographic factors. With increasing levels of disability, the reported intensity of physical activity was lower, and the frequency of overweight or obesity was higher.

Conclusions

Patients with MS exhibit frequent adverse health behaviors, increasing the risk of other chronic diseases. Further research is needed to determine how these behaviors influence disability progression, quality of life, and other MS-related outcomes.

Smoking status over two years in patients with multiple sclerosis

BACKGROUND

Smoking increases the risk of multiple sclerosis (MS) and possibly disease progression. The reliability of self-reported smoking status is unknown in MS. We assessed the reliability of self-reported smoking status among participants in the North American Research Committee on Multiple Sclerosis (NARCOMS) Registry.

METHODS

In 2004 and 2006, NARCOMS participants reported smoking status using Behavioral Risk Factor Surveillance Survey questions. We compared responses from 5,458 participants answering both questionnaires. We measured agreement regarding smoking status (ever/current) using a kappa coefficient, and agreement for ages of starting and quitting smoking, and number of cigarettes smoked using an intraclass correlation coefficient (ICC).

RESULTS

In 2004, 2,885 (53.4%) participants reported ever smoking. The kappa coefficient for ever smoking was 0.90 (95% confidence interval, CI: 0.89-0.92) and for current smoking 0.92 (95% CI: 0.90-0.94). The ICC for age at starting smoking was 0.73 (95% CI: 0.71-0.75) and for age at quitting smoking 0.90 (95% CI: 0.89-0.91). African-Americans, younger participants and those of lower socioeconomic status were less reliable. Depressed participants reported current smoking status less consistently (odds ratio: 0.51; 95% CI: 0.39-0.67).

CONCLUSIONS

NARCOMS participants reliably report smoking status. The impact of depression on reliability of self-reported smoking status needs re-evaluation.

Work-place social capital and smoking cessation: the Finnish Public Sector Study

AIMS

To examine whether high social capital at work is associated with an increased likelihood of smoking cessation in baseline smokers.

DESIGN

Prospective cohort study.

SETTING

Finland.

PARTICIPANTS

A total of 4853 employees who reported to be smokers in the baseline survey in 2000-2002 (response rate 68%) and responded to a follow-up survey on smoking status in 2004-2005 (response rate 77%).

MEASUREMENTS

Work-place social capital was assessed using a validated and psychometrically tested eight-item measure. Control variables included sex, age, socio-economic position, marital status, place of work, heavy drinking, physical activity, body mass index and physician-diagnosed depression.

FINDINGS

In multi-level logistic regression models adjusted for all the covariates, the odds for being a non-smoker at follow-up were 1.26 [95% confidence interval (CI)=1.03-1.55] times higher for baseline smokers who reported high individual-level social capital than for their counterparts with low social capital. In an analysis stratified by socio-economic position, a significant association between individual-level social capital and smoking cessation was observed in the high socio-economic group [odds ratio (OR) (95% CI)=1.63 (1.01-2.63)], but not in intermediate [(OR=1.10 (0.83-1.47)] or low socio-economic groups [(OR=1.28 (0.86-1.91)]. Work unit-level social capital was not associated with smoking cessation.

CONCLUSIONS

If the observed associations are causal, these findings suggest that high perceived social capital at work may facilitate smoking cessation among smokers in higher-status jobs.

Smoking cessation: significance and implications for children

A number of people in the USA who are still current smokers remain a staggering figure. Although this number continues to decrease, there is still a considerable amount of second-hand smoke. More importantly and for the purpose of this review, the detrimental effects of passive smoke in children is significant. We will not review the specific health effects of passive smoke, but for pediatricians, in particular, it is important to place in perspective programs that are available to influence the parents of children to stop smoking. Indeed, approximately 25% of all children aged 3-11 live in a household with at least one smoker. Despite the increasing number of communities in the states that have instituted restrictions or complete bans on smoking in the workplace and in many public areas, the principal site of smoking remains the home.

Developments in pharmacotherapy for tobacco dependence: past, present and future

In the mid-1970s there were no effective pharmacological treatments for tobacco dependence. The invention of nicotine gum was a major treatment advance and also greatly helped our understanding of the nature of tobacco dependence. There are now eight effective pharmacotherapies (nicotine gum, patch, nasal spray, inhaler, lozenge/tablet, bupropion, nortriptyline and clonidine) available to aid smoking cessation. Other non-nicotine agents that show promise are under investigation, including glucose, rimonabant, selegiline and varenicline. Greater knowledge of the mechanisms of action of the effective non-nicotine agents should lead to better understanding of the nature of tobacco dependence. Future research into optimal treatments should examine long-term combination pharmacotherapy combined with improved psychosocial support that is partly designed to enhance medication compliance. In addition, there is a need for studies designed to evaluate the efficacy of pharmacotherapies in populations such as youth, pregnant smokers and smokers with co-occurring mental health problems.