Effect of Depression on Smoking Cessation Outcomes
Sonne SC1, Nunes EV2, Jiang H2, Gan W2, Tyson C1, Reid MS3
1Medical University of South Carolina, 2Columbia University/New York Psychiatric Institute, 3New York University School of Medicine
ABSTRACT: A great deal of literature has been published on the effect of both cigarette smoking and cessation on mood. Less information is available on the effect of mood on smoking cessation outcomes, particularly in a substance abusing population. The NIDA ClinicalTrials Network recently completed a randomized, open label trial comparing the use of nicotine patches plus group counseling and treatment as usual (TAU) to TAU alone for substance-dependent outpatients interested in quitting smoking. We evaluated the effect of depressionon smoking cessation outcomes. A total of 225 individuals were randomized in a 2:1 ratio to either Smoking Cessation (SC; n=153) or TAU (n=72). Approximately 31.1% of the sample (n=70) had baseline Beck Depression Inventory (BDI) scores > 20, and approximately half ofthe sample (n=110) reported a lifetime history of major depression (MDD). Individuals with a history of MDD reported an earlier age of onset for cigarette smoking (13.1 (3.7) vs. 14.3 (4.6) yrs; p=0.032), an earlier age of regular smoking (15.2 (3.7) vs. 16.7 yrs; p=0.010) as wellas a higher baseline Fagerstrom score (6.6 (1.9) vs. 5.3 (2.0; p<0.001). Individuals with baseline BDI scores > 20 smoked 26.3 (14.6) cigarettes/day vs. 21.3 (9.0) p=0.002) as well as started regular smoking at an earlier age (15.0 (3.8) vs. 16.5 (4.9); p=0.034). Although therewas not a statistically significant effect of lifetime history of major depression on smoking abstinence rates (9.3% MDD, vs. 4.3% no MDD), there was a greater probability for smoking abstinence for those with lower baseline BDI scores (p=0.041). These data suggest that forindividuals with substance dependence who are interested in quitting smoking, evaluation and treatment of depressive symptoms may play an important role in improving smoking cessation outcomes.
INTRODUCTION
METHODS
RESULTS- Baseline
RESULTS- Baseline (continued)
RESULTS Outcome
Although there is a great deal of data on the effect of smokingcessation on mood, there is less information on the effect of moodon smoking cessation outcomes. The Clinical Trials Networkrecently completed an 8-week, open-label trial comparing the useof nicotine patches plus group counseling and treatment as usual(TAU) to TAU alone in a group of substance dependantoutpatients interested in quitting smoking. We conducted asecondary analysis to evaluate the effect of depression onsmoking cessation outcomes.
This study was an 8-week open-label trial comparing TAU plusnicotine patches and smoking cessation counseling (SC) to TAUalone; participants were randomized in a 2:1 ratio.
SUBJECTS
•225 men and women, 18 years of age or older
•Enrolled in a drug-free or opioid replacement treatmentprogram for the last 30 days and scheduled to remain intreatment for 30 days after randomization
•Must meet DSM-IV criteria for drug or alcohol dependence inthe last year; if on opioid replacement must be on stabledose
•Must smoke at least 10 cigarettes/day and have aCO>10ppm
•Could not be receiving any other smoking cessationinterventions
•Could not be have a medical or psychiatric condition inimmediate need of treatment or that would be negativelyaffected by study
PERTINENT ASSESSMENTS
•Psychiatric/Medical History
•Beck Depression Inventory II
•DSM-IV Checklist
•Fagerstrom Test for Nicotine Dependence
•Substance Use Report
•Smoking Status/Exhaled Carbon Monoxide (CO)
•Smoker Belief Questionnaire
•Smoking History Survey
Participants were seen twice a week for the first two weeks thenweekly.
Table 1. Describes the total sample of 225 participants. As can beseen, there were no statistically significant differences in demographicsbetween treatment groups.
Also in Table 3, alcohol was more often the primary substance of abuse for those with a BDI > 20 compared to those with a BDI<20 (p=0.015), andthere was a trend (p=0.07 and; p=0.06, respectively) for a higher percentage of cocaine and amphetamine as primary for those with a BDI score <20.
In order to evaluate the effect of depression on smoking cessationoutcomes, the total sample was divided into those who reported everbeing treated for depression (MDD) vs. those had not (no MDD); the totalwas also divided into those with a baseline BDI score < 20 vs. those witha baseline BDI score of > 20. As can be seen in Table 2, those with ahistory of MDD were less likely to be employed at baseline (p=0.034),and there was a trend for the same group to be less educated (p=0.061)
CONCLUSIONS
Variable
MDD
(n=110)
No MDD
(n=115)
Test Stat
BDI<20
(n=149)
BDI>20
(n=70)
TestStat
Age
42.1 (9.3)
42.3 (10.2)
NS
41.6 (9.3)
43.8 (10.2)
NS
% Male
46.4
57.4
2=2.74;p=0.098
52.3
51.4
NS
Education
11.3 (2.3)
11.8 (2.0)
t=1.88;
p=0.061
11.7 (2.1)
11.3 (2.2)
NS
Race
% Caucasian
% African Am
% Hispanic
42.7
23.6
31.8
34.2
29.0
36.0
NS
37.8
26.4
34.5
37.1
28.6
32.9
NS
% Employed
38.2
50.4
2=4.5;p=0.034
44.3
41.4
NS
Table 1. Demographics by Treatment Group
NS
33%
40%
% Employed
NS
42%
22%
30%
37%
28%
35%
Race
% Caucasian
% African Am.
% Hispanic
NS
11.9 (2.1)
11.4 (2.3)
Education (yrs)
NS
53%
51%
% Male
NS
41.0 (8.6)
41.6 (10.2)
Mean Age
Test
Statistic
TAU (n=72)
SC (n=153)
Characteristic
Table 2. Demographics by Affective Group
Variable
MDD (n=110)
No MDD (n=115)
Test Stat
BDI<20 (n=149)
BDI>20 (n=70)
Test Stat
Total BDI-II score
19.6 (12)
12.5 (9.5)
t=-4.89 p<.001
9.6 (5.7)
29.4 (8.1)
t=20.89 p<.001
Primary Substance of
abuse (DSM-IV)
Alcohol (%)
Amphetamines (%)
Cannabis (%)
Cocaine (%)
Opioids (%)
Sedatives/BZDs (%)
10.91
3.64
10.0
21.91
50.91
3.64
4.35
5.22
6.96
16.52
63.48
3.48
NS
NS
NS
NS
2=3.14; p=0.08NS
4.03
6.71
6.71
22.82
57.72
2.01
14.29
0.00
12.86
11.43
55.71
5.71
2=5.96; p=0.015
2=3.50; p=0.06
NS
2=3.29; p=0.07
NS
NS
Table 3. Clinical Characteristics
Variable
MDD (n=110)
No MDD (n=115)
Test Stat
BDI<20 (n=149)
BDI>20 (n=70)
Test Stat
Age 1st Smoked
13.1 (3.7)
14.3 (4.6)
t=2.15 p=0.032
13.9 (4.4)
13.1 (3.8)
NS
Age of regular smoking
15.2 (3.7)
16.7 (5.2)
t=2.6 p=0.010
16.5 (4.9)
15.0 (3.8)
t=-2.13 p=0.034
Avg. cigarettes per day
24.4 (13)
22.1 (10.5)
NS
21.3 (9.0)
26.3 (14.6)
t=3.15 p=0.002
% Use of non-cig tobacco
25.5
22.6
NS
22.2
27.1
NS
# quit attempts
4.7 (5.7)
5.6 (15.9)
NS
4.6 (12.0)
6.4 (12.6)
NS
Baseline Fagerstrom
6.6 (1.9)
5.3 (2.0)
t=-4.93 p<0.001
5.6 (2.1)
6.6 (1.8)
t=3.46 p<0.001
Table 4. Smoking Characteristics by Affective Group
As can be seen in Table 4, those with a history of MDD had earlier age of smoking initiation as well as an earlier age of regular smoking.Individuals with a higher baseline BDI were found to smoke more cigarettes than those with a BDI < 20. Individuals with history of MDD or abaseline BDI score > 20 were found to have higher Fagerstrom scores for nicotine dependence.
As can be seen in Table 3, opioids were the primary substance of abuse forthe majority of participants. Most of the recruitment sites used in this trialwere opioid replacement programs. When evaluating primary substance byaffective group, there was a trend for there to be more primary opioid use inthose without a history of MDD (p=0.08).
During the treatment phase of the study, the smoking abstinent rates in theTAU group were almost 0, so only those randomized to SC were evaluatedto determine if depression moderates the effect of smoking abstinence.
•There is no strong evidence that history of MDD moderated the effectof treatment on the smoking abstinence.
•There is no strong evidence that baseline BDI level when used as adichotomous variable (i.e. BDI<20 vs. BDI>20), moderated the effect oftreatment on the smoking abstinence. However, when baseline BDI scorewas used as a continuous variable, there was a significant effect ofbaseline BDI on smoking abstinence in which lower BDI scores predictedgreater smoking abstinence (p = 0.0408).
•The effect of the SC treatment in the smoking abstinence isgreater for those with a low baseline BDI than for those with ahigh baseline BDI. Thus, in this trial the baseline BDI scoremoderated the treatment effect on smoking abstinence rates.
•These data suggest that for individuals with substancedependence who are interested in quitting smoking, evaluationand treatment of depressive symptoms may play an importantrole in improving smoking cessation outcomes.
Sponsored by the NIDA Clinical Trials Network
