Effect of Depression on Smoking Cessation Outcomes

1
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 Clinical Trials
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 depression on smoking
cessation outcomes. A total of 225 individuals
were randomized in a 21 ratio to either Smoking
Cessation (SC n153) or TAU (n72).
Approximately 31.1 of the sample (n70) had
baseline Beck Depression Inventory (BDI) scores gt
20, and approximately half of the sample (n110)
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 p0.032),
an earlier age of regular smoking (15.2 (3.7) vs.
16.7 yrs p0.010) as well as a higher baseline
Fagerstrom score (6.6 (1.9) vs. 5.3 (2.0
plt0.001). Individuals with baseline BDI scores gt
20 smoked 26.3 (14.6) cigarettes/day vs. 21.3
(9.0) p0.002) as well as started regular smoking
at an earlier age (15.0 (3.8) vs. 16.5 (4.9)
p0.034). Although there was 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 (p0.041). These data
suggest that for individuals 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
RESULTS- Baseline
RESULTS- Baseline (continued)
Also in Table 3, alcohol was more often the
primary substance of abuse for those with a BDI gt
20 compared to those with a BDIlt20 (p0.015), and
there was a trend (p0.07 and p0.06,
respectively) for a higher percentage of cocaine
and amphetamine as primary for those with a BDI
score lt20.
Table 1. Describes the total sample of 225
participants. As can be seen, there were no
statistically significant differences in
demographics between treatment groups.
Although there is a great deal of data on the
effect of smoking cessation on mood, there is
less information on the effect of mood on smoking
cessation outcomes. The Clinical Trials Network
recently completed an 8-week, open-label trial
comparing the use of nicotine patches plus group
counseling and treatment as usual (TAU) to TAU
alone in a group of substance dependant
outpatients interested in quitting smoking. We
conducted a secondary analysis to evaluate the
effect of depression on smoking cessation
outcomes.
Table 3. Clinical Characteristics
Table 1. Demographics by Treatment Group
METHODS
This study was an 8-week open-label trial
comparing TAU plus nicotine patches and smoking
cessation counseling (SC) to TAU alone
participants were randomized in a 21 ratio.

• SUBJECTS
• 225 men and women, 18 years of age or older
• Enrolled in a drug-free or opioid replacement
  treatment program for the last 30 days and
  scheduled to remain in treatment for 30 days
  after randomization
• Must meet DSM-IV criteria for drug or alcohol
  dependence in the last year if on opioid
  replacement must be on stable dose
• Must smoke at least 10 cigarettes/day and have a
  COgt10ppm
• Could not be receiving any other smoking
  cessation interventions
• Could not be have a medical or psychiatric
  condition in immediate need of treatment or that
  would be negatively affected 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 then weekly.

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 lt
20. Individuals with history of MDD or a
baseline BDI score gt 20 were found to have higher
Fagerstrom scores for nicotine dependence.
In order to evaluate the effect of depression on
smoking cessation outcomes, the total sample was
divided into those who reported ever being
treated for depression (MDD) vs. those had not
(no MDD) the total was also divided into those
with a baseline BDI score lt 20 vs. those with a
baseline BDI score of gt 20. As can be seen in
Table 2, those with a history of MDD were less
likely to be employed at baseline (p0.034), and
there was a trend for the same group to be less
educated (p0.061)
Table 4. Smoking Characteristics by Affective
Group
Table 2. Demographics by Affective Group
RESULTS Outcome
CONCLUSIONS

• During the treatment phase of the study, the
  smoking abstinent rates in the TAU group were
  almost 0, so only those randomized to SC were
  evaluated to determine if depression moderates
  the effect of smoking abstinence.
• There is no strong evidence that history of MDD
  moderated the effect of treatment on the smoking
  abstinence.
• There is no strong evidence that baseline BDI
  level when used as a dichotomous variable (i.e.
  BDIlt20 vs. BDIgt20), moderated the effect of
  treatment on the smoking abstinence. However,
  when baseline BDI score was used as a continuous
  variable, there was a significant effect of
  baseline BDI on smoking abstinence in which lower
  BDI scores predicted greater smoking abstinence
  (p 0.0408).

• The effect of the SC treatment in the smoking
  abstinence is greater for those with a low
  baseline BDI than for those with a high baseline
  BDI. Thus, in this trial the baseline BDI score
  moderated the treatment effect on smoking
  abstinence rates.
• These data suggest that for individuals 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.

As can be seen in Table 3, opioids were the
primary substance of abuse for the majority of
participants. Most of the recruitment sites used
in this trial were opioid replacement programs.
When evaluating primary substance by affective
group, there was a trend for there to be more
primary opioid use in those without a history of
MDD (p0.08).
Sponsored by the NIDA Clinical Trials Network