The influence of quality of life and depressed mood on smoking cessation among medically ill smokers

Improvements in health-related quality of life among smokers who quit after hospitalization

Few rigorous longitudinal assessments have examined health-related quality of life (HRQoL) changes after smoking cessation, especially among recently-hospitalized smokers. We compared the change in HRQoL between those who did or did not quit smoking 6 months after hospital discharge. Participants were 1357 smokers recruited for a cessation trial between 2012 and 2014 while hospitalized at two hospitals in Massachusetts and one in Pennsylvania. Cessation was defined as biochemically confirmed 7-day point prevalence abstinence at 6 months or as self-reported continuous abstinence at 1, 3, or 6 months post discharge. HRQoL measures included a single-item global health measure (SF1); the Patient Health Questionnaire for Depression and Anxiety (PHQ-4) screening tool for psychological distress; and the EQ-5D-5L health utilities measure. Multivariable models controlled for age, sex, race, education, insurance, study site, study arm, discharge diagnoses, and baseline HRQoL. Improvements in HRQoL were evident in the first month after discharge among those achieving abstinence compared to continuing smokers. At 6 months post-discharge, those with biochemically confirmed cessation were 30% more likely to report at least good health by the SF1 (aRR 95% CI 1.14-1.45), 19% less likely to screen positive for psychological distress (aRR, 95% CI 0.68-0.93), and had EQ-5D-5L health utility scores 0.05 points (95% CI 0.02-0.08) higher than continuing smokers. Results were similar when assessed as a function of self-reported cessation. Hospital-initiated smoking cessation is associated with rapid statistically and clinically significant improvements in a range of HRQoL measures, providing an additional tool clinicians and health systems could use to encourage smoking cessation.

Nursing interventions for smoking cessation

BACKGROUND

Healthcare professionals, including nurses, frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

To determine the effectiveness of nursing-delivered smoking cessation interventions in adults. To establish whether nursing-delivered smoking cessation interventions are more effective than no intervention; are more effective if the intervention is more intensive; differ in effectiveness with health state and setting of the participants; are more effective if they include follow-ups; are more effective if they include aids that demonstrate the pathophysiological effect of smoking.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register and CINAHL in January 2017.

SELECTION CRITERIA

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically-validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed-effect model and reported the outcome as a risk ratio (RR) with a 95% confidence interval (CI).

MAIN RESULTS

Fifty-eight studies met the inclusion criteria, nine of which are new for this update. Pooling 44 studies (over 20,000 participants) comparing a nursing intervention to a control or to usual care, we found the intervention increased the likelihood of quitting (RR 1.29, 95% CI 1.21 to 1.38); however, statistical heterogeneity was moderate (I² = 50%) and not explained by subgroup analysis. Because of this, we judged the quality of evidence to be moderate. Despite most studies being at unclear risk of bias in at least one domain, we did not downgrade the quality of evidence further, as restricting the main analysis to only those studies at low risk of bias did not significantly alter the effect estimate. Subgroup analyses found no evidence that high-intensity interventions, interventions with additional follow-up or interventions including aids that demonstrate the pathophysiological effect of smoking are more effective than lower intensity interventions, or interventions without additional follow-up or aids. There was no evidence that the effect of support differed by patient group or across healthcare settings.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that behavioural support to motivate and sustain smoking cessation delivered by nurses can lead to a modest increase in the number of people who achieve prolonged abstinence. There is insufficient evidence to assess whether more intensive interventions, those incorporating additional follow-up, or those incorporating pathophysiological feedback are more effective than one-off support. There was no evidence that the effect of support differed by patient group or across healthcare settings.

Psychological, pharmacological, and combined smoking cessation interventions for smokers with current depression: A systematic review and meta-analysis

We conducted a systematic literature review and meta-analysis (ID: CRD42016051017) of smoking cessation interventions for patients with current depression. We examined the effectiveness of smoking cessation treatments in improving abstinence rates and depressive symptoms. The following electronic databases were used for potentially eligible studies: PUBMED, PSYCINFO, DIALNET and WEB OF KNOWLEDGE. The search terms used were: smoking cessation, depressive disorder, depression, mood, depressive, depressed, smoking, smokers, nicotine, nicotine dependence, and tobacco cigarette smoking. The methodological quality of included studies was assessed using the Effective Public Health Practice Project Quality assessment tool (EPHPP). Of the 6,584 studies identified, 20 were eligible and included in the review. Trial designs of studies were 16 randomized controlled trials and 4 secondary studies. Studies included three types of intervention: psychological (6/30%), pharmacological (6/30%) or combined (8/40%). Four trials comprised special populations of smokers. Four studies received a strong methodological quality, 7 were scored as moderate and 9 studies received a weak methodological rating. Analyses of effectiveness showed that smoking cessation interventions appear to increase short-term and long-term smoking abstinence in individuals with current depression. Subgroup analyses revealed stronger effects among studies that provided pharmacological treatments than in studies using psychological treatments. However, the evidence is weak due to the small number of studies. Smoking abstinence appears to be associated with an improvement in depressive symptoms. Heterogeneity in protocols in similar types of treatment also prevent firm conclusions being drawn on the effectiveness of any particular treatment model to optimally manage abstinence among depressed smokers. Further research is required to strengthen the evidence base.

Depression Symptoms Among Homeless Smokers: Effect of Motivational Interviewing

BACKGROUND

Tobacco use is higher among homeless individuals than the general population. Homeless individuals are also more likely to have symptoms of depression. Depression symptoms may add to the burden of homelessness by increasing psychological distress and serve as a barrier to quitting smoking.

OBJECTIVES

The primary goal of this study is to assess the impact of depression symptoms on psychological distress in homeless smokers. The effect of depression symptoms on abstinence and the effect of Motivational Interviewing (MI) on cessation among smokers is also explored.

METHODS

Homeless smokers (N = 430) enrolled in a smoking cessation study were randomized to Motivational Interviewing (MI) or standard care (SC). Participants received nicotine replacement therapy and were followed for 26 weeks. Participants were categorized into a depression symptoms (DS) group or control group using the Patient Health Questionnaire-9. Between group differences of perceived stress, hopelessness, confidence, craving and abstinence were assessed at weeks 8 and 26. The interaction between depression symptoms (levels: DS and control) and the intervention (levels: MI and SC) was also assessed.

RESULTS

Homeless smokers in the DS group reported higher levels of hopelessness, perceived stress, and craving. There was no effect of DS status on abstinence at week 8 or week 26. There was no significant interaction between depression symptoms (DS vs. Control) and the intervention (MI vs. SC).

CONCLUSION

Despite reporting greater psychological distress, homeless smokers with depression symptoms in this sample had abstinence levels similar to the control group. Future research should explore protective factors among depressed smokers.

Tobacco Use Among People Who Have Been in Prison: Relapse and Factors Associated with Trying to Quit

Introduction

Tobacco use is common among people who have been in prison. The relationship between social stressors, risky health behaviours, and smoking cessation has not been studied in people recently released from prison. Studying this relationship could yield information that guides strategic and cost-effective tobacco cessation interventions for an under-resourced population.

Methods

One hundred and forty-three smokers were interviewed 7 to 21 days after they had been released from USA prisons. Independent variables included employment status, housing security, relationship problems, educational achievement, risky drinking behaviour, recent drug use, history of drug dependence, and depression. The primary outcome was 'trying to quit smoking.' Data were analysed using Pearson chi-square tests and single and multivariable logistic regression models.

Results

Of those who had to quit smoking due to tobacco-free prison policies, 98% reported relapsing on tobacco after release. Trying to quit smoking was associated with the absence of risky drinking behaviour in the past 30 days (adjusted odds ratio [AOR] 6.44, 95% confidence interval [CI] 2.02-20.48).

Conclusions

The absence of risky drinking behaviour is associated with trying to quit smoking among people recently released from prison. Further research may determine whether interventions addressing risky alcohol use can reduce smoking relapse.

Trajectories of smoking behavior as a function of mood and satisfaction with life: What matters most?

BACKGROUND

Worldwide, tobacco use causes more than 5 million deaths per year. The present study investigated possible preventative factors of nicotine dependence, such as mood and Satisfaction With Life (SWL).

METHODS

Longitudinal Internet survey of 1957 individuals assessed three times at a two week interval (2007-2010).

OUTCOME MEASURES

Cigarette Dependence Scale (CDS), feeling prisoner to cigarettes, smoking cessation, reduction, and relapse.

PREDICTORS

Time (i.e. trajectory of dependence over time), smoking status (daily, occasional or ex-smoker), mood, and SWL. All measures were assessed at each time point.

RESULTS

Both SWL, and mood, respectively were significantly associated with dependence (slopeSWL=-0.03, slopeSWL=-0.11, ps<0.001). With respect to feeling prisoner to cigarettes, mood but not SWL showed a significant association (slopeSWL=-0.14, p<0.001). Occasional, and ex-smokers showed significantly greater decrease in psychological dependence, as mood increased, than daily smokers (slopeoccasional=-0.28, poccasional=0.011; slopeex=-0.27, pex<0.001). Smoking cessation decreased over time, and both mood, as well as SWL had a significant impact on cessation (ORmood=1.43, pmood<0.01, ORSWL=1.15, pSWL=0.042). Reduction in smoking was predicted by SWL only (ORSWL=1.21, p=0.043), whereas relapse was predicted by mood only (ORmood=0.55, p<0.01).

LIMITATIONS

The participants were self-selected. Possible confounding relationships (e.g., medication) have to be further assessed.

CONCLUSIONS

Cigarette dependence, feeling prisoner to cigarettes, cessation, and reduction are significantly influenced by both mood and SWL. Treatments may thus tackle mood regulation, SWL, and nicotine dependence in tandem.

Polycyclic aromatic hydrocarbons and cytochrome P450 in HIV pathogenesis

High prevalence of cigarette smoking in HIV patients is associated with increased HIV pathogenesis and disease progression. While the effect of smoking on the occurrence of lung cancer has been studied extensively, the association between smoking and HIV pathogenesis is poorly studied. We have recently shown the possible role of cytochrome P450 (CYP) in smoking/nicotine-mediated viral replication. In this review, we focus on the potential role of CYP pathway in polycyclic aromatic hydrocarbons (PAH), important constituents of cigarette smoke, mediated HIV pathogenesis. More specifically, we will discuss the role of CYP1A1 and CYP1B1, which are the major PAH-activating CYP enzymes. Our results have shown that treatment with cigarette smoke condensate (CSC) increases viral replication in HIV-infected macrophages. CSC contains PAH, which are known to be activated by CYP1A1 and CYP1B1 into procarcinogens/toxic metabolites. The expression of these CYPs is regulated by aryl hydrocarbon receptors (AHR), the cellular target of PAH, and an important player in various diseases including cancer. We propose that PAH/AHR-mediated CYP pathway is a novel target to develop new interventions for HIV positive smokers.

Tobacco Use, Quitting Behavior, and Health Characteristics Among Current Electronic Cigarette Users in a National Tri-Ethnic Adult Stable Smoker Sample

INTRODUCTION

The present study characterizes the tobacco use, quitting behaviors, and health characteristics of cigarette smokers who did not change their smoking pattern over the past 6 months and have used electronic cigarettes (ECs) in the past 30 days. This is an important subpopulation to characterize if EC dual use with cigarettes continues to grow.

METHODS

Participants (N = 2,376) from a research survey panel completed an online cross-sectional survey between June and August 2012. Sampling was stratified to recruit equal numbers of cigarette smoking participants by race/ethnicity (Black, Hispanic, and Caucasian) and smoking frequency (nondaily and daily). All displayed a stable rate of smoking for the past 6 months and were not currently in treatment. Bivariate and multivariate analyses were used to examine correlates of current EC use (any use within the past 30 days).

RESULTS

Current EC use was reported by 9.2% (n = 219) of the total sample. Of current EC users, 44% reported having used ECs as a quit method. Bivariate and multivariate analyses showed that current EC use was significantly associated with greater nicotine dependence, concurrent poly-tobacco use, more past-year quit attempts, past use of multiple cessation methods, and more depressive symptoms. No demographic variables were significantly associated with current EC use.

CONCLUSIONS

This study suggests that stable smokers who currently use ECs possess characteristics that are associated with difficulty in achieving smoking cessation. These characteristics should be considered when examining the effectiveness of ECs on cessation and in designing future cessation trials using ECs.

Smoking cessation interventions for smokers with current or past depression

BACKGROUND

Individuals with current or past depression are often smokers who are more nicotine dependent, more likely to suffer from negative mood changes after nicotine withdrawal, and more likely to relapse to smoking after quitting than the general population, which contributes to their higher morbidity and mortality from smoking-related illnesses. It remains unclear what interventions can help them to quit smoking.

OBJECTIVES

To evaluate the effectiveness of smoking cessation interventions, with and without specific mood management components, in smokers with current or past depression.

SEARCH METHODS

In April 2013, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, other reviews, and asked experts for information on trials.

SELECTION CRITERIA

Criteria for including studies in this review were that they had to be randomised controlled trials (RCTs) comparing smoking cessation interventions in adult smokers with current or past depression. Depression was defined as major depression or depressive symptoms. We included studies where subgroups of participants with depression were identified, either pre-stated or post hoc. The outcome was abstinence from smoking after six months or longer follow-up. We preferred prolonged or continuous abstinence and biochemically validated abstinence where available.

DATA COLLECTION AND ANALYSIS

When possible, we estimated pooled risk ratios (RRs) with the Mantel-Haenszel method (fixed-effect model). We also performed subgroup analyses, by length of follow-up, depression measurement, depression group in study, antidepressant use, published or unpublished data, format of intervention, level of behavioural support, additional pharmacotherapy, type of antidepressant medication, and additional nicotine replacement therapy (NRT).

MAIN RESULTS

Forty-nine RCTs were included of which 33 trials investigated smoking cessation interventions with specific mood management components for depression. In smokers with current depression, meta-analysis showed a significant positive effect for adding psychosocial mood management to a standard smoking cessation intervention when compared with standard smoking cessation intervention alone (11 trials, N = 1844, RR 1.47, 95% CI 1.13 to 1.92). In smokers with past depression we found a similar effect (13 trials, N = 1496, RR 1.41, 95% CI 1.13 to 1.77). Meta-analysis resulted in a positive effect, although not significant, for adding bupropion compared with placebo in smokers with current depression (5 trials, N = 410, RR 1.37, 95% CI 0.83 to 2.27). There were not enough trial data to evaluate the effectiveness of fluoxetine and paroxetine for smokers with current depression. Bupropion (4 trials, N = 404, RR 2.04, 95% CI 1.31 to 3.18) might significantly increase long-term cessation among smokers with past depression when compared with placebo, but the evidence for bupropion is relatively weak due to the small number of studies and the post hoc subgroups for all the studies. There were not enough trial data to evaluate the effectiveness of fluoxetine, nortriptyline, paroxetine, selegiline, and sertraline in smokers with past depression.Twenty-three of the 49 trials investigated smoking cessation interventions without specific components for depression. There was heterogeneity between the trials which compared psychosocial interventions with standard smoking cessation counselling for both smokers with current and past depression. Therefore, we did not estimate a pooled effect. One trial compared nicotine replacement therapy (NRT) versus placebo in smokers with current depression and found a positive, although not significant, effect (N = 196, RR 2.64, 95% CI 0.93 to 7.45). Meta-analysis also found a positive, although not significant, effect for NRT versus placebo in smokers with past depression (3 trials, N = 432, RR 1.17, 95% CI 0.85 to 1.60). Three trials compared other pharmacotherapy versus placebo and six trials compared other interventions in smokers with current or past depression. Due to heterogeneity between the interventions of the included trials we did not estimate pooled effects.

AUTHORS' CONCLUSIONS

Evidence suggests that adding a psychosocial mood management component to a standard smoking cessation intervention increases long-term cessation rates in smokers with both current and past depression when compared with the standard intervention alone. Pooled results from four trials suggest that use of bupropion may increase long-term cessation in smokers with past depression. There was no evidence found for the use of bupropion in smokers with current depression. There was not enough evidence to evaluate the effectiveness of the other antidepressants in smokers with current or past depression. There was also not enough evidence to evaluate the group of trials that investigated interventions without specific mood management components for depression, including NRT and psychosocial interventions.

Nursing interventions for smoking cessation

BACKGROUND

Healthcare professionals, including nurses, frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

To determine the effectiveness of nursing-delivered smoking cessation interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group specialized Register and CINAHL in June 2013.

SELECTION CRITERIA

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed-effect model and reported the outcome as a risk ratio (RR) with a 95% confidence interval (CI).

MAIN RESULTS

Forty-nine studies met the inclusion criteria. Pooling 35 studies (over 17,000 participants) comparing a nursing intervention to a control or to usual care, we found the intervention to increase the likelihood of quitting (RR 1.29; 95% CI 1.20 to 1.39). In a subgroup analysis the estimated effect size was similar for the group of seven studies using a particularly low intensity intervention but the confidence interval was wider. There was limited indirect evidence that interventions were more effective for hospital inpatients with cardiovascular disease than for inpatients with other conditions. Interventions in non-hospitalized adults also showed evidence of benefit. Eleven studies comparing different nurse-delivered interventions failed to detect significant benefit from using additional components. Six studies of nurse counselling on smoking cessation during a screening health check or as part of multifactorial secondary prevention in general practice (not included in the main meta-analysis) found nursing intervention to have less effect under these conditions.

AUTHORS' CONCLUSIONS

The results indicate the potential benefits of smoking cessation advice and/or counselling given by nurses, with reasonable evidence that intervention is effective. The evidence for an effect is weaker when interventions are brief and are provided by nurses whose main role is not health promotion or smoking cessation. The challenge will be to incorporate smoking behaviour monitoring and smoking cessation interventions as part of standard practice so that all patients are given an opportunity to be asked about their tobacco use and to be given advice and/or counselling to quit along with reinforcement and follow-up.

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 between Smoking and Depression Post-Acute Coronary Syndrome

The purpose of the current paper is to review research on the relationship between smoking cessation and depressed mood post-Acute Coronary Syndrome (Myocardial infarction or unstable angina; ACS). Emerging evidence regarding the effect of anhedonia-a specific subcomponent of mood disturbance characterized by reduced pleasure-on post-ACS outcomes is also discussed. There is strong evidence that depression prospectively predicts post-ACS relapse to smoking. Weaker evidence suggests that smoking at the time of ACS is related to post-ACS depression. Bupropion is a particularly promising treatment for this population because of its smoking cessation and anti-depressant effects. Future research should focus on the relative risk of using nicotine replacement therapies post-ACS, the efficacy of bupropion for smoking cessation and depression reduction in post-ACS patients, the role of anhedonia in post-ACS smoking cessation, and the development and testing of integrated behavioral treatments (smoking cessation plus interventions targeting mood management) for ACS patients.

Depressive symptoms and smoking in middle-aged and older women

INTRODUCTION

Smoking research and intervention efforts have neglected older women. Depressive symptoms, which are common in middle-aged and older women, are related to the maintenance of adult smoking.

METHODS

This study investigated the relation of a composite measure of current depressive symptoms, derived from a short form of the Center for Epidemiological Studies Depression Scale, and history of depressive symptoms, derived from two items from the Diagnostic Interview Schedule, to smoking outcomes in the Women's Health Initiative Observational Study (N = 90,627). Participants were postmenopausal with an average age of 63.6 years at baseline. Participants were recruited from urban, suburban, and rural areas surrounding 40 clinical centers in the United States. Analyses controlled for age, educational level, and ethnicity.

RESULTS

In multinomial logistic regression analyses, depressive symptoms were related cross-sectionally to current light (odds ratio [OR] = 1.19, 95% CI = 1.14-1.23) and heavier (OR = 1.28, 95% CI = 1.23-1.32) smoking at baseline compared with nonsmokers. In prospective multiple logistic regression analyses, baseline depressive symptoms were negatively predictive of smoking cessation at a 1-year follow-up (OR = .85, 95% CI = 0.77-0.93) and at participants' final assessments in the study (OR = .92, 95% CI = 0.85-0.98). Light smokers had more than 2 times higher odds of smoking cessation than did heavier smokers.

CONCLUSIONS

The present findings demonstrate a consistent link between depressive symptoms and negative smoking-related behaviors among middle-aged and older women at both light and heavier smoking levels.