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.

Treatment adherence in a smoking cessation clinical trial for individuals with current or past major depressive disorder: Predictors and association with cessation

INTRODUCTION

Individuals with major depressive disorder (MDD) exhibit high rates of tobacco use and lower responsiveness to tobacco cessation treatments. Treatment adherence is a strong predictor of treatment outcomes in the general population but has not been evaluated in this under-served community of smokers with MDD.

METHODS

We used data from a randomized clinical trial on smoking cessation treatment among 300 smokers with MDD to examine the rate of adherence (medication and counseling), the association of adherence with cessation outcomes, and factors associated with adherence, including demographic and smoking characteristics, psychiatric characteristics, smoking cessation processes (e.g., withdrawal, reinforcers), and treatment-related side effects (e.g., nausea).

RESULTS

Overall, 43.7% of participants were adherent with medication and 63.0% were adherent with counseling. Medication adherence was significantly associated with cessation, with 32.1% of adherent vs. 13.0% of non-adherent participants quitting smoking at EOT. Counseling adherence was also significantly associated with cessation, with 32.3% of adherent vs. 2.7% of non-adherent participants quitting smoking. Multivariate regression models showed that medication adherence was associated with higher engagement in complementary reinforcers and higher baseline smoking reward, while counseling adherence was associated with identifying as female, lower alcohol use and nicotine dependence, higher baseline smoking reward, and higher engagement in substitute and complementary reinforcers within the first weeks of medication use.

CONCLUSIONS

As with the general population of smokers, non-adherence to treatment in smokers experiencing depression is widespread and a significant barrier to cessation. Interventions that target reinforcers may improve rates of treatment adherence.

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

Objective:

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

Methods:

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

Results:

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

Conclusions:

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

Cognitive-Behavioral Treatment of Nicotine Dependence for a Female With a History of Alcohol and Respiratory Problems

This case study describes the effectiveness of cognitive-behavioral therapy for nicotine dependence among smokers with comorbid alcohol dependence and severe respiratory difficulties. Although clinical practice guidelines exist for the treatment of nicotine dependence, smokers with complicated psychological and medical histories remain resilient to recommended treatments. Successfulsmoking cessation programs for these patients require a comprehensive biopsychosocial assessment as well as a tailored treatment approach. A theoretical and empirically based rationale for cognitive-behavioral treatment is provided followed by the development of a case conceptualization, course of treatment, use of assessment data, and recommendations.

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

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

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.

Intention to quit tobacco use among clients in substance use disorder treatment settings

The purpose of this study was to investigate the influence of age, gender, tobacco-related knowledge, treatment modality, and changes in smoking patterns on intention to quit tobacco use among individuals participating in substance use disorder (SUD) treatment in Ohio. Of the 791 SUD program attendees, 91.7% currently used tobacco, with cigarette smoking being the most prevalent form of use. Among tobacco users, 67% reported intention to quit tobacco use. Four of the five hypothesized predictor variables had a significant relationship with intention to quit tobacco: gender, age, treatment modality, and smoking pattern, with age and gender demonstrating the strongest relationships to intention to quit smoking.

Correlates of motivation to quit smoking among alcohol dependent patients in residential treatment

Substance use and smoking co-occur at high rates and substance abusers smoke more and have greater difficulty quitting smoking compared to the general population. Methods of increasing smoking cessation among alcoholics are needed to improve their health. This study investigated predictors of motivation to quit smoking among patients early in residential treatment for substance abuse. The 198 alcohol dependent patients were participating is a larger smoking study at an inner-city residential substance abuse treatment program. Motivation was measured by the Contemplation Ladder. A hierarchical multiple regression was conducted to assess whether perceived barriers to smoking cessation and self-efficacy about quitting were associated with motivation to quit smoking independent of the influence of degree of tobacco involvement, substance use, and comorbid depressive symptoms. Motivation was higher with longer previous smoking abstinence, fewer barriers to quitting, and greater self-efficacy but was not influenced by smoking rate, dependence, or gender. While the combination of alcohol and drug use, alcohol and drug problem severity, and depressive symptoms predicted motivation, no one of these variables was significant. Since barriers to change and self-efficacy are potentially modifiable in treatment, these could be salient targets for intervention efforts. This could be integrated into treatment by assessing barriers and providing corrective information about consequences and methods of overcoming barriers and by providing coping skills to increase confidence in one's ability to quit smoking.

Craving and other characteristics of the comorbidity of alcohol and nicotine dependence

PURPOSE

In this cross-sectional study we compared alcohol-dependent smokers and non-alcohol-dependent smokers with respect to intensity of nicotine dependence, craving conditions, sleep disturbances, comorbidity with major depression, reasons for smoking, accompanying somatic diseases and patients' prolonged abstinence from smoking during the 3 years preceding the study.

SUBJECTS AND METHODS

Fifty-one alcohol-dependent smokers and 327 non-alcohol-dependent smokers diagnosed as ICD-10 and DSM-IV-nicotine dependent, were investigated by means of the Fagerström Test for Nicotine Dependence, the Lübeck Craving-Recurrence Risk Questionnaire and the Lesch Alcohol Dependence Typology (both adapted to smoking).

RESULTS

The intensity of nicotine dependence was more enhanced in alcohol-dependent smokers compared to non-alcohol-dependent smokers. Several variables of all factors of craving ("depressive mood", "stimulation", "relaxation", "socially triggered tension") were significantly increased in alcohol-dependent patients (P<0.05). Alcohol-dependent smokers showed depressive symptoms and sleep disturbances, whilst non-alcohol-dependent individuals mainly smoked for stress release and weight control.

DISCUSSION

Our study demonstrates that the intensity of nicotine dependence, several conditions of craving for nicotine, sleep disturbances and symptoms of depression appear to be enhanced in alcohol-dependent smokers compared with non-alcohol-dependent smokers. Conclusions. - It is hoped that the factors of craving and reasons for smoking identified in this study will contribute to a better understanding of smoking temptation in alcohol-dependent smokers and non-alcohol-dependent smokers in future.

Changes in cigarette consumption and drinking outcomes: findings from Project MATCH

Individuals undergoing treatment for alcohol use disorders smoke at rates that exceed those reported in the general population, and most patients will continue to smoke after treatment completion. A growing body of research indicates that quitting smoking is associated with better alcoholism treatment outcomes. Studies that dichotomize participants into smokers and nonsmokers, however, may be overlooking the possibility that even decreases in cigarette consumption over time among continuing smokers may also be related to improved alcohol use outcomes. The purpose of this article was to examine the relationship between cigarette consumption and alcohol use outcomes using data from Project MATCH. Smokers were divided into three groups according to whether their cigarette consumption decreased, increased, or remained constant from baseline to the 15-month follow-up. Results showed that smokers whose cigarette consumption decreased were significantly less likely to relapse to alcohol use than those whose consumption increased or remained unchanged. These findings suggest that even reductions in tobacco use may be associated with better drinking outcomes in alcoholism treatment.

A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery

This meta-analysis examined outcomes of smoking cessation interventions evaluated in 19 randomized controlled trials with individuals in current addictions treatment or recovery. Smoking and substance use outcomes at posttreatment and long-term follow-up (> or = 6 months) were summarized with random effects models. Intervention effects for smoking cessation were significant at posttreatment and comparable for participants in addictions treatment and recovery; however, intervention effects for smoking cessation were nonsignificant at long-term follow-up. Smoking cessation interventions provided during addictions treatment were associated with a 25% increased likelihood of long-term abstinence from alcohol and illicit drugs. Short-term smoking cessation effects look promising, but innovative strategies are needed for long-term cessation. Contrary to previous concerns, smoking cessation interventions during addictions treatment appeared to enhance rather than compromise long-term sobriety.

Perceived barriers to quitting smoking among alcohol dependent patients in treatment

Little is known about the perceived barriers to quitting smoking among alcohol abusers. In addition to the usual barriers perceived by smokers, alcohol dependent smokers may have a few barriers unique to their addictive lifestyle. The Barriers to Quitting Smoking in Substance Abuse Treatment (BQS-SAT) was administered to 96 alcohol dependent smokers in residential substance abuse treatment. The BQS-SAT is designed to assess perceived barriers to quitting smoking among alcohol abusers using eleven true-false items. One open-ended item was included to gather information about potential additional barriers. The majority of respondents reported withdrawal-related barriers such as expecting to feel irritable, anxious, restless, and about half expected intolerable urges to smoke if they were to quit smoking, as most smokers do. However, concerns about effects on sobriety and needing cigarettes to cope with feeling down were also endorsed by almost half of the patients. Total number of perceived barriers was significantly related to smoking history, expected effects from smoking, and smoking temptation but was not associated with severity of alcohol use or dependence on admission. Providing corrective feedback about these barriers could be useful when addressing smoking with patients who have alcohol abuse or dependence.