Addressing heavy drinking in smoking cessation treatment: a randomized clinical trial

The effects of alcohol use on smoking cessation treatment with nicotine replacement therapy: An observational study

INTRODUCTION

Concurrent users of tobacco and alcohol are at greater risk of harm than use of either substance alone. It remains unclear how concurrent tobacco and alcohol use affects smoking cessation across levels of alcohol use and related problems. This study assessed the relationship between smoking cessation and levels of alcohol use problems.

METHODS

59,018 participants received nicotine replacement therapy through a smoking cessation program. Alcohol use and related symptoms were assessed using the Alcohol Use Disorders Identification Test (AUDIT-10) and the AUDIT-Concise (AUDIT-C). The primary outcome was 7-day point prevalence cigarette abstinence (PPA) at 6-month follow-up. We evaluated the association between alcohol use (and related problems) and smoking cessation using descriptive methods and mixed-effects logistic regression.

RESULTS

7-day PPA at 6-months was lower in groups meeting hazardous alcohol consumption criteria, with the lowest probability of smoking abstinence observed in the highest risk group. The probability of successful tobacco cessation fell with increasing levels of alcohol use and related problems. Adjusted predicted probabilities were 30.3 (95 % CI = 29.4, 31.1) for non-users, 30.2 (95 % CI = 29.4, 31.0) for low-risk users, 29.0 (95 % CI = 28.1, 29.9) for those scoring below 8 on the AUDIT-10, 27.3 (95 % CI = 26.0, 28.6) for those scoring 8-14, and 24.4 (95 % CI = 22.3, 26.5) for those scoring 15 or higher.

CONCLUSION

Heavy, hazardous alcohol use is associated with lower odds of successfully quitting smoking compared to low or non-use of alcohol. Targeting alcohol treatment to this group may improve tobacco cessation outcomes.

A smoking cessation intervention for rural veterans tailored to individual risk factors: A multicenter randomized clinical trial

INTRODUCTION

Rates of cigarette use remain elevated among those living in rural areas. Depressive symptoms, risky alcohol use, and weight concerns frequently accompany cigarette smoking and may adversely affect quitting. Whether treatment for tobacco use that simultaneously addresses these issues affects cessation outcomes is uncertain.

METHODS

The study was a multicenter, two-group, randomized controlled trial involving mostly rural veterans who smoke (N = 358) receiving treatment at one of five Veterans Affairs Medical Centers. The study randomly assigned participants to a tailored telephone counseling intervention or referral to their state tobacco quitline. Both groups received guideline-recommended smoking cessation pharmacotherapy, selected using a shared decision-making approach. The primary outcome was self-reported seven-day point prevalence abstinence (PPA) at three and six months. The study used salivary cotinine to verify self-reported quitting at six months.

RESULTS

Self-reported PPA was significantly greater in participants assigned to Tailored Counseling at three (OR = 1.66; 95 % CI: 1.07-2.58) but not six (OR = 1.35; 95 % CI: 0.85-2.15) months. Post hoc subgroup analyses examining treatment group differences based on whether participants had a positive screen for elevated depressive symptoms, risky alcohol use, and/or concerns about weight gain indicated that the cessation benefit of Tailored Counseling at three months was limited to those with ≥1 accompanying concern (OR = 2.02, 95 % CI: 1.20-3.42). Biochemical verification suggested low rates of misreporting.

CONCLUSIONS

A tailored smoking cessation intervention addressing concomitant risk factors enhanced short-term abstinence but did not significantly improve long-term quitting. Extending the duration of treatment may be necessary to sustain treatment effects.

Integrating long-acting injectable treatment to improve medication adherence among persons living with HIV and opioid use disorder: study protocol

BACKGROUND

Oral antiretroviral therapy (ART) has been effective at reducing mortality rates of people with HIV. However, despite its effectiveness, people who use drugs face barriers to maintaining ART adherence. Receipt of opioid agonist treatment, in the context of HIV care, is associated with medication adherence and decreased HIV viral loads. Recent pharmacological advancements have led to the development of novel long-acting, injectable, medications for both HIV (cabotegravir co-administered with rilpivirine) and OUD (extended-release buprenorphine). These therapies have the potential to dramatically improve adherence by eliminating the need for daily pill-taking. Despite the extensive evidence base supporting long-acting injectable medications for both HIV and OUD, and clinical guidelines supporting integrated care provision, currently little is known about how these medications may be optimally delivered to this population. This paper presents the study design for the development of a clinical protocol to guide the delivery of combined treatment for HIV and OUD using long-acting injectable medications.

METHODS

The study aims are to: (1) develop a clinical protocol to guide the delivery of combined LAI for HIV and OUD by conducting in-depth interviews with prospective patients, clinical content experts, and other key stakeholders; and (2) conduct This single group, open pilot trial protocol to assess feasibility, acceptability, and safety among patients diagnosed with HIV and OUD. Throughout all phases of the study, information on patient-, provider-, and organizational-level variables will be collected to inform future implementation.

DISCUSSION

Findings from this study will inform the development of a future study to conduct a fully-powered Hybrid Type 1 Effectiveness-Implementation design.

Pilot randomized controlled trial of mindfulness-based relapse prevention vs cognitive behavioral therapy for smoking and alcohol use

BACKGROUND

The combined use of cigarettes and alcohol is associated with a synergistic increase in the risk of morbidity and mortality. Continued alcohol use during a smoking quit attempt is a considerable risk factor for smoking relapse. As such, there is a need for interventions that address both behaviors concurrently. Mindfulness-based interventions hold much promise for simultaneously addressing tobacco and alcohol use.

METHOD

This pilot study evaluated the feasibility and acceptability of a mindfulness-based intervention using a two-arm randomized controlled trial of Mindfulness-Based Relapse Prevention for Smoking and Alcohol (MBRP-SA) vs Cognitive Behavioral Therapy (CBT). Interventions were delivered via telehealth in a group setting; all participants received a 6-week supply of the nicotine patch. Participants (N = 69) were adults who smoked cigarettes who reported binge drinking and were motivated to both quit smoking and change their alcohol use. Primary outcomes were feasibility and acceptability of MBRP-SA compared to CBT. Changes in tobacco and alcohol use are also presented.

RESULTS

Participants in MBRP-SA and CBT indicated that the treatments were highly acceptable, meeting a priori benchmarks. Feasibility was mixed with some outcomes meeting benchmarks (e.g., recruitment) and others falling below (e.g., retention). Participants in both conditions demonstrated significant reductions in tobacco and alcohol use at the end of treatment.

CONCLUSIONS

In sum, MBRP-SA had comparable outcomes to CBT on all metrics measured. Future research should evaluate the efficacy of MBRP-SA on smoking abstinence and drinking reductions in a large-scale, fully powered trial. This study was registered on clinicaltrials.gov (NCT03734666).

The effect of alcohol use on smoking cessation: A systematic review

Only a small minority of all attempts to stop smoking are successful, especially among smokers who are heavy drinkers and those with an alcohol use disorder. The current systematic review focuses on the negative effects of alcohol use, either before or during attempts to quit smoking, on the success rate of these attempt(s) in alcohol-drinking tobacco smokers. We conducted a systematic review of naturalistic and experimental studies, which included at least 40 tobacco smokers with a recorded drinking status (non-drinking, heavy drinking, alcohol use disorder) and a clearly documented change in alcohol consumption. We could not conduct a meta-analysis and, thus, used consistency across studies to draw conclusions. The evidence presented here shows that alcohol use is associated with lower rates of success in quitting smoking in 20 out of 27 studies. This includes both lapses and relapses. Similarly, in 19 out of 20 long-term follow-up studies, the duration of smoking abstinence was shorter among persons with higher alcohol consumption. Finally, 12 out of 13 experimental studies showed that exposure of smokers to alcohol cues or to drinking of alcohol induce a strong propensity to smoke. It is, therefore, recommended for smokers who drink alcohol and who intend to quit smoking to use an integrated approach, i.e., to stop or substantially reduce their alcohol consumption before and/or during their attempt to quit smoking.

Combination treatment with varenicline and naltrexone reduces World Health Organization risk drinking levels

BACKGROUND

The U.S. Food and Drug Administration identifies abstinence and the absence of heavy drinking days as outcomes for pharmacotherapy trials for alcohol use disorder (AUD). However, many individuals with AUD struggle to achieve these outcomes, which may discourage them from seeking treatment. World Health Organization (WHO) risk drinking levels have garnered attention in the alcohol field as potential non-abstinent outcomes for AUD medication trials. Further, testing combination pharmacotherapy for AUD represents an important direction in the field, particularly using medications such as naltrexone and varenicline, which are approved for treating AUD and smoking, respectively. The objective of the current study was to test the utility of the WHO risk drinking levels as a drinking outcome in a randomized clinical trial of combined varenicline and naltrexone for smoking cessation and drinking reduction. These analyses provide additional tests of the efficacy of this combination treatment.

METHODS

The current study is a secondary analysis of a phase 2, randomized, double-blind clinical trial, wherein participants (N = 165) who were daily smokers and heavy drinkers were randomly assigned to receive either 2 mg/day of varenicline plus 50 mg/day of naltrexone or 2 mg/day of varenicline plus placebo for 12 weeks. Medication effects on 1- and 2-level reductions in WHO risk drinking levels were assessed at 4, 8, and 12 weeks into the active medication period.

RESULTS

In logistic growth curve models individuals receiving the combined treatment had greater reductions in WHO risk drinking levels than individuals taking varenicline alone when assessed at 4 weeks into the active medication period. Among individuals who were WHO high and very high risk drinkers at baseline, the largest effect sizes favoring combination treatment were at Week 4 for the WHO 2-level reduction outcome (Cohen's h = 0.202) and Week 12 for the WHO 1-level reduction outcome (Cohen's h = 0.244), although these effects did not reach statistical significance.

CONCLUSIONS

These findings provide evidence that combined varenicline plus naltrexone treatment is effective at reducing WHO risk drinking levels, particularly among individuals who smoke cigarettes daily and drink heavily. These results add to a growing body of literature validating reductions in WHO risk drinking levels as outcomes of alcohol medication trials.

Efficacy of smartphone applications for smoking cessation in heavy-drinking adults: Secondary analysis of the iCanQuit randomized trial

INTRODUCTION

Efficacious smoking cessation treatments are needed for heavy-drinking adults who often have difficulty quitting smoking. In a secondary analysis of a parent randomized controlled trial, we explored the efficacy of an Acceptance and Commitment Therapy (ACT)-based smartphone application (iCanQuit) versus a US Clinical Practice Guidelines (USCPG)-based smartphone application (QuitGuide) for smoking cessation among heavy-drinking participants (4 + drinks/day for women; 5 + drinks/day for men).

METHODS

Participants were randomized to receive iCanQuit (n = 188) or QuitGuide (n = 160) for 12-months. Smoking cessation outcomes were measured at 3, 6 and 12-months. The primary outcome was self-reported complete-case 30-day point prevalence abstinence (PPA) at 12-months. Secondary outcomes were 7-day PPA at all timepoints; prolonged abstinence; and cessation of all nicotine-containing products at 12-months. Multiple imputation and missing-as-smoking analyses were also conducted. Exploratory outcomes were cessation of both smoking and heavy drinking and change in alcohol use (drinks/day) at 12-months. Treatment engagement and satisfaction and change in ACT-based processes were compared between arms.

RESULTS

Retention rate was 85% at 12-months and did not differ by arm. At 12-months, iCanQuit participants had nearly double the odds of smoking cessation compared to QuitGuide (complete-case 30-day PPA = 24% vs. 15%; OR = 1.87 95% CI: 1.03, 3.42). Findings were similar for the multiple imputation and missing-as-smoking outcomes at 12-months. Combined cessation of smoking and heavy drinking, and alcohol use at 12-months did not differ by arm. iCanQuit was significantly more engaging and satisfying than QuitGuide. Increased acceptance of thoughts about smoking mediated the effect of treatment on cessation of heavy drinking at 12-months.

CONCLUSIONS

The iCanQuit smartphone application was more efficacious and engaging for smoking cessation among heavy-drinking adults than a USCPG-based smartphone application.

The Effects of Menstrual Cycle Hormones on Responses to Varenicline and Naltrexone Among Female Heavy Drinking Smokers

Aims

Women often experience poorer smoking cessation outcomes in comparison to men. Menstrual cycle phase and sex hormones may influence smoking behavior and alter response to opioid antagonist medications. Less is known about the effects of sex hormones in response to pharmacotherapy for female heavy drinking smokers.

Methods

This study is a secondary analysis of premenopausal female heavy drinking smokers who completed a 12-week randomized clinical trial comparing varenicline plus placebo versus varenicline plus naltrexone for smoking cessation and drinking reduction. Participants (n = 26; total observations = 66) provided saliva samples for assays of progesterone (P4) and estradiol (E2) post-randomization at Weeks 4, 8 and 12. We examined the effects of P4/E2 ratio and medication on smoking and drinking outcomes.

Results

For drinking outcomes, there was a significant interaction for percent days abstinent (b = 0.017, P = 0.05), suggesting that greater P4/E2 ratio is associated with greater percent days abstinent for women assigned to the varenicline plus naltrexone condition. There were no interaction effects for the remaining drinking outcomes (P’s ≥ 0.12). Results found no significant interaction effect of P4/E2 ratio and medication on smoking abstinence (P = 0.19).

Conclusion

Our results imply that when women show a greater P4/E2 ratio, typically observed during the luteal phase of the menstrual cycle, they experience an added benefit of naltrexone, versus placebo, for drinking outcomes as shown by greater percent days abstinent. Additional studies in larger samples are warranted as sex hormones offer important information above and beyond comparing women versus men.

Efficacy of Combining Varenicline and Naltrexone for Smoking Cessation and Drinking Reduction: A Randomized Clinical Trial

OBJECTIVE

Pharmacological treatments that can concomitantly address cigarette smoking and heavy drinking stand to improve health care delivery for these highly prevalent co-occurring conditions. This superiority trial compared the combination of varenicline and naltrexone against varenicline alone for smoking cessation and drinking reduction among heavy-drinking smokers.

METHODS

This was a phase 2 randomized double-blind clinical trial. Participants (N=165) who were daily smokers and drank heavily received either 2 mg/day of varenicline plus 50 mg/day of naltrexone or 2 mg/day of varenicline plus matched placebo pills for 12 weeks. Primary outcomes were 7-day point prevalence of nicotine abstinence (bioverified by a breath CO reading ≤5 ppm) at the 26-week follow-up and number of drinks per drinking day during the 12-week treatment phase.

RESULTS

Smoking abstinence at week 26 was significantly higher in the varenicline plus placebo condition than in the varenicline plus naltrexone condition (N=37 [45.1%] compared with N=22 [26.5%]). For drinks per drinking day, there was a medication effect favoring the combination of varenicline and naltrexone over varenicline alone across the 12-week treatment phase, although it did not meet the significance threshold.

CONCLUSIONS

These findings suggest that smoking cessation and drinking reduction can be concomitantly targeted with pharmacotherapy and that while varenicline alone may be sufficient as a smoking cessation aid in heavy-drinking smokers, the combination of varenicline and naltrexone may confer benefits with regard to drinking outcomes, particularly during the 12-week period of active medication treatment.

Binge Drinking Moderates the Association Between Chronic Lung Disease and E-Cigarette Use

BACKGROUND

There is a paucity of research on e-cigarette use among adults with chronic lung disease. Accordingly, little is known about the factors that may contribute to e-cigarette use in this population. The purpose of this study was to evaluate the relationship between chronic lung disease and e-cigarette use and to determine whether binge drinking moderates this relationship.

METHODS

Data were derived from the 2018 Behavioral Risk Factor Surveillance System (BRFSS). Logistic regression was used to test the association between chronic lung disease status and e-cigarette use, controlling for demographic variables and chronic health conditions. We conducted moderation analyses to test the hypothesis that the association between chronic lung disease and lifetime e-cigarette use would be modified by binge drinking.

RESULTS

The prevalence of lifetime e-cigarette use was higher among adults with chronic lung disease than among those without, and more frequent binge drinking was associated with an increased likelihood of lifetime e-cigarette use independent of chronic lung disease status. Binge drinking moderated the relationship between chronic lung disease and lifetime use of e-cigarettes such that the association between chronic lung disease and e-cigarette use was weaker among those who engaged in more episodes of binge drinking in the past 30 d. Among those without chronic lung disease, binge drinking was associated with an increased likelihood of e-cigarette use.

CONCLUSIONS

E-cigarette use appears to be more common among adults with chronic lung disease. Although binge drinking was positively associated with e-cigarette use, more frequent binge drinking weakened the relationship between chronic lung disease and e-cigarette use. Though future studies are needed to determine precisely how binge drinking affects this association, it is possible that individuals with chronic lung disease who binge drink more frequently use e-cigarettes less frequently, despite an increased likelihood of having ever used an e-cigarette. (ClinicalTrials.gov registration NCT04135404.).

A Facebook intervention to address cigarette smoking and heavy episodic drinking: A pilot randomized controlled trial

BACKGROUND

Co-occurrence of tobacco use and heavy episodic drinking (HED; 5+ drinks for men and 4+ drinks for women per occasion) is common among young adults; both warrant attention and intervention. In a two-group randomized pilot trial, we investigated whether a Facebook-based smoking cessation intervention addressing both alcohol and tobacco use would increase smoking abstinence and reduce HED compared to a similar intervention addressing only tobacco.

METHODS

Participants were 179 young adults (age 18-25; 49.7% male; 80.4% non-Hispanic white) recruited from Facebook and Instagram who reported smoking 4+ days/week and past-month HED. The Smoking Tobacco and Drinking (STAND) intervention (N = 84) and the Tobacco Status Project (TSP), a tobacco-only intervention (N = 95), both included daily Facebook posts for 90 days and weekly live counseling sessions in private "secret" groups. We verified self-reported 7-day smoking abstinence via remote salivary cotinine tests at 3, 6, and 12 months (with retention at 83%, 66%, and 84%, respectively). Participants self-reported alcohol use.

RESULTS

At baseline, the participants averaged 10.4 cigarettes per day (SD = 6.9) and 8.9 HED occasions in the past month (SD = 8.1), with 27.4% in a preparation stage of change for quitting smoking cigarettes. Participants reported significant improvements in cigarette smoking and alcohol use outcomes over time, with no significant differences by condition. At 12 months, intent-to-treat smoking abstinence rates were 3.5% in STAND vs. 0% in TSP (biochemically verified) and 29.4% in STAND vs. 25.5% in TSP (self-reported). Compared to TSP, participants rated the STAND intervention more favorably for supporting health and providing useful information.

CONCLUSIONS

Adding an alcohol treatment component to a tobacco cessation social media intervention was acceptable and engaging but did not result in significant differences by treatment condition in smoking or alcohol use outcomes. Participants in both conditions reported smoking and drinking less over time, suggesting covariation in behavioral changes.

Large-scale systematic analysis of exposure to multiple cancer risk factors and the associations between exposure patterns and cancer incidence

Exposures to cancer risk factors such as smoking and alcohol are not mutually independent. We aimed to identify risk factor exposure patterns and their associations with sociodemographic characteristics and cancer incidence. We considered 120,771 female and, separately, 100,891 male participants of the Australian prospective cohort 45 and Up Study. Factor analysis grouped 36 self-reported variables into 8 combined factors each for females (largely representing 'smoking', 'alcohol', 'vigorous exercise', 'age at childbirth', 'Menopausal Hormone Therapy', 'parity and breastfeeding', 'standing/sitting', 'fruit and vegetables') and males (largely representing 'smoking', 'alcohol', 'vigorous exercise', 'urology and health', 'moderate exercise', 'standing/sitting', 'fruit and vegetables', 'meat and BMI'). Associations with cancer incidence were investigated using multivariable logistic regression (4-8 years follow-up: 6193 females, 8749 males diagnosed with cancer). After multiple-testing correction, we identified 10 associations between combined factors and cancer incidence for females and 6 for males, of which 14 represent well-known relationships (e.g. bowel cancer: females 'smoking' factor Odds Ratio (OR) 1.16 (95% Confidence Interval (CI) 1.08-1.25), males 'smoking' factor OR 1.15 (95% CI 1.07-1.23)), providing evidence for the validity of this approach. The catalogue of associations between exposure patterns, sociodemographic characteristics, and cancer incidence can help inform design of future studies and targeted prevention programmes.

Development of a mindfulness-based treatment for smoking cessation and the modification of alcohol use: A protocol for a randomized controlled trial and pilot study findings

The combined use of cigarettes and alcohol is associated with an increased risk of morbidity and mortality. Yet, efficacious interventions that address both behaviors concurrently are lacking. Smoking cessation and alcohol modification not only garner health benefits, but there is also value in addressing alcohol use in the context of smoking cessation to reduce the risk for smoking relapse. In this paper we describe the development of mindfulness-based relapse prevention for smoking cessation and alcohol modification (MBRP-SA) and pilot study findings (Phase 1). Next, details regarding the methods and design of an ongoing, randomized controlled trial, Project RISE (Phase 2), are described. MBRP-SA is a group-based intervention that consists of eight weekly treatment sessions. Results from the Phase 1 pilot study (N = 21 enrolled) indicated that participants planned to use the skills learned in their everyday activities and to address their smoking and alcohol goals. Based on the progression of Phase 1 cohorts, modifications were made to the inclusion/exclusion criteria and recruitment methods that will be implemented in Phase 2. Phase 2 will assess the feasibility and acceptability of MBRP-SA, delivered via live online groups, as a primary treatment option for smoking cessation and alcohol use modification.

An integrated behavioural intervention combined with varenicline for heavy-drinking smokers: a randomized pilot study

Objectives

Combined smoking and heavy drinking is a significant health burden. Varenicline, an efficacious tobacco pharmacotherapy that also shows promise for drinking, has yielded mixed results among heavy-drinking smokers. This pilot study investigated integrated tobacco and alcohol counselling plus varenicline for this vulnerable group.

Design

Twelve-week parallel, randomized controlled pilot trial of two behavioural interventions in combination with open-label varenicline. Participants were randomized using computer-generated tables, stratified by sex.

Setting

Outpatient academic medical centre research clinic.

Participants

Volunteers who reported smoking and heavy drinking and sought tobacco or alcohol treatment (N = 26). Intervention. (1) Integrated tobacco + alcohol counselling (INT; n = 13) or (2) counselling focused on their presenting concern (i.e., tobacco or alcohol) (SINGLE; n = 13), plus varenicline (2 mg) for 12 weeks.

Main outcomes

Feasibility/acceptability, smoking quit rates and heavy drinking.

Results

INT feasibility/acceptability was high among men but not women. More participants quit smoking in INT than SINGLE. This outcome was only in men, not significant, but had a medium effect size. Both conditions yielded significant drinking reductions.

Conclusion

Integrated tobacco and alcohol behavioural counselling plus varenicline may be feasible and promote smoking cessation among men who smoke and drink heavily, but a larger sample is needed to replicate this finding.

Effectiveness of Psychosocial Interventions Targeting Hazardous and Harmful Alcohol Use and Alcohol-Related Symptoms in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

In low- and middle-income countries (LMIC), the mismatch between the number of individuals needing and those receiving treatment for alcohol use disorders (AUD) is substantial. In order to provide suggestions for the scaling up of effective service provision we systematically reviewed the current evidence on the effectiveness of AUD-focused psychosocial interventions in LMIC.

METHODS

We used a systematic review methodology following the PRISMA guidelines. Twelve electronic databases listing published and grey literature were searched and only randomized-controlled trials (RCTs) were included. Where possible, effect sizes were calculated using Hedges' g indices.

RESULTS

Twenty-one RCTs conducted in 15 different LMIC between 1992 and 2018 fulfilled inclusion criteria. Most studies employed brief one-on-one interventions facilitated by trained primary care staff. Eighty-six percent of RCTs based their interventions on the principles of motivational interviewing (MI) with the majority supplementing MI-based interventions with alcohol-tailored elements of cognitive-behavioral therapy (CBT). The remaining RCTs employed CBT-components exclusively. Just over 40% of studies included in quantitative analyses (n=17) yielded an at least medium-sized effect (g≥.50) of the respective intervention compared to alcohol-related and unrelated control conditions or waiting list. Only half of the trials implementing the widely applied MI-based approaches (or MI-based approaches blended with CBT-elements) were superior to their respective control conditions.

CONCLUSION

To date, a relatively small number of RCTs investigating AUD-focused treatments has been conducted in LMIC. The majority of between condition effect size estimates were small and no type of intervention can clearly be recommended over another. No RCTs were conducted in conflict-affected areas in LMIC although they would merit particular attention since AUD is often linked to trauma-related mental health disorders. More RCTs in LMIC are required and alternatives to MI-based approaches should be investigated. This systematic review summarizes properties of effective interventions and provides implications for future research.

A Digital Smoking Cessation Program for Heavy Drinkers: Pilot Randomized Controlled Trial

Background

Heavy drinking (HD) is far more common among smokers compared with nonsmokers and interferes with successful smoking cessation. Alcohol-focused smoking cessation interventions delivered by counselors have shown promise, but digital versions of these interventions—which could have far greater population reach—have not yet been tested.

Objective

This pilot randomized controlled trial aimed to examine the feasibility, acceptability, and effect sizes of an automated digital smoking cessation program that specifically addresses HD using an interactive web-based intervention with an optional text messaging component.

Methods

Participants (83/119, 69.7% female; 98/119, 82.4% white; mean age 38.0 years) were daily smokers recruited on the web from a free automated digital smoking cessation program (BecomeAnEX.org, EX) who met the criteria for HD: women drinking 8+ drinks/week or 4+ drinks on any day and men drinking 15+ drinks/week or 5+ drinks on any day. Participants were randomized to receive EX with standard content (EX-S) or an EX with additional content specific to HD (EX-HD). Outcomes were assessed by web-based surveys at 1 and 6 months.

Results

Participants reported high satisfaction with the website and the optional text messaging component. Total engagement with both EX-S and EX-HD was modest, with participants visiting the website a median of 2 times, and 52.9% of the participants enrolled to receive text messages. Participants in both the conditions showed substantial, significant reductions in drinking across 6 months of follow-up, with no condition effects observed. Although smoking outcomes tended to favor EX-HD, the condition effects were small and nonsignificant. A significantly smaller proportion of participants in EX-HD reported having a lapse back to smoking when drinking alcohol (7/58, 16%) compared with those in EX-S (18/61, 41%; χ²₁=6.2; P=.01).

Conclusions

This is the first trial to examine a digital smoking cessation program tailored to HD smokers. The results provide some initial evidence that delivering such a program is feasible and may reduce the risk of alcohol-involved smoking lapses. However, increasing engagement in this and other web-based interventions is a crucial challenge to address in future work.

Trial Registration

ClinicalTrials.gov NCT03068611; https://clinicaltrials.gov/ct2/show/NCT03068611

Considering Systemic Barriers to Treating Tobacco Use in Clinical Settings in the United States

The Comorbidity Workgroup of the Tobacco Treatment Research Network, within the Society for Research on Nicotine and Tobacco, previously highlighted the need to provide tobacco treatment to patients diagnosed with comorbid physical and mental health conditions. Yet, systemic barriers in the United States health care system prevent many patients who present for medical treatment from getting the evidence-based tobacco treatment that they need. The identified barriers include insufficient training in the epidemiologic impact of tobacco use, related disorders, and pharmacological and behavioral treatment approaches; misunderstanding among clinicians about the effectiveness of tobacco treatment; lack of therapeutic support from clinical staff; insufficient use of health information technology to improve tobacco use identification and treatment; and limited time and reimbursement for clinicians to provide treatment. We highlight three vignettes demonstrating the complexities of practical barriers at the health care system level. We consider each of the barriers in turn and discuss evidence-based strategies that could be implemented in the clinical care of patients with comorbid conditions. In addition, in the absence of compelling data to guide implementation approaches, we offer suggestions for potential strategies and avenues for future research. Implications: Three vignettes highlighted in this article illustrate some systemic barriers to providing tobacco treatment for patients being treated for comorbid conditions. We explore the barriers to tobacco treatment and offer suggestions for changes in training, health care systems, clinical workflow, and payment systems that could enhance the reach and the quality of tobacco treatment within the US health care system.

The time-varying effect of alcohol use on cigarette smoking relapse risk

BACKGROUND

Alcohol consumption promotes lapses to smoking among smokers trying to quit, perhaps particularly among smokers with lower dependence. We assessed how the role of alcohol in lapses varies over time.

METHODS

This is a secondary analysis of ecological momentary assessment data collected from 159 daily smokers (mean age = 43.90 (SD = 10.41), 56.60% female) who drink alcohol. During the 4 weeks following initial cessation (quit >24 h), a logistic time-varying effect model (TVEM) modeled momentary assessments of lapses and temptations to smoke compared to randomly-selected moments as a function of concurrently-assessed recent alcohol use (past 15 min). Time was examined continuously.

RESULTS

Recent alcohol use was associated with smoking lapses, particularly for less nicotine dependent individuals, and the association varied across time. For individuals who did not smoke within 5 min of waking, alcohol use became a significant predictor of lapse on Day 1 post-quit, increased in strength until Day 7, then decreased such that alcohol use was no longer associated with lapse by Day 25. For this subgroup, the associations between alcohol use and temptations were relatively stable and significant from Day 1 to 22 post-quit. Results were similar when dependence was assessed by the Nicotine Dependence Symptom Scale.

CONCLUSIONS

The association between drinking and smoking lapse and temptations varies over time, peaking early in smoking abstinence and declining thereafter. This could reflect progressive relapse of most vulnerable individuals or habituation to alcohol as a smoking cue. Interventions to prevent alcohol-related lapses are essential early in the quit period.

Smoking characteristics and alcohol use among women in treatment for alcohol use disorder

BACKGROUND

Understanding the association between smoking and alcohol use among women may help inform the delivery of targeted interventions to address both of these health behaviors.

METHODS

This study analyzed data from N = 138 women enrolled in a randomized clinical trial comparing female-specific individual versus group cognitive-behavior therapy for alcohol use disorder (AUD). We assessed cigarette use patterns, participants' interest in quitting smoking and motivation to quit smoking during treatment for AUD, and examined the relationship between smoking and alcohol use before and during alcohol treatment.

RESULTS

Over a third of the sample reported smoking cigarettes at baseline (N = 47, 34.1%), with the majority of smokers reporting daily cigarette use. At baseline, those who smoked reported a high interest in quitting smoking M = 7.8 out of 10 (SD = 2.7), although most believed they should quit smoking only after achieving some success in quitting drinking (50.0%). However, participants who smoked cigarettes (compared to non-smokers) reported more alcohol abuse and dependence symptoms (p = .001), lower rates of completing the alcohol treatment (p = .03), attended significantly fewer treatment sessions (p = .008), and consumed significantly more drinks per day on average both at baseline (p = .002) and during the treatment period (p = .04).

CONCLUSIONS

Findings suggest that women with AUD who also smoke cigarettes have greater difficulty engaging in or responding to treatment for their alcohol use. However, these participants reported high interest in quitting smoking but low perceived readiness during AUD treatment, suggesting that motivational interventions should be considered that could take advantage of the opportunity to treat women for both of these co-occurring behaviors while in treatment.

Reducing sexual health risks and substance use in the prenatal setting: A study protocol for a randomized controlled trial

Sexually transmitted infections (STIs) are at a record high in the United States, and STI risk is a critical and costly public health concern for childbearing women. STIs can lead to a number of serious health risks including premature birth, low birth weight, ectopic pregnancy, and fetal death. Similarly, there has been a dramatic increase in substance use during pregnancy, leading to complications during pregnancy and poorer birth outcomes. Women who misuse substances are disproportionately more likely to engage in risky sexual behaviors that can result in STIs. The proposed study will test whether the Health Check-Up for Expectant Moms (HCEM), a computer-delivered brief intervention that simultaneously targets STI risk and alcohol/illicit drug use during pregnancy, reduces antenatal and postpartum risk more than an attention, time, and information matched control condition among pregnant women seeking prenatal care. The study is a two-group, randomized controlled trial in which a diverse sample of 250 pregnant women will be recruited from prenatal care clinics and assigned to either (a) a computer-delivered, single-session brief intervention plus two booster sessions); or (b) a computer-delivered control condition. Follow-up assessments will occur at 2 and 6 months from baseline, and at 6 weeks postpartum. Our objective measures include STI incidence and birth outcomes. The results of this trial will fill a critical gap and provide much-needed data on the efficacy, costs, and resource utilization of a practical computer-delivered, brief motivational intervention tailored to reach high-risk women during pregnancy and extending impact to postpartum.

Cannabis use during alcohol treatment is associated with alcohol-related problems one-year post-treatment

BACKGROUND

Prior research shows that cannabis use during treatment for Alcohol Use Disorders (AUD) is related to fewer abstinent days from alcohol, although only among those who use cannabis 1-2x/month. Here we extend prior research by assessing the relationship between the frequency of cannabis use during AUD treatment and post-treatment alcohol-related consequences.

METHODS

Data come from the Combined Pharmacotherapies and Behavioral Interventions (COMBINE) Study, a large US randomized control trial of treatments for AUD. The current analyses include 206 cannabis users and 999 cannabis abstainers and compare longitudinal drinking data between those who used cannabis versus those who abstained during COMBINE treatment. The primary exposure was quartiles of cannabis use (Q1: less than 1x/month during treatment, Q2: 1-2x/month, Q3: 4-8x/month, Q4: 12x/month or more), with cannabis abstainers as the reference group. Outcomes were alcohol-related problems at the end of treatment and one-year post-treatment as measured by the Drinker Inventory Consequences.

RESULTS

Compared to cannabis abstinence, the most frequent use during treatment was related to 1.44 times as many physical consequences one-year post-treatment. Cannabis use was not related to physical consequences immediately after treatment, or to intrapersonal, interpersonal, social responsibility or impulse control problems at either post-treatment time point.

CONCLUSIONS

In a sample of individuals in treatment for AUD, using cannabis 12x/month or more during treatment is associated with increased rates of physical consequences attributed to alcohol use. Individuals in treatment for AUD who also use cannabis might benefit from reducing or stopping cannabis use to avoid alcohol-related physical problems.

Multicomponent mHealth Intervention for Large, Sustained Change in Multiple Diet and Activity Risk Behaviors: The Make Better Choices 2 Randomized Controlled Trial

BACKGROUND

Prevalent co-occurring poor diet and physical inactivity convey chronic disease risk to the population. Large magnitude behavior change can improve behaviors to recommended levels, but multiple behavior change interventions produce small, poorly maintained effects.

OBJECTIVE

The Make Better Choices 2 trial tested whether a multicomponent intervention integrating mHealth, modest incentives, and remote coaching could sustainably improve diet and activity.

METHODS

Between 2012 and 2014, the 9-month randomized controlled trial enrolled 212 Chicago area adults with low fruit and vegetable and high saturated fat intakes, low moderate to vigorous physical activity (MVPA) and high sedentary leisure screen time. Participants were recruited by advertisements to an open-access website, screened, and randomly assigned to either of two active interventions targeting MVPA simultaneously with, or sequentially after other diet and activity targets (N=84 per intervention) or a stress and sleep contact control intervention (N=44). They used a smartphone app and accelerometer to track targeted behaviors and received personalized remote coaching from trained paraprofessionals. Perfect behavioral adherence was rewarded with an incentive of US $5 per week for 12 weeks. Diet and activity behaviors were measured at baseline, 3, 6, and 9 months; primary outcome was 9-month diet and activity composite improvement.

RESULTS

Both simultaneous and sequential interventions produced large, sustained improvements exceeding control (P<.001), and brought all diet and activity behaviors to guideline levels. At 9 months, the interventions increased fruits and vegetables by 6.5 servings per day (95% CI 6.1-6.8), increased MVPA by 24.7 minutes per day (95% CI 20.0-29.5), decreased sedentary leisure by 170.5 minutes per day (95% CI -183.5 to -157.5), and decreased saturated fat intake by 3.6% (95% CI -4.1 to -3.1). Retention through 9-month follow-up was 82.1%. Self-monitoring decreased from 96.3% of days at baseline to 72.3% at 3 months, 63.5% at 6 months, and 54.6% at 9 months (P<.001). Neither attrition nor decline in self-monitoring differed across intervention groups.

CONCLUSIONS

Multicomponent mHealth diet and activity intervention involving connected coaching and modest initial performance incentives holds potential to reduce chronic disease risk.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01249989; https://clinicaltrials.gov/ct2/show/NCT01249989 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT01249989).

Trajectories of 12-Month Usage Patterns for Two Smoking Cessation Websites: Exploring How Users Engage Over Time

BACKGROUND

Little is known about how individuals engage with electronic health (eHealth) interventions over time and whether this engagement predicts health outcomes.

OBJECTIVE

The objectives of this study, by using the example of a specific type of eHealth intervention (ie, websites for smoking cessation), were to determine (1) distinct groups of log-in trajectories over a 12-month period, (2) their association with smoking cessation, and (3) baseline user characteristics that predict trajectory group membership.

METHODS

We conducted a functional clustering analysis of 365 consecutive days of log-in data from both arms of a large (N=2637) randomized trial of 2 website interventions for smoking cessation (WebQuit and Smokefree), with a primary outcome of 30-day point prevalence smoking abstinence at 12 months. We conducted analyses for each website separately.

RESULTS

A total of 3 distinct trajectory groups emerged for each website. For WebQuit, participants were clustered into 3 groups: 1-week users (682/1240, 55.00% of the sample), 5-week users (399/1240, 32.18%), and 52-week users (159/1240, 12.82%). Compared with the 1-week users, the 5- and 52-week users had 57% higher odds (odds ratio [OR] 1.57, 95% CI 1.13-2.17; P=.007) and 124% higher odds (OR 2.24, 95% CI 1.45-3.43; P<.001), respectively, of being abstinent at 12 months. Smokefree users were clustered into 3 groups: 1-week users (645/1309, 49.27% of the sample), 4-week users (395/1309, 30.18%), and 5-week users (269/1309, 20.55%). Compared with the 1-week users, 5-week users (but not 4-week users; P=.99) had 48% higher odds (OR 1.48, 95% CI 1.05-2.07; P=.02) of being abstinent at 12 months. In general, the WebQuit intervention had a greater number of weekly log-ins within each of the 3 trajectory groups as compared with those of the Smokefree intervention. Baseline characteristics associated with trajectory group membership varied between websites.

CONCLUSIONS

Patterns of 1-, 4-, and 5-week usage of websites may be common for how people engage in eHealth interventions. The 5-week usage of either website, and 52-week usage only of WebQuit, predicted a higher odds of quitting smoking. Strategies to increase eHealth intervention engagement for 4 more weeks (ie, from 1 week to 5 weeks) could be highly cost effective.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01812278; https://www.clinicaltrials.gov/ct2/show/NCT01812278 (Archived by WebCite at http://www.webcitation.org/6yPO2OIKR).

Drinking Level Versus Drinking Pattern and Cigarette Smoking Among Older Adults

BACKGROUND

There is a lack of research on the role of alcohol consumption in cigarette smoking among older adults, and the few studies on alcohol use and smoking with older adults have failed to distinguish between average level and pattern of drinking as predictors of smoking. The main purpose of this study was to examine the independent contributions of average level versus pattern of drinking as predictors of cigarette smoking among older adults. A subsidiary purpose was to examine the link between continued smoking and mortality among older smokers.

METHODS

We investigated average level and pattern of drinking as predictors of current smoking among 1,151 older adults at baseline and of continued smoking and mortality among the subset of 276 baseline smokers tracked across 20 years. We used multiple linear and logistic regression analyses and, to test mediation, bias-corrected bootstrap confidence intervals.

RESULTS

A high level of average drinking and a pattern of episodic heavy drinking were concurrently associated with smoking at baseline. However, only episodic heavy drinking was prospectively linked to continued smoking among baseline smokers. Continued smoking among baseline smokers increased the odds of 20-year mortality and provided an indirect pathway through which heavy episodic drinking related to mortality.

CONCLUSIONS

Smokers who misuse alcohol are a challenging population for smoking cessation efforts. Older adults who concurrently misuse alcohol and smoke cigarettes provide a unique target for public health interventions.

A Brief Smoking Cessation Intervention for Heavy Drinking Smokers: Treatment Feasibility and Acceptability

Approximately 20-25% of regular smokers report heavy drinking. Abstinent smokers are five times as likely to experience a smoking lapse during drinking episodes. Current efforts seek to improve treatments for this subgroup of heavy-drinking smokers. This study tested the feasibility and acceptability of addressing alcohol use in a brief, single session smoking cessation intervention (SMK+A) compared to smoking cessation counseling only (SMK); these interventions were grounded in a motivational interview framework and included personalized feedback, decisional balance, quit day setting, and tailored skills building (e.g., breathing techniques, coping with urges, dealing with social pressures) to maintain abstinence. Descriptive outcomes included reported helpfulness of intervention skills, readiness to change scores, and feasibility of participant recruitment and retention. We also assessed 7-day point prevalence of smoking cessation, and smoking and drinking reduction at 1-month follow-up. Participants (N = 22) were community-based treatment-seeking daily smokers (≥5 cigarettes/day) who were also heavy drinkers (≥14 drinks/week for men, ≥ 7 drinks/week for women; or ≥5 drinks on one episode in past week for men, ≥4 for women). Twenty five percent of interested individuals were eligible after initial phone screen, and all randomized participants were retained through follow up. All skills demonstrated high acceptability (i.e., rated between moderately and very helpful), and a significant proportion of participants in each condition reported taking action to reduce cigarette smoking and/or alcohol use at 1-month post-quit. Three participants in each condition (27.3%) attained bioverified (CO ≤ 4 parts per million and cotinine ≤ 3 ng/mL) smoking quit at follow-up. Given the modified intervention's acceptability and flexibility, larger studies may help to elucidate this intervention's effects on readiness to change, smoking cessation, and alcohol reduction.

The Interaction of Depressive Symptoms and Hazardous Drinking in Relation to Tobacco Craving Among Treatment Seeking Depressed Smokers: Sex Differences

OBJECTIVES

The present study sought to address whether there is sex effect in the interactive effect between depressive symptoms and hazardous drinking in the prediction of smoking craving after cognitive-behavioral smoking cessation treatment among those with at least mild depression.

METHODS

Participants (n = 114, mean age 42.0, SD = 9.73, 64% women) were treatment-seeking smokers who attended 6 weekly 1-hour sessions involving psychological treatment for cessation. Participants reported depressive symptoms and alcohol use at baseline and reported craving at baseline and after treatment.

RESULTS

Results indicated that there was a statistically significant 3-way interaction (depression by alcohol use by sex) for smoking craving (B = -0.30, standard error [SE] = 0.14, P = 0.042) and appetitive craving (B = -.21, SE = 0.09, P = 0.031), but not negative reinforcement craving. The form of the significant interactions indicted that higher levels of depressive symptoms and alcohol use were related to greater levels of craving at the end of treatment only among men.

CONCLUSIONS

The current findings provide novel empirical evidence suggesting that there is a clinically relevant interplay between depressive symptoms and alcohol use regarding general craving and appetitive craving among male treatment-seeking smokers. Although the present results should be replicated in larger samples, this type of research can inform the development of sex-specific interventions for smoking cessation.

Prohibition of e-cigarettes in the US: Are prohibitions where alcohol is consumed related to lower alcohol consumption?

Recently, research has suggested negative consequences related to electronic cigarette (e-cig) use, including the increased risk for alcohol use and abuse. Previous work found that cigarette smoking ban legislation lowered overall smoking and alcohol use rates; however, researchers have not yet examined the potential effects of prohibiting e-cig use. The present study surveyed 617 individuals from a community-based online sample in the US (mean age = 33.33, SD = 10.50, 54.7 per cent female) who reported their smoking/e-cig use status, alcohol consumption, and the presence of e-cig prohibitions where they consume alcohol. E-cig prohibition was associated with a lower likelihood of being an e-cig user (OR = 0.12, p < 0.001) or dual user (use both cigarettes and e-cigs) (OR = 0.07, p < 0.001). Alcohol Use Disorder Identification Test scores (b = -1.92, p < 0.001), total drinks consumed over 14 days (b = -4.58, p = 0.002), and average drinks per drinking day (b = -0.71, p < 0.001) were all lower when e-cigs were prohibited. Findings are an initial step in this line of research and suggest important future work examining implications of e-cig prohibition recommendations and policy.

A Double-Blind Randomized Placebo-Controlled Trial of Oral Naltrexone for Heavy-Drinking Smokers Seeking Smoking Cessation Treatment

BACKGROUND

Post hoc analyses of 2 randomized controlled trials suggest naltrexone may reduce alcohol use and improve smoking cessation outcomes among heavy drinkers receiving smoking cessation treatment. However, no studies have been conducted specifically to examine naltrexone for this purpose or to test whether naltrexone has benefit when added to smoking cessation counseling that explicitly addresses heavy drinking.

METHODS

We recruited heavy-drinking smokers from the community and randomized them to receive 10 weeks of either (i) 50 mg naltrexone (n = 75) or (ii) placebo (n = 75) daily. Participants received 6 weeks of transdermal nicotine patch and 6 sessions of counseling that addressed both heavy drinking and smoking. Participants were followed for 26 weeks after their target quit smoking date.

RESULTS

Across medication conditions, there were substantial reductions at follow-up in percent heavy drinking days (primary outcome) and average drinks per week (secondary outcome). However, participants receiving naltrexone did not differ significantly from those receiving placebo on percent heavy drinking days (effect size d = -0.04, 95% CI [-0.30, 0.22], p = 0.76) or average drinks per week (d = -0.09, 95% CI [-0.35, 0.18], p = 0.54) during follow-up. Naltrexone compared to placebo was not associated with a significant increase in smoking abstinence rates during follow-up, odds ratio = 0.93, 95% CI [0.46, 1.86], p = 0.83. The effect of naltrexone on these outcomes was not significantly moderated by current alcohol dependence or gender.

CONCLUSIONS

Results indicate that heavy-drinking smokers, including those with current alcohol dependence, can make substantial reductions in drinking in the context of smoking cessation treatment. However, this study provided no evidence that naltrexone is efficacious for enhancing reductions in drinking or improving smoking cessation in this population. Limitations of this study included lower-than-desired sample size and modest adherence to study medication.

"Essentially, All Models are Wrong, but Some Are Useful": A Preliminary Conceptual Model Of Co-Occurring E-Cig and Alcohol Use

PURPOSE OF REVIEW

As prevalence rates of electronic cigarette (e-cig) use increase, researchers and clinicians should not only be paying careful attention to the direct health effects of e-cigs, but also the potential impact e-cigs may have on alcohol use behaviors. We review the current state of the literature and propose a conceptual model for the relationship between e-cig and alcohol use, including important consequences, mechanisms, and moderators of this relationship.

RECENT FINDINGS

The model is based in emerging literature examining the direct relationship between e-cig and alcohol use, as well as indirect evidence concerning potential mechanisms from research on cigarette and alcohol use. Overall, research indicates a robust relationship between e-cig and alcohol use.

SUMMARY

We suggest that a relationship between e-cig use and alcohol use could be particularly problematic, especially for adolescents and for those with or at risk for alcohol use disorders. We hope the presented conceptual model can stimulate research in this area. We make research recommendations, including the need for more methodological rigor, including improved measurement of e-cig use, and expanding research to longitudinal and experimental designs.

Relationship of nicotine deprivation and indices of alcohol use behavior to implicit alcohol and cigarette approach cognitions in smokers

Alcohol and smoking frequently co-occur and alcohol is a primary trigger for smoking behavior and relapse back to smoking. This study examined whether several indices of alcohol use behavior and consequences of use would be associated with changes in implicit alcohol-approach versus implicit cigarette-approach cognitions under cigarette deprived and non-deprived cognitions in 109 smokers who drank at risky or non-risky levels. An Implicit Association Task (IAT) measured how quickly respondents paired alcohol and cigarette pictures with approach and avoid words. Regression analyses examined the associations of quantity/frequency, proportion heavy drinking days, number of DSM-IV alcohol use disorder (AUD) symptoms, and risky drinking status to IAT scores under deprived conditions, controlling for IAT order effects, non-deprived IAT score, and deprived cigarette craving and withdrawal. Interactions with craving and withdrawal intensity were also examined. Results showed a significant positive association between proportion of heavy drinking days and stronger alcohol-approach than cigarette-approach motivations when deprived. There was also a conditional association of AUD symptoms to alcohol-approach motivations among respondents reporting more intense withdrawal when deprived. Alcohol quantity and frequency, as well as risky drinking status were unrelated to change in IAT scores. Findings suggest that cigarette deprivation may magnify motivation to drink, rather than smoke, among smokers who engage in more frequent bouts of heavy drinking and who report more alcohol-related problems. Results also show relative momentary and unconscious "preference" or choice for alcohol over cigarettes in some high-risk smokers, when cigarette craving and withdrawal are high.

Group behaviour therapy programmes for smoking cessation

BACKGROUND

Group therapy offers individuals the opportunity to learn behavioural techniques for smoking cessation, and to provide each other with mutual support.

OBJECTIVES

To determine the effect of group-delivered behavioural interventions in achieving long-term smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register, using the terms 'behavior therapy', 'cognitive therapy', 'psychotherapy' or 'group therapy', in May 2016.

SELECTION CRITERIA

Randomized trials that compared group therapy with self-help, individual counselling, another intervention or no intervention (including usual care or a waiting-list control). We also considered trials that compared more than one group programme. We included those trials with a minimum of two group meetings, and follow-up of smoking status at least six months after the start of the programme. We excluded trials in which group therapy was provided to both active therapy and placebo arms of trials of pharmacotherapies, unless they had a factorial design.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data in duplicate on the participants, the interventions provided to the groups and the controls, including programme length, intensity and main components, the outcome measures, method of randomization, and completeness of follow-up. The main outcome measure was abstinence from smoking after at least six months follow-up in participants smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically-validated rates where available. We analysed participants lost to follow-up as continuing smokers. We expressed effects as a risk ratio for cessation. Where possible, we performed meta-analysis using a fixed-effect (Mantel-Haenszel) model. We assessed the quality of evidence within each study and comparison, using the Cochrane 'Risk of bias' tool and GRADE criteria.

MAIN RESULTS

Sixty-six trials met our inclusion criteria for one or more of the comparisons in the review. Thirteen trials compared a group programme with a self-help programme; there was an increase in cessation with the use of a group programme (N = 4395, risk ratio (RR) 1.88, 95% confidence interval (CI) 1.52 to 2.33, I² = 0%). We judged the GRADE quality of evidence to be moderate, downgraded due to there being few studies at low risk of bias. Fourteen trials compared a group programme with brief support from a health care provider. There was a small increase in cessation (N = 7286, RR 1.22, 95% CI 1.03 to 1.43, I² = 59%). We judged the GRADE quality of evidence to be low, downgraded due to inconsistency in addition to risk of bias. There was also low quality evidence of benefit of a group programme compared to no-intervention controls, (9 trials, N = 1098, RR 2.60, 95% CI 1.80 to 3.76 I² = 55%). We did not detect evidence that group therapy was more effective than a similar intensity of individual counselling (6 trials, N = 980, RR 0.99, 95% CI 0.76 to 1.28, I² = 9%). Programmes which included components for increasing cognitive and behavioural skills were not shown to be more effective than same-length or shorter programmes without these components.

AUTHORS' CONCLUSIONS

Group therapy is better for helping people stop smoking than self-help, and other less intensive interventions. There is not enough evidence to evaluate whether groups are more effective, or cost-effective, than intensive individual counselling. There is not enough evidence to support the use of particular psychological components in a programme beyond the support and skills training normally included.

Combined treatment for at-risk drinking and smoking cessation among Puerto Ricans: A randomized clinical trial

Tobacco and alcohol use are linked behaviors that individually and synergistically increase the risk for negative health consequences. This study was a two-group, randomized clinical trial evaluating the efficacy of a behavioral intervention, "Motivation And Problem Solving Plus" (MAPS+), designed to concurrently address smoking cessation and the reduction of at-risk drinking. Targeted interventions may promote coaction, the likelihood that changing one behavior (smoking) increases the probability of changing another behavior (alcohol use). Puerto Ricans (N=202) who were smokers and at-risk drinkers were randomized to standard MAPS treatment focused exclusively on smoking cessation (S-MAPS), or MAPS+, focused on cessation and at-risk drinking reduction. Drinking outcomes included: number of at-risk drinking behaviors, heavy drinking, binge drinking, and drinking and driving. MAPS+ did not have a significant main effect on reducing at-risk drinking relative to S-MAPS. Among individuals who quit smoking, MAPS+ reduced the number of drinking behaviors, the likelihood of meeting criteria for heavy drinking relative to S-MAPS, and appeared promising for reducing binge drinking. MAPS+ did not improve drinking outcomes among individuals who were unsuccessful at quitting smoking. MAPS+ showed promise in reducing at-risk drinking among Puerto Rican smokers who successfully quit smoking, consistent with treatment enhanced coaction. Integrating an alcohol intervention into cessation treatment did not reduce engagement in treatment, or hinder cessation outcomes, and positively impacted at-risk drinking among individuals who quit smoking. Findings of coaction between smoking and drinking speak to the promise of multiple health behavior change interventions for substance use treatment and chronic disease prevention.

Transitioning From Cigarettes to Electronic Cigarettes Increases Alcohol Consumption

OBJECTIVE

Electronic cigarettes (e-cigs) are a nicotine delivery device that have recently been linked to alcohol use. Many individuals that smoke cigarettes transition to e-cigs as an alternative to cigarette use, despite potential negative health effects of e-cigs. No research to date has examined how former smokers that have transitioned to e-cigs differ from former smokers that do not use e-cigs, particularly in relation to alcohol use. Further, no research has examined how former smokers that use e-cigs regularly or socially may differ in alcohol consumption.

METHOD

Using an online community dwelling sample (Former smokers N = 198, mean age = 34.70, SD = 11.45, 56.1% female, 78.3% Caucasian, 37.9% e-cig users), the present study assessed smoking status and alcohol use, with the latter assessed using a timeline followback calendar and the alcohol use disorder identification test (AUDIT).

RESULTS

In all former smokers, total drinks (b = 4.01, p = 0.02) and average drinks per drinking day (b = 0.61, p =.01) were both related to e-cig use status, with e-cig users reporting higher alcohol consumption. Among e-cig using former smokers, social users, but not regular users, showed positive relationships with AUDIT scores, b = 1.90, p =.02, total drinks, b = 9.12, p <.001, average drinks, b = 0.98, p =.006, and hazardous drinking status, OR = 3.21, p =.01.

CONCLUSIONS

Findings suggest that: (1) former smokers who use e-cigs may have a potential for higher alcohol use; and (2) those who use e-cigs socially may be at heightened risk for hazardous patterns of alcohol consumption. This should be taken into consideration by healthcare providers.

Current insights into the mechanisms and development of treatments for heavy drinking cigarette smokers

There is a strong association between cigarette smoking and alcohol use at the epidemiological, behavioral, and molecular levels, and this co-use creates substantial impediments to smoking cessation among smokers who are also heavy drinkers. Compared with individuals who only smoke, those who both drink and smoke heavily experience more severe health consequences and have greater difficulty in quitting smoking. During smoking abstinence, greater alcohol use is associated with decreased odds of smoking cessation, and smokers are substantially more likely to experience a smoking lapse during drinking episodes. As heavy drinking smokers are less responsive to the currently available pharmacological treatments, this subgroup of high-risk substance users possesses a unique clinical profile and treatment needs. Thus, treatment development for heavy drinking smokers represents a significant and understudied research area within the field of smoking cessation. This review will briefly describe findings from epidemiological, behavioral, and molecular studies illustrating alcohol and tobacco co-use and identify how the behavioral and neurobiological mechanisms underlying the interaction of alcohol and nicotine may inform the development of targeted treatments for this unique population of smokers.

Exploring Issues of Comorbid Conditions in People Who Smoke

Smoking affects comorbid disease outcomes, and patients with comorbid conditions may have unique characteristics that are important to consider when treating tobacco use. However, addressing tobacco in patients being treated for comorbid conditions is not a consistent practice. Recognizing the need for a "call-to-action" to address tobacco use in people with comorbid conditions, the Tobacco Treatment Network within the Society for Research on Nicotine and Tobacco (SRNT) convened a Comorbidities Workgroup to explore the relationship between smoking and comorbid disease to identify common themes including: the harms associated with continued tobacco use, the frequency of comorbid disease and tobacco use, the potential effect of comorbid disease on the ability to quit tobacco use, the association between tobacco use and suboptimal disease-specific treatment response, and evidence regarding potential approaches to improve addressing tobacco use in patients with comorbid disease. Five candidate conditions (psychiatric, cancer, cardiovascular, pulmonary, and human immunodeficiency virus infected patients) were explored. Across comorbid conditions, smoking adversely affects treatment efficacy and promotes other adverse health conditions. People with comorbid conditions who smoke are motivated to quit and respond to evidence-based smoking cessation treatments. However, tobacco cessation is not regularly incorporated into the clinical care of many individuals with comorbidities. Optimal strategies for addressing tobacco use within each comorbid disease are also not well defined. Further work is needed to disseminate evidence-based care into clinical practice for smokers with comorbid disease and addiction research should consider comorbid conditions as an important construct to explore.

IMPLICATIONS

This article explores how physical and psychiatric conditions may interact in the treatment of tobacco dependence, and discusses the need for smoking cessation as a critical component of comorbid condition management. Five common comorbid domains-psychiatric, cancer, pulmonary, cardiovascular, and human immunodeficiency virus (HIV)-are highlighted to illustrate how these different conditions might interact with smoking with respect to prevalence and harm, motivation to quit, and cessation treatment utilization and success.

Combined expectancies of alcohol and e-cigarette use relate to higher alcohol use

Electronic cigarettes (e-cigs) were created to approximate the look, feel, and experience of using a cigarette. Since cigarette and alcohol use co-occur, we hypothesized that e-cig and alcohol use also co-occur, likely due to shared positive drug expectations. Using self-report data from two independent samples of community-dwelling alcohol using adults, the present study: (1) modified the Nicotine and Other Substance Interaction Expectancy Questionnaire (NOSIE) to assess expectancies of combined e-cig and alcohol use (i.e. the individuals perceived likelihood of using e-cigs and alcohol together; NOSIE-ER); and (2) examined the relationships among e-cig use, expectancies, and alcohol use across e-cig use status. In the first sample (N=692, mean age=32.6, SD=9.74, 50.7% female, 82.2% Caucasian), exploratory factor analysis suggested the presence of two factors: (1) alcohol use leads to e-cig use (Scale 1; α=0.85); and (2) e-cig use leads to alcohol use (Scale 2; α=0.91). In the second sample (N=714, mean age=34.1, SD=10.89, 47.8% female, 75.6% Caucasian), confirmatory factor analysis supported this factor structure (χ(2)=47.00, p<0.01, df=19; RMSEA=0.08, 90% CI=0.05-0.11; TLI=0.99; CFI=0.99). Compared to non e-cig users, e-cig users had significantly higher problematic alcohol use in both samples (b's=0.09 to 0.14, p's<.05). Expectancies of combined e-cig and alcohol use were significantly related to problematic alcohol use (b's=-0.92 to 0.26, p's<.05). In sum, e-cig use is related to alcohol use and expectancies of combined e-cig and alcohol use; consequently, reshaping of beliefs about needs or desires to co-use could be a prime point of intervention.

Heavy-Drinking Smokers' Treatment Needs and Preferences: A Mixed-Methods Study

The purpose of this mixed methods study was to describe the smoking and psychological characteristics of heavy-drinking smokers, their perceptions of smoking and drinking, and their smoking and alcohol treatment preferences to inform an integrated smoking and alcohol intervention. Heavy-drinking smokers (N=26) completed standardized surveys and participated in semi-structured focus group interviews. Participants reported a strong association between their smoking and drinking. Participants were more motivated to quit smoking than to reduce their drinking but perceived greater barriers to smoking cessation. Stress/negative affect was closely linked with both behaviors. They expressed overall enthusiasm for a smoking and alcohol intervention but had specific format and content preferences. Half preferred an integrated treatment format whereas others preferred a sequential treatment model. The most preferred content included personalized health feedback and a way to monitor health gains after behavior changes.

A randomized trial for hazardous drinking and smoking cessation for callers to a quitline

OBJECTIVE

This study evaluated whether tobacco quitline telephone coaches can be trained to counsel hazardous-drinking smokers to improve smoking cessation success and to limit or abstain from alcohol use.

METHOD

Smokers (N = 1,948) who called the New York State Smokers' Quitline and reported hazardous drinking (exceeding sex-specific weekly limits [14 drinks for men, 7 drinks for women] or meeting/exceeding daily drinking limits [5 drinks for men, 4 drinks for women] at least once in the past year) were randomized to receive either brief motivational counseling to limit or abstain from alcohol plus an alcohol reduction booklet added to standard care (Alcohol + Tobacco Counseling; ATC), or only smoking cessation counseling plus a smoking cessation booklet added to standard care (Tobacco-Only Counseling; TOC).

RESULTS

Acceptable coach adherence was achieved. The intention-to-treat (ITT) analysis showed that ATC was associated with a significantly higher rate of smoking abstinence at 7-month follow-up (13.5%) compared with TOC (10.3%; p = .03). The respondent analysis (ATC= 26.2%; TOC = 20.4%) paralleled the ITT findings. When controlling for treatment condition, participants who did not report any heavy drinking were significantly more likely to quit smoking than those who reported any heavy drinking (OR = 1.87, 95% CI [1.29, 2.71]; p = .001).

CONCLUSIONS

A brief alcohol intervention plus standard care via a telephone quitline resulted in significantly higher smoking cessation rates for hazardous-drinking callers. Given that quitline coaches were trained to provide the intervention with acceptable adherence, the potential to extend this intervention for wide-scale implementation and impact is promising.

Screening and concurrent brief intervention of conjoint hazardous or harmful alcohol and tobacco use in hospital out-patients in Thailand: a randomized controlled trial

Background

The aim of this study was to conduct a cluster randomized control trial to assess the efficacy of screening and brief intervention (SBI) for conjoint alcohol and tobacco use among hospital out-patients.

Method

In all 620 hospital out-patients who screened positive for both tobacco and alcohol moderate risk in four hospitals were randomized into 2 control and 1 intervention condition using the hospital as a unit of randomization (2 intervention and 2 control hospitals) to 405 patients in the two control groups (tobacco only intervention, n = 199, and alcohol only intervention, n = 206) and 215 in the intervention group. The intervention or control consisted of three counselling sessions.

Results

Results of the interaction (Group × Time) effects using GEE indicated that there were statistically significant differences between the three study groups over the 6-month follow-up on the ASSIST tobacco score (Wald χ² = 8.43, P = 0.004), and past week tobacco use abstinence (Wald χ² = 7.34, P = 0.007). Although there were no significant interaction effects on the other outcomes (Alcohol ASSIST score, low alcohol risk score, past week tobacco abstinence or low alcohol risk score, and past week tobacco abstinence and low alcohol risk score), the scores in all of the six outcome measures showed consistent improvements. For past week tobacco abstinence the tobacco only intervention was more effective than the alcohol only intervention and the integrated alcohol and tobacco intervention. For the outcome of low alcohol risk, the alcohol only intervention and the integrated alcohol and tobacco intervention was more effective than the tobacco only or alcohol only intervention.

Conclusions

The study found that for past week tobacco abstinence the tobacco only intervention was more effective than the alcohol only intervention and the polydrug use (alcohol and tobacco) integrated intervention.

Smoking processes, panic, and depressive symptoms among treatment-seeking smokers

OBJECTIVES

The present study evaluated the relative contribution of panic and depressive symptoms in relation to past cessation difficulties and smoking motives among treatment-seeking daily smokers.

METHODS

The sample included 392 treatment-seeking daily smokers (47.07% female; Mage = 35.48; SD = 13.56), who reported smoking an average of 10 or more cigarettes daily for at least one year.

RESULTS

Findings indicated that panic and depressive symptoms were significantly associated with quit problems as well as addictive and negative affect motives for smoking. However, depressive symptoms were not associated with habitual smoking motives.

CONCLUSIONS

Differential patterns of associations with smoking-based processes imply that although panic and depression are related, there are important distinctions. Such data highlight the need for additional research to examine the putative role of panic and depressive symptoms in relation to smoking behaviors to further elucidate the mechanisms through which panic, depression, and smoking impact one another.

Pharmacological Options for Smoking Cessation in Heavy-Drinking Smokers

There is a high prevalence of comorbid tobacco use and alcohol use disorder (AUD), affecting more than 6 million people in the US. Globally, tobacco and alcohol use rank fourth and fifth, respectively, for disability-adjusted life-years lost. Levels of alcohol use are higher in smokers than nonsmokers, and the prevalence of smoking is higher in heavy drinkers compared with nondrinkers. This relationship is driven by many different factors, including genetics, neurobiological mechanisms, conditioning processes, and psychosocial influences. Although this unique population tends to experience more negative health consequences, more severe AUD, and poorer response to treatment than those with either AUD or tobacco use disorder alone, there are currently no available treatment protocols tailored to this comorbid condition. In this review, we provide a comprehensive review of ongoing clinical research into smoking cessation options for heavy-drinking smokers (HDS) through an evaluation of the effect of promising novel pharmacotherapies as well as combination therapies, including varenicline, naltrexone, the combination of varenicline and naltrexone, and the combination of naltrexone and nicotine replacement therapy (NRT). These treatments are considered in light of the standard of care for smoking cessation, and seek to improve upon the available guidelines for this sizeable subgroup of smokers, namely those smokers who drink heavily.

Acute effects of low and high dose alcohol on smoking lapse behavior in a laboratory analogue task

RATIONALE

Smoking lapses (i.e., returns to smoking after quitting) often occur following alcohol consumption with observational data suggesting greater quantities of alcohol lead to greater risk. However, a causal dose-dependent effect of alcohol consumption on smoking lapse behavior has not been established, and the mechanisms that might account for such an effect have not been tested.

OBJECTIVES

In a within-subjects design, we examined the effects of low- (0.4 g/kg) and high-dose (0.8 g/kg) alcohol, relative to placebo, on smokers' ability to resist initiating smoking after acute smoking abstinence.

METHODS

Participants were 100 heavy alcohol drinkers, smoking 10-30 cigarettes per day. Across three separate days, participants consumed placebo, low-dose, or high-dose alcohol following 3 h of smoking abstinence and, 35 min later, were offered the opportunity to smoke while resisting smoking was monetarily reinforced proportional to the amount of time delayed.

RESULTS

Consistent with a dose-response effect, participants smoked 3.35 min (95 % confidence intervals (CI) [-7.09, 0.40], p = .08) earlier following low-dose alcohol and 6.36 min (95 % CI [-9.99, -2.73], p = .0006) earlier following high-dose alcohol compared to drinking a placebo beverage. Effects of dose on smoking behavior were partially mediated by increases in urge to smoke. There was no evidence that alcohol's effects on urge to smoke or ability to resist smoking were mediated through its stimulating or sedating effects.

CONCLUSIONS

Alcohol can reduce the ability to resist smoking in a dose-dependent fashion, in part, due to its effect on increasing the intensity of smoking urges.

Naltrexone improves quit rates, attenuates smoking urge, and reduces alcohol use in heavy drinking smokers attempting to quit smoking

BACKGROUND

Heavy drinking smokers (HDS) have more difficulty quitting smoking than lighter drinkers or abstainers. The opioid antagonist naltrexone may improve smoking quit rates and reduce alcohol use in drinker-smokers, but its relative efficacy in smokers with a range of drinking patterns is unknown. The current study tested the hypothesis that HDS would show differential benefit of naltrexone versus placebo relative to moderate-to-light or nondrinking smokers in terms of improving smoking outcomes and reducing alcohol consumption.

METHODS

Adult smokers (N = 315) enrolled in a 12-week, double-blinded, placebo-controlled trial of 50 mg naltrexone for smoking cessation were categorized into subgroups based upon past 6-month drinking patterns: HDS (n = 69; i.e., averaged ≥2 heavy drinking episodes per month), moderate-to-light drinking smokers (n = 204, i.e., consumed 1 drink up to a maximum of <2 heavy drinking episodes per month on average), or nondrinking smokers (n = 42, no alcohol consumed in the past 6 months). The groups were compared on the main study outcomes of biochemically verified prolonged abstinence quit rates (i.e., no smoking weeks 2 to 12), and smoking urge and alcohol use (drinks/wk) during treatment.

RESULTS

Naltrexone significantly increased 12-week smoking abstinence rates and decreased smoking urge and alcohol use among HDS, but not moderate-to-light or nondrinking smokers. Mediation analyses in HDS revealed that naltrexone's effect on smoking urge during the first 4 weeks of treatment mediated its effect on quit rates.

CONCLUSIONS

HDS appear to be particularly sensitive to naltrexone effects on smoking and drinking outcomes. This group may represent an important target for adjunctive treatment with naltrexone to optimize smoking cessation outcomes.

EPA Guidance on Tobacco Dependence and Strategies for Smoking Cessation in People with Mental Illness

Tobacco dependence is the most common substance use disorder in adults with mental illness. The prevalence rates for tobacco dependence are two to four times higher in these patients than in the general population. Smoking has a strong, negative influence on the life expectancy and quality of life of mental health patients, and remains the leading preventable cause of death in this group. Despite these statistics, in some countries smokers with mental illness are disadvantaged in receiving intervention and support for their tobacco dependence, which is often overlooked or even tolerated. This statement from the European Psychiatric Association (EPA) systematically reviews the current evidence on tobacco dependence and withdrawal in patients with mental illness and their treatment. It provides seven recommendations for the core components of diagnostics and treatment in this patient group. These recommendations concern: (1) the recording process, (2) the timing of the intervention, (3) counselling specificities, (4) proposed treatments, (5) frequency of contact after stopping, (6) follow-up visits and (7) relapse prevention. They aim to help clinicians improve the care, health and well-being of patients suffering from mental illness.

Positive Psychotherapy for Smoking Cessation: Treatment Development, Feasibility and Preliminary Results

Low positive and high negative affect predict low rates of smoking abstinence among smokers making a quit attempt. Positive Psychotherapy can both increase positive affect and decrease negative affect and therefore may be a useful adjunct to behavioral smoking counseling. The purpose of the present study was to assess the feasibility and acceptability of a Positive Psychotherapy for Smoking Cessation (PPT-S) intervention that integrates standard smoking cessation counseling with nicotine patch and a package of positive psychology interventions. We delivered PPT-S to 19 smokers who were low in positive affect at baseline. Rates of session attendance and satisfaction with treatment were high, and most participants reported using and benefiting from the positive psychology interventions. Almost one-third of participants (31.6%) sustained smoking abstinence for 6 months after their quit date. Future studies to assess the relative efficacy of PPT-S compared to standard smoking cessation treatment are warranted.

Pilot randomized trial on mindfulness training for smokers in young adult binge drinkers

Background

We report results of a pilot study designed to test a novel smoking cessation intervention, Mindfulness Training for Smokers (MTS), in smokers age 18-29 years with regular episodes of binge drinking. Mindfulness is a cognitive skill of applying close moment-to-moment attention to experience with a mental posture of acceptance and non-reactivity. The MTS intervention consisted of six weekly classes that provided instruction on how to use mindfulness to manage known precursors of smoking relapse including smoking triggers, strong emotions, stressful situations, addictive thoughts, urges, and withdrawal symptoms.

Methods

The MTS intervention was compared to Interactive Learning for Smokers (ILS), a time/intensity matched control group using daily non-directed walking instead of mindfulness meditation. Recruitment was conducted primarily at local technical colleges. Primary outcome measures included biochemically-confirmed smoking abstinence and reduction in alcohol use at the end of treatment (2-weeks post-quit attempt).

Results

The sample (N = 55) was 70.9% male, with a mean age of 21.9 years, and a mean of 11.76 alcoholic drinks consumed per week. Intent-to-treat analysis showed biochemically-confirmed 7-day point prevalence abstinence rates at 2-weeks post-quit for MTS = 20.0% and ILS = 4.0%, p = .08. Secondary analysis showed number of drinks per week in the first 2-weeks post-quit correlated with smoking relapse at 2-weeks post-quit (p < .01).

Conclusions

This pilot study demonstrated that Mindfulness Training for Smokers shows promise for smoking cessation and alcohol use reduction in treating young adult smokers with alcohol abuse. Results suggest the need for a study with larger sample size and methods that reduce attrition.

Trial registration

ClnicalTrial.gov, NCT01679236

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.