Exercise and Counseling for Smoking Cessation in Smokers With Depressive Symptoms: A Randomized Controlled Pilot Trial

The effectiveness of a transtheoretical model-based smoking cessation intervention for rural smokers: A quasi-experimental longitudinal study

OBJECTIVE

Cigarette smoking is highly prevalent, despite being a primary preventable cause of disease and mortality. This study examined the effect of a Transtheoretical Model (TTM)-based psychoeducational intervention for smoking cessation (SC) on knowledge, SC-related parameters, and progression through the TTM stages of change among rural smokers.

METHODS

This quasi-experimental study recruited 200 smokers from an outpatient clinic. The comparison group was recruited before the experimental group to address possible self-selection bias. Structured questionnaires were administered pre- and post-intervention (three months) and at follow-up (six months).

RESULTS

A generalised estimation equation model indicated that the TTM-based intervention significantly increased participants' SC-knowledge and improved progression through TTM stages by the six-month follow-up. No significant group differences were found in self-efficacy and nicotine dependence scores or daily cigarette consumption.

CONCLUSIONS

A TTM-based intervention enhances SC-knowledge and fosters progress through change stages. However, it does not directly impact nicotine dependence or cigarette consumption. Outpatient settings may employ TTM-based programmes for SC education and motivation. Detecting anticipated effects may require a longer intervention duration exceeding six months.

PRACTICE IMPLICATIONS

Such TTM-based programmes may facilitate SC-knowledge and motivation in outpatient settings. Further research to comprehend patients' context and experiences during the stages of change is required.

Randomized Controlled Trial of Aerobic Exercise for Smoking Cessation Among Individuals With Elevated Depressive Symptoms

INTRODUCTION

Adults with depression have higher rates of cigarette smoking and are more likely to relapse than those without depression. Pharmacological, psychological, and combined interventions have largely yielded small improvements in smoking outcomes for adults with depression. Aerobic exercise (AE) may facilitate smoking cessation in this subpopulation.

METHODS

This study was a 12-week two-arm randomized controlled trial that evaluated the effect of a moderate-intensity AE program compared to a health education contact (HEC) control on smoking cessation in adults with elevated depressive symptoms (mild to severe). Participants (n = 231) were randomized to AE or HEC and received smoking cessation treatment (telephone counseling and nicotine replacement therapy). Primary (biologically confirmed 7-day point prevalence abstinence) and secondary (depressive symptoms, objective and self-reported physical activity, and cardiorespiratory fitness) outcomes were assessed at baseline, 3, 6, and 12 months. Data were analyzed with mixed-effects generalized linear models controlling for age, gender, nicotine dependence, history of major depression disorder, and month of follow-up assessment.

RESULTS

There were no significant differences in primary or secondary outcomes between the AE and HEC groups.

CONCLUSIONS

The AE program was not superior to HEC in facilitating smoking cessation, increases in physical activity, or improved depressive symptoms. Given evidence for the positive acute effects of exercise on mood and smoking urges, future research should consider testing alternative exercise approaches for aiding smoking cessation beyond structured, AE programs.

IMPLICATIONS

This study found that an adjunctive aerobic exercise (AE) program was not superior to a health education contact control for adults with elevated depressive symptoms, all of whom also received standard smoking cessation treatment. This finding adds to the growing body of literature that structured AE programs for smoking cessation may have limited efficacy for cessation outcomes. Future research is needed to test alternative methods of integrating AE into smoking cessation treatment, such as strategically using exercise to manage cravings and low mood in the moment.

Exercise and Smoking Cessation

Smoking is a public health crisis, leading to a multitude of health complications. Exercise is associated with numerous health benefits and is accepted by health professionals and smokers as a potentially effective smoking cessation aid. This chapter discusses the extant literature on the relation between exercise and smoking, including cross-sectional studies, experiments, and randomized clinical trials. There is robust evidence for exercise's efficacy in reducing cigarette craving, tobacco withdrawal symptoms, and negative affect. Further, exercise-based interventions appear to boost short-term abstinence yet may fall short of facilitating long-term abstinence. Methodological limitations of extant work are reviewed. We conclude with a discussion of the next steps in this line of work to fine-tune exercise interventions and their application for smoking cessation.

The effects of exercise with nicotine replacement therapy for smoking cessation in adults: A systematic review

Objective

This systematic review aimed to evaluate the efficacy of exercise programmes with nicotine replacement therapy (NRT) for smoking cessation in adults.

Introduction

Nicotine addiction is mediated by dopamine. Exercise can also activate the dopamine reward system. Therefore, exercise may effectively facilitate NRT to reduce cigarette cravings and withdrawal symptoms.

Inclusion criteria

Clinical trials between 2000 and 2022 used exercise protocols of any intensity for smoking cessation, in current smokers or recent quitters of both genders, aged 18-70, without severe diseases and pregnancy. Mental disorders were not excluded, as exercise can improve mental health status. Therefore, it may be as effective among people with mental health issues as the general population in preventing nicotine cravings and supporting abstinence.

Methods

Four databases (PubMed, Embase, Cochrane, and Medline) were searched for papers in English using the terms "nicotine replacement therapy', "exercise," and "smoking cessation." Titles and abstracts were screened for potentially eligibility before full texts were reviewed. Sample size, gender, study duration, and age was then extracted. The certainty of the evidence was assessed using Joanna Briggs Institute's (JBI's) GRADE approach.

Results

Seventeen studies were identified with a total of 3,191 participants. Three studies are not a randomised control study. There was moderate-high quality evidence that exercise can aid NRT in promoting smoking cessation in the short term. Several studies reported temporary reductions in cravings; however, only one trial reported a decrease in cigarette consumption due to exercise intervention and one demonstrated increased smoking abstinence at 1 year of the intervention.

Conclusion

Exercise with NRT aids smoking cessation in the short term, but no evidence suggests its efficacy in the long term when combined. Future trials should include larger sample sizes and strategies to increase exercise adherence.

Aerobic exercise as a promising nonpharmacological therapy for the treatment of substance use disorders

Despite the prevalence and public health impact of substance use disorders (SUDs), effective long-term treatments remain elusive. Aerobic exercise is a promising, nonpharmacological treatment currently under investigation as a strategy for preventing drug relapse. Aerobic exercise could be incorporated into the comprehensive treatment regimens for people with substance abuse disorders. Preclinical studies of SUD with animal models have shown that aerobic exercise diminishes drug-seeking behavior, which leads to relapse, in both male and female rats. Nevertheless, little is known regarding the effects of substance abuse-induced cellular and physiological adaptations believed to be responsible for drug-seeking behavior. Accordingly, the overall goal of this review is to provide a summary and an assessment of findings to date, highlighting evidence of the molecular and neurological effects of exercise on adaptations associated with SUD.

Add-on exercise interventions for smoking cessation in people with mental illness: a systematic review and meta-analysis

BACKGROUND

Smoking is the most common substance use disorder among people with mental illness. In contrast to people without mental illness, among whom the proportion of smokers has declined in recent decades, the proportion of smokers among people with mental illness remains high. There is a growing body of literature suggesting the use of exercise interventions in combination with smoking cessation in people without mental illness, but to our knowledge the available studies on this treatment option in people with mental illness have not been systematically reviewed. Therefore, this systematic review and meta-analysis aims to assess the effectiveness of exercise interventions as an adjunctive treatment for smoking cessation in people with mental illness.

METHODS

Electronic databases (PubMed, Web of Science, PsycInfo, Sport Discus and Base) were searched for randomised controlled trials and prospective single-group studies that investigated exercise interventions in combination with smoking cessation programmes alone or in comparison with a control group in people with mental illness. A meta-analysis using the Mantel-Haenszel fixed-effect model was conducted to estimate the overall effect of treatment on smoking cessation (abstinence rate at the end of the intervention and at 6-month follow-up).

RESULTS

Six studies, five randomised controlled trials and one study with a prospective single-group design, were included in the systematic review and four randomised controlled trials were included in the meta-analysis. The meta-analysis found a significantly higher abstinence rate after additional exercise at the end of the intervention [risk ratio (RR) 1.48, 95% confidence interval (CI) 1.13-1.94], but not at the 6-month follow-up (RR 1.34, 95% CI 0.89-2.04).

CONCLUSIONS

Exercise appears to be an effective adjunctive therapy to temporarily increase abstinence rates in individuals with mental illness at the end of the intervention. However, due to the small number of included studies and some risk of bias in the included studies, the results should be treated with caution. Therefore, future studies with larger samples are needed to provide a more accurate estimate of the effect in people with mental illness. Registration The systematic review and meta-analysis were registered in the International Prospective Register of Systematic Reviews (PROSPERO) (registration number: CRD42020178630).

The effect of aerobic exercises of different intensities on anxiety, cigarette addiction, sleep quality, and quality of life in former smokers

BACKGROUND

There is a worldwide struggle to quit smoking and prevent relapsing. Aerobic exercises are frequently utilized to aid in smoking cessation and prevent relapse.

AIMS

This study aimed to investigate the effects of aerobic exercises of different intensity on the level of anxiety, smoking addiction, and quality of sleep and life in former smokers.

METHODS

The study included 60 people aged 18 to 45 who had quit smoking within the previous month. Individuals were randomly assigned to control (CON), mild-intensity aerobic activity (MIA), and moderate-intensity aerobic activity (MoIA) groups. The MIA group did submaximal aerobic exercises at 40% of maximum heart rate (MHR), while the MoIA group did them at 60% of MHR for 8 weeks/3 days. Participants' anxiety levels were assessed using the Beck Anxiety Scale (BAS), smoking addiction was assessed using the Fagerström Test for Nicotine Dependence and Substance Craving Scale (SCS), sleep quality was assessed using the Pittsburgh Sleep Quality Index, and quality of life was assessed using the SF-36 Short Form Scale (SF-36).

RESULTS

The SCS score of the MoIA group declined more than the MIA and CON groups, and the MIA group had a lower sleep disturbance score than other groups when the influence of exercise training was assessed over time (p < 0.05). Aerobic exercise had no influence on SF-36 or BAS scores (p > 0.05).

CONCLUSIONS

The benefits of mild and moderate aerobic exercise on quality of life and anxiety are similar. However, mild-intensity aerobic exercises may be suitable for sleep difficulties while moderate-intensity aerobic exercises may be preferred for reducing smoking addiction.

Exercise in the Treatment of Addiction: A Systematic Literature Review

BACKGROUND

Exercise has been recognized as a promising and emerging treatment for individuals recovering from addiction. The purpose of this article was to systematically review scientific studies using exercise as a means to improve, sustain, or treat addictions, and to provide suggestions for the future use of exercise as a treatment method for addiction.

METHODS

Using PRISMA guidelines, a database search was conducted for articles that tested the impact of exercise interventions on addiction-related outcomes. To be included, peer-reviewed experimental design studies had to use human subjects to investigate the relationship between exercise and the treatment of or recovery from addiction. Garrard's Matrix Method was used to extract data from reviewed articles (n = 53).

RESULTS

Nearly three quarters of the studies reviewed documented a significant change in addiction-related outcomes (e.g., more days abstinent, reduced cravings) in response to exercise exposure, particularly while someone was receiving treatment at an in or outpatient clinic. Many studies investigated the effect of acute bouts of exercise on nicotine dependence, and many studies had small sample sizes, leaving room for future research on how exercise might benefit people recovering from substance and process addictions.

CONCLUSION

Results affirm that exercise can be a helpful aspect of addiction treatment. Future researchers should investigate different exercise settings (e.g., group-based exercise vs individual) and explore exercise maintenance and the long-term outcomes following discharge from treatment facilities.

Supporting smoking cessation and preventing relapse following a stay in a smoke-free setting: a meta-analysis and investigation of effective behaviour change techniques

BACKGROUND AND AIMS

Admission to a smoke-free setting presents a unique opportunity to encourage smokers to quit. However, risk of relapse post-discharge is high, and little is known about effective strategies to support smoking cessation following discharge. We aimed to identify interventions that maintain abstinence following a smoke-free stay and determine their effectiveness, as well as the probable effectiveness of behaviour change techniques (BCTs) used in these interventions.

METHODS

Systematic review and meta-analyses of studies of adult smokers aged ≥ 18 years who were temporarily or fully abstinent from smoking to comply with institutional smoke-free policies. Institutions included prison, inpatient mental health, substance misuse or acute hospital settings. A Mantel-Haenszel random-effects meta-analysis of randomized controlled trials (RCTs) was conducted using biochemically verified abstinence (7-day point prevalence or continuous abstinence). BCTs were defined as 'promising' in terms of probable effectiveness (if BCT was present in two or more long-term effective interventions) and feasibility (if BCT was also delivered in ≥ 25% of all interventions).

RESULTS

Thirty-seven studies (intervention n = 9041, control n = 6195) were included: 23 RCTs (intervention n = 6593, control n = 5801); three non-randomized trials (intervention n = 845, control n = 394) and 11 cohort studies (n = 1603). Meta-analysis of biochemically verified abstinence at longest follow-up (4 weeks-18 months) found an overall effect in favour of intervention [risk ratio (RR) = 1.27, 95% confidence interval (CI) = 1.08-1.49, I²  = 42%]. Nine BCTs (including 'pharmacological support', 'goal-setting (behaviour)' and 'social support') were characterized as 'promising' in terms of probable effectiveness and feasibility.

CONCLUSIONS

A systematic review and meta-analyses indicate that behavioural and pharmacological support is effective in maintaining smoking abstinence following a stay in a smoke-free institution. Several behaviour change techniques may help to maintain smoking abstinence up to 18 months post-discharge.

Interventions for preventing weight gain after smoking cessation

BACKGROUND

Most people who stop smoking gain weight. This can discourage some people from making a quit attempt and risks offsetting some, but not all, of the health advantages of quitting. Interventions to prevent weight gain could improve health outcomes, but there is a concern that they may undermine quitting.

OBJECTIVES

To systematically review the effects of: (1) interventions targeting post-cessation weight gain on weight change and smoking cessation (referred to as 'Part 1') and (2) interventions designed to aid smoking cessation that plausibly affect post-cessation weight gain (referred to as 'Part 2').

SEARCH METHODS

Part 1 - We searched the Cochrane Tobacco Addiction Group's Specialized Register and CENTRAL; latest search 16 October 2020. Part 2 - We searched included studies in the following 'parent' Cochrane reviews: nicotine replacement therapy (NRT), antidepressants, nicotine receptor partial agonists, e-cigarettes, and exercise interventions for smoking cessation published in Issue 10, 2020 of the Cochrane Library. We updated register searches for the review of nicotine receptor partial agonists.

SELECTION CRITERIA

Part 1 - trials of interventions that targeted post-cessation weight gain and had measured weight at any follow-up point or smoking cessation, or both, six or more months after quit day. Part 2 - trials included in the selected parent Cochrane reviews reporting weight change at any time point.

DATA COLLECTION AND ANALYSIS

Screening and data extraction followed standard Cochrane methods. Change in weight was expressed as difference in weight change from baseline to follow-up between trial arms and was reported only in people abstinent from smoking. Abstinence from smoking was expressed as a risk ratio (RR). Where appropriate, we performed meta-analysis using the inverse variance method for weight, and Mantel-Haenszel method for smoking.

MAIN RESULTS

Part 1: We include 37 completed studies; 21 are new to this update. We judged five studies to be at low risk of bias, 17 to be at unclear risk and the remainder at high risk.  An intermittent very low calorie diet (VLCD) comprising full meal replacement provided free of charge and accompanied by intensive dietitian support significantly reduced weight gain at end of treatment compared with education on how to avoid weight gain (mean difference (MD) -3.70 kg, 95% confidence interval (CI) -4.82 to -2.58; 1 study, 121 participants), but there was no evidence of benefit at 12 months (MD -1.30 kg, 95% CI -3.49 to 0.89; 1 study, 62 participants). The VLCD increased the chances of abstinence at 12 months (RR 1.73, 95% CI 1.10 to 2.73; 1 study, 287 participants). However, a second study  found that no-one completed the VLCD intervention or achieved abstinence. Interventions aimed at increasing acceptance of weight gain reported mixed effects at end of treatment, 6 months and 12 months with confidence intervals including both increases and decreases in weight gain compared with no advice or health education. Due to high heterogeneity, we did not combine the data. These interventions increased quit rates at 6 months (RR 1.42, 95% CI 1.03 to 1.96; 4 studies, 619 participants; I² = 21%), but there was no evidence at 12 months (RR 1.25, 95% CI 0.76 to 2.06; 2 studies, 496 participants; I² = 26%). Some pharmacological interventions tested for limiting post-cessation weight gain (PCWG) reduced weight gain at the end of treatment (dexfenfluramine, phenylpropanolamine, naltrexone). The effects of ephedrine and caffeine combined, lorcaserin, and chromium were too imprecise to give useful estimates of treatment effects. There was very low-certainty evidence that personalized weight management support reduced weight gain at end of treatment (MD -1.11 kg, 95% CI -1.93 to -0.29; 3 studies, 121 participants; I² = 0%), but no evidence in the longer-term 12 months (MD -0.44 kg, 95% CI -2.34 to 1.46; 4 studies, 530 participants; I² = 41%). There was low to very low-certainty evidence that detailed weight management education without personalized assessment, planning and feedback did not reduce weight gain and may have reduced smoking cessation rates (12 months: MD -0.21 kg, 95% CI -2.28 to 1.86; 2 studies, 61 participants; I² = 0%; RR for smoking cessation 0.66, 95% CI 0.48 to 0.90; 2 studies, 522 participants; I² = 0%). Part 2: We include 83 completed studies, 27 of which are new to this update. There was low certainty that exercise interventions led to minimal or no weight reduction compared with standard care at end of treatment (MD -0.25 kg, 95% CI -0.78 to 0.29; 4 studies, 404 participants; I² = 0%). However, weight was reduced at 12 months (MD -2.07 kg, 95% CI -3.78 to -0.36; 3 studies, 182 participants; I² = 0%). Both bupropion and fluoxetine limited weight gain at end of treatment (bupropion MD -1.01 kg, 95% CI -1.35 to -0.67; 10 studies, 1098 participants; I² = 3%); (fluoxetine MD -1.01 kg, 95% CI -1.49 to -0.53; 2 studies, 144 participants; I² = 38%; low- and very low-certainty evidence, respectively). There was no evidence of benefit at 12 months for bupropion, but estimates were imprecise (bupropion MD -0.26 kg, 95% CI -1.31 to 0.78; 7 studies, 471 participants; I² = 0%). No studies of fluoxetine provided data at 12 months. There was moderate-certainty that NRT reduced weight at end of treatment (MD -0.52 kg, 95% CI -0.99 to -0.05; 21 studies, 2784 participants; I² = 81%) and moderate-certainty that the effect may be similar at 12 months (MD -0.37 kg, 95% CI -0.86 to 0.11; 17 studies, 1463 participants; I² = 0%), although the estimates are too imprecise to assess long-term benefit. There was mixed evidence of the effect of varenicline on weight, with high-certainty evidence that weight change was very modestly lower at the end of treatment (MD -0.23 kg, 95% CI -0.53 to 0.06; 14 studies, 2566 participants; I² = 32%); a low-certainty estimate gave an imprecise estimate of higher weight at 12 months (MD 1.05 kg, 95% CI -0.58 to 2.69; 3 studies, 237 participants; I² = 0%).

AUTHORS' CONCLUSIONS

Overall, there is no intervention for which there is moderate certainty of a clinically useful effect on long-term weight gain. There is also no moderate- or high-certainty evidence that interventions designed to limit weight gain reduce the chances of people achieving abstinence from smoking.

Effectiveness of Aerobic Exercise on Smoking Cessation in Adults: A Systematic Review and Meta-Analysis

BACKGROUND

The specific benefits of aerobic exercises in smoking cessation are unclear, as they have different characteristics, intensities, and durations. The purpose of this systematic review with meta-analysis was to evaluate the effects of aerobic exercise, with or without co-interventions, compared with a control group of cognitive behavior treatment on smoking cessation.

METHODS

This review was prospectively registered on PROSPERO, and the searches were performed from 2016 to 2018. Randomized controlled trials evaluating the effects of aerobic exercise, with or without nicotine therapy replacement, compared with usual care were included. The primary outcome was smoking cessation defined as the prevalence of those who quit or continuous abstinence. Meta-analysis was calculated using random effects model in the comprehensive meta-analysis software.

RESULTS

The authors identified 18 trials reporting data for a total of 2815 participants. There was moderate-quality evidence that aerobic exercise was better than usual care in promoting smoking cessation at short term (11 trials, risk ratio 0.79; 95% confidence interval, 0.66-0.94). However, there were no differences between aerobic exercises and usual care at medium- or long-term follow-ups.

CONCLUSIONS

According to review, aerobic exercise may be effective in promoting smoking cessation at short-term, but not at medium- and long-term follow-ups.

Long-Term Outcomes of a Preoperative Lung Resection Smoking Cessation Program

BACKGROUND

Smoking cessation programs for patients with cancer suggest 6-mo quit rates between 22% and 40%, and 1-y rates of 33%. We sought to investigate the long-term outcomes of an intensive, preoperative smoking cessation program in patients undergoing lung resection.

MATERIAL AND METHODS

A retrospective analysis of an IRB-approved, prospective database was performed. Elective lung resections between January 1, 2015 and June 30, 2017 were identified. Demographics, smoking status, pack years, occurrence of smoking cessation counseling, complications, and quit date were obtained. Smoking cessation included face-to-face motivational interviewing, choice of nicotine replacement therapy, discussion that surgery may be canceled or delayed without cessation, and follow-up as needed.

RESULTS

A total of 340 patients underwent lung resection. Of these, 82 patients were classified as current smokers. All were advised to quit and encouraged to meet with a certified tobacco treatment specialist. Sixty-three patients met with a tobacco treatment specialist and 19 did not. Overall, 60 patients (73%) were able to quit before surgery. At 2 y postoperatively, 15 (18%) were lost to follow-up and 9 (11%) had died. Excluding deaths and censoring those lost to follow-up, cessation rates at 6, 12, and 24 mo postoperatively were 55.3%, 55.6%, and 51.7%, respectively.

CONCLUSIONS

Implementation of an intensive smoking cessation program in the preoperative period demonstrated high initial, mid-term, and long-term success rates. The preoperative period, particularly one centered around lung cancer, is an effective time for smoking cessation intervention and can lead to a high rate of cessation up to 2 y after surgery.

Combined health risks of cigarette smoking and low levels of physical activity: a prospective cohort study in England with 12-year follow-up

OBJECTIVES

To (1) estimate the combined risks of cigarette smoking and physical inactivity for chronic disease, disability and depressive symptoms and (2) determine whether risks associated with these behaviours are additive or synergistic.

DESIGN AND SETTING

Longitudinal observational population study using data from Waves 2 (2004/2005) through 8 (2016/2017) of the English Longitudinal Study of Ageing, a prospective study of community-dwelling older adults in England.

PARTICIPANTS

6425 men and women aged ≥52 years (mean (SD) 65.88 (9.34) years) at baseline.

MAIN OUTCOME MEASURES

Smoking status (never, former, current) and level of physical activity (high, defined as moderate/vigorous physical activity (MVPA) more than once a week; low, defined as MVPA once a week or less) were self-reported at Wave 2 baseline. Self-rated health, limiting long-standing illness, chronic conditions (coronary heart disease (CHD), stroke, cancer, chronic lung disease) and depressive symptoms were reported in each biennial wave.

RESULTS

Both smoking and low levels of physical activity were associated with increased risk of incident health problems over the 12-year follow-up period. Current smokers with low levels of physical activity had especially high risks of developing fair/poor self-rated health, CHD, stroke, cancer and chronic lung disease compared with highly active never smokers (adjusted relative risk range 1.89-14.00). While additive effects were evident, tests of multiplicative interactions revealed no evidence of large synergistic effects of smoking and low physical activity (Bayes factor range 0.04-0.61), although data were insensitive to detect smaller effects.

CONCLUSIONS

Among older adults in England, there was no evidence of large synergistic effects of smoking and low levels of physical activity on risk of developing chronic disease or depressive symptoms over 12 years. However, additive effects of smoking and low levels of physical activity were evident, underscoring the importance of each of these lifestyle risk behaviours for disease onset.

Psychological interventions for co-occurring depression and substance use disorders

BACKGROUND

Comorbid depression and substance use disorders are common and have poorer outcomes than either disorder alone. While effective psychological treatments for depression or substance use disorders are available, relatively few randomised controlled trials (RCTs) have examined the efficacy of these treatments in people with these comorbid disorders.

OBJECTIVES

To assess the efficacy of psychological interventions delivered alone or in combination with pharmacotherapy for people diagnosed with comorbid depression and substance use disorders.

SEARCH METHODS

We searched the following databases up to February 2019: Cochrane Central Register of Controlled Trials, PubMed, Embase, CINAHL, Google Scholar and clinical trials registers. All systematic reviews identified, were handsearched for relevant articles.

SELECTION CRITERIA

The review includes data from RCTs of psychological treatments for people diagnosed with comorbid depression and substance use disorders, using structured clinical interviews. Studies were included if some of the sample were experiencing another mental health disorder (e.g. anxiety); however, studies which required a third disorder as part of their inclusion criteria were not included. Studies were included if psychological interventions (with or without pharmacotherapy) were compared with no treatment, delayed treatment, treatment as usual or other psychological treatments.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Seven RCTs of psychological treatments with a total of 608 participants met inclusion criteria. All studies were published in the USA and predominately consisted of Caucasian samples. All studies compared different types of psychological treatments. Two studies compared Integrated Cognitive Behavioural Therapy (ICBT) with Twelve Step Facilitation (TSF), another two studies compared Interpersonal Psychotherapy for Depression (IPT-D) with other treatment (Brief Supportive Therapy (BST) or Psychoeducation). The other three studies compared different types or combinations of psychological treatments. No studies compared psychological interventions with no treatment or treatment as usual control conditions. The studies included a diverse range of participants (e.g. veterans, prisoners, community adults and adolescents). All studies were at high risk of performance bias, other main sources were selection, outcome detection and attrition bias. Due to heterogeneity between studies only two meta-analyses were conducted. The first meta-analysis focused on two studies (296 participants) comparing ICBT to TSF. Very low-quality evidence revealed that while the TSF group had lower depression scores than the ICBT group at post-treatment (mean difference (MD) 4.05, 95% confidence interval (CI) 1.43 to 6.66; 212 participants), there was no difference between groups in depression symptoms (MD 1.53, 95% CI -1.73 to 4.79; 181 participants) at six- to 12-month follow-up. At post-treatment there was no difference between groups in proportion of days abstinent (MD -2.84, 95% CI -8.04 to 2.35; 220 participants), however, the ICBT group had a greater proportion of days abstinent than the TSF group at the six- to 12-month follow-up (MD 10.76, 95% CI 3.10 to 18.42; 189 participants). There were no differences between the groups in treatment attendance (MD -1.27, 95% CI -6.10 to 3.56; 270 participants) or treatment retention (RR 0.95, 95% CI 0.72 to 1.25; 296 participants). The second meta-analysis was conducted with two studies (64 participants) comparing IPT-D with other treatment (Brief Supportive Psychotherapy/Psychoeducation). Very low-quality evidence indicated IPT-D resulted in significantly lower depressive symptoms at post-treatment (MD -0.54, 95% CI -1.04 to -0.04; 64 participants), but this effect was not maintained at three-month follow-up (MD 3.80, 95% CI -3.83 to 11.43) in the one study reporting follow-up outcomes (38 participants; IPT-D versus Psychoeducation). Substance use was examined separately in each study, due to heterogeneity in outcomes. Both studies found very low-quality evidence of no significant differences in substance use outcomes at post-treatment (percentage of days abstinent, IPD versus Brief Supportive Psychotherapy; MD -2.70, 95% CI -28.74 to 23.34; 26 participants) or at three-month follow-up (relative risk of relapse, IPT-D versus Psychoeducation; RR 0.67, 95% CI 0.30 to 1.50; 38 participants). There was also very low-quality evidence for no significant differences between groups in treatment retention (RR 1.00, 95% CI 0.81 to 1.23; 64 participants). No adverse events were reported in any study.

AUTHORS' CONCLUSIONS

The conclusions of this review are limited due to the low number and very poor quality of included studies. No conclusions can be made about the efficacy of psychological interventions (delivered alone or in combination with pharmacotherapy) for the treatment of comorbid depression and substance use disorders, as they are yet to be compared with no treatment or treatment as usual in this population. In terms of differences between psychotherapies, although some significant effects were found, the effects were too inconsistent and small, and the evidence of too poor quality, to be of relevance to practice.

Exercise interventions for smoking cessation

BACKGROUND

Taking regular exercise, whether cardiovascular-type exercise or resistance exercise, may help people to give up smoking, particularly by reducing cigarette withdrawal symptoms and cravings, and by helping to manage weight gain.

OBJECTIVES

To determine the effectiveness of exercise-based interventions alone, or combined with a smoking cessation programme, for achieving long-term smoking cessation, compared with a smoking cessation intervention alone or other non-exercise intervention.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register for studies, using the term 'exercise' or 'physical activity' in the title, abstract or keywords. The date of the most recent search was May 2019.

SELECTION CRITERIA

We included randomised controlled trials that compared an exercise programme alone, or an exercise programme as an adjunct to a cessation programme, with a cessation programme alone or another non-exercise control group. Trials were required to recruit smokers wishing to quit or recent quitters, to assess abstinence as an outcome and have follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Smoking cessation was measured after at least six months, using the most rigorous definition available, on an intention-to-treat basis. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of comparison, as either smoking cessation or relapse prevention. We carried out meta-analyses where appropriate, using Mantel-Haenszel random-effects models.

MAIN RESULTS

We identified 24 eligible trials with a total of 7279 adult participants randomised. Two studies focused on relapse prevention among smokers who had recently stopped smoking, and the remaining 22 studies were concerned with smoking cessation for smokers who wished to quit. Eleven studies were with women only and one with men only. Most studies recruited fairly inactive people. Most of the trials employed supervised, group-based cardiovascular-type exercise supplemented by a home-based exercise programme and combined with a multi-session cognitive behavioural smoking cessation programme. The comparator in most cases was a multi-session cognitive behavioural smoking cessation programme alone. Overall, we judged two studies to be at low risk of bias, 11 at high risk of bias, and 11 at unclear risk of bias. Among the 21 studies analysed, we found low-certainty evidence, limited by potential publication bias and by imprecision, comparing the effect of exercise plus smoking cessation support with smoking cessation support alone on smoking cessation outcomes (RR 1.08, 95% CI 0.96 to 1.22; I² = 0%; 6607 participants). We excluded one study from this analysis as smoking abstinence rates for the study groups were not reported. There was no evidence of subgroup differences according to the type of exercise promoted; the subgroups considered were: cardiovascular-type exercise alone (17 studies), resistance training alone (one study), combined cardiovascular-type and resistance exercise (one study) and type of exercise not specified (two studies). The results were not significantly altered when we excluded trials with high risk of bias, or those with special populations, or those where smoking cessation intervention support was not matched between the intervention and control arms. Among the two relapse prevention studies, we found very low-certainty evidence, limited by risk of bias and imprecision, that adding exercise to relapse prevention did not improve long-term abstinence compared with relapse prevention alone (RR 0.98, 95% CI 0.65 to 1.47; I² = 0%; 453 participants).

AUTHORS' CONCLUSIONS

There is no evidence that adding exercise to smoking cessation support improves abstinence compared with support alone, but the evidence is insufficient to assess whether there is a modest benefit. Estimates of treatment effect were of low or very low certainty, because of concerns about bias in the trials, imprecision and publication bias. Consequently, future trials may change these conclusions.

Advances in Health Technology Use and Implementation in the Era of Healthy Living: Implications for Precision Medicine

Much of the focus of precision medicine has been directed toward genomics, despite the fact that "lifestyle and behavioral factors" are included in the description of precision medicine. Numerous structured diet and PA interventions have demonstrated success in preventing and/or reducing chronic-disease risk. The use of personal health technologies has expanded exponentially in the health care arena; there are a number of consumer-based technologies yielding health information to individual users. The explosion in technology use provides an opportunity for broader dissemination of health care services and products. In addition, tracking cardiovascular disease risk and lifestyle and behavioral aspects of healthy living (HL) profiles in those products may be an important leveraging interface for precision medicine. This review will discuss and present an overview of current health technologies, their use in promotion of HL metrics and how this data may be integrated into venues that support HL and precision medicine.

Nonpharmacologic management of hypertension: a multidisciplinary approach

PURPOSE OF REVIEW

Nonpharmacologic lifestyle modification interventions (LMIs), such as increasing physical activity, dietary modification, weight-loss, reducing alcohol consumption and smoking cessation, are effective strategies to lower resting blood pressures (BPs) in prehypertensive or hypertensive patients. However, the limited time shared between a physician and a patient is not adequate to instill an adoption of LMI. The purpose of this review is to therefore highlight evidence-based BP lowering, LMI strategies that can feasibly be implemented in clinical practices.

RECENT FINDINGS

Interventions focusing on modifying physical activity, diet, weight-loss, drinking and smoking habits have established greater efficacy in reducing elevated BP compared with providing guideline recommendations based on national guidelines. Alone greater reductions in BP can be achieved through programmes that provide frequent contact time with exercise, nutrition and/or wellness professionals. Programmes that educate individuals to lead peer support groups can be an efficient method of ensuring compliance to LMI.

SUMMARY

Evidence of a multidisciplinary approach to LMI is an effective and attractive model in managing elevated BP. This strategy is an attractive model that provides the necessary patient attention to confer lifestyle maintenance.

Survey of potential receptivity to robotic-assisted exercise coaching in a diverse sample of smokers and nonsmokers

A prior project found that an intensive (12 weeks, thrice weekly sessions) in-person, supervised, exercise coaching intervention was effective for smoking cessation among depressed women smokers. However, the sample was 90% White and of high socioeconomic status, and the intensity of the intervention limits its reach. One approach to intervention scalability is to deliver the supervised exercise coaching using a robotic human exercise trainer. This is done in real time via an iPad tablet placed on a mobile robotic wheel base and controlled remotely by an iOS device or computer. As an initial step, this preliminary study surveyed potential receptivity to a robotic-assisted exercise coaching intervention among 100 adults recruited in two community settings, and explored the association of technology acceptance scores with smoking status and other demographics. Participants watched a brief demonstration of the robot-delivered exercise coaching and completed a 19-item survey assessing socio-demographics and technology receptivity measured by the 8-item Technology Acceptance Scale (TAS). Open-ended written feedback was obtained, and content analysis was used to derive themes from these data. Respondents were: 40% female, 56% unemployed, 41% racial minority, 38% current smoker, and 58% depression history. Mean total TAS score was 34.0 (SD = 5.5) of possible 40, indicating overall very good receptivity to the robotic-assisted exercise intervention concept. Racial minorities and unemployed participants reported greater technology acceptance than White (p = 0.015) and employed (p<0.001) respondents. No association was detected between the TAS score and smoking status, depression, gender or age groups. Qualitative feedback indicated the robot was perceived as a novel, motivating, way to increase intervention reach and accessibility, and the wave of the future. Robotic technology has potential applicability for exercise coaching in a broad range of populations, including depressed smokers. Our next step will be to conduct a pilot trial to assess acceptability and potential efficacy of the robotic-assisted exercise coaching intervention for smoking cessation.

Effectiveness of pharmacological or psychological interventions for smoking cessation in smokers with major depression or depressive symptoms: A systematic review of the literature

BACKGROUND

Smokers with major depressive disorder (MDD) or depressive symptoms (DS) represent a subgroup in need of attention, since they have specific clinical features and prognosis.

METHODS

A systematic review of the literature (Cochrane, MEDLINE, ScienceDirect, Web of Science databases from inception to June 2017) of randomized clinical trials assessing the effectiveness of pharmacological, psychological, or combined interventions for smoking cessation in subjects with current or past MDD/DS without medical or comorbid psychiatric disorder(s) was run following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Twenty-seven studies met the inclusion criteria. Nicotine, varenicline, and staged-care intervention were more effective in smokers with current MDD; nicotine and fluoxetine plus nicotine were more effective in smokers with DS; naltrexone and nicotine plus fluoxetine were more effective in smokers with severe current DS. Cognitive-behavioral therapy and cognitive and behavioral cessation and relapse prevention skills training were superior to placebo in smokers with past MDD.

CONCLUSIONS

More research is needed into effectively addressing smoking in people with concurrent mental disorder. Data currently available need to be confirmed in randomized trials aimed at replicating the results and disentangling the effects of each therapeutic ingredient when a combination therapy is proposed. Studies on tolerability of treatments are warranted, as well as those aimed at identifying factors of vulnerability to adverse effects.

The impact of an add-on video assisted structured aerobic exercise module on mood and somatic symptoms among women with depressive disorders: Study from a tertiary care centre in India

BACKGROUND

The evidence in favor of exercise as a treatment for depression is compelling, but what kind of exercise, how much, how often, and at what intensity is necessary to make a significant difference. There is serious dearth of such data from India, in particular. We examined the impact of low-moderate intensity aerobic exercises on mood and somatic symptoms among women with depressive disorders.

METHODS

A pre test- post test control group design was adopted with a sample size of 40 (20 subjects randomized to both experimental and control group) women inpatients diagnosed with depressive disorder at a tertiary care centre, Bengaluru, India. After pre-test, experimental group received 10 sessions of add-on intervention (video assisted structured aerobic exercise module) and the control group received treatment as usual. Hamilton Depression Rating Scale (HDRS), Visual Analogue Mood Scale (VAMS) and Depression Somatic Symptom scale (DSSS) were used as clinical outcome measures.

RESULTS

The estimated mean change within the group in HDRS was 4.30 (95% CI 3.15 to 5.44; p<0.001) in the experimental group as compared to 2.70 (95% CI 1.50 to 3.89; p<0.001) in control group. RMANOVA (F=4.08) revealed a significant reduction in mean mood score in HDRS in the experimental group as compared to the control group at p<0.05. There was no statistically significant reduction in mean somatic symptom score between the groups (p=0.142).

CONCLUSION

The study findings support that add-on aerobic exercise is associated with significantly greater improvements in mood symptoms of women with depressive disorders, when performed in a structured and supervised setting.

Effects of Behavioral Activation on the Quality of Life and Emotional State of Lung Cancer and Breast Cancer Patients During Chemotherapy Treatment

Research suggests that the progressive abandonment of activities in cancer patients are related to depression and worse quality of life. Behavioral activation (BA) encourages subjects to activate their sources of reinforcement and modify the avoidance responses. This study assesses the effectiveness of BA in improving quality of life and preventing emotional disorders during chemotherapy treatment. One sample of lung cancer patients and another of breast cancer patients were randomized into a BA experimental group (E.G._lung/4sess.n = 50; E.G._breast/6sess.n = 33) and a control group (C.G._lung/4sess.n = 40; C.G._{breast/6sess.}n = 35), respectively. In each session and in follow-ups (3/6/9 months), all participants completed different assessment scales. The results converge to show the effectiveness of BA, encouraging cancer patients to maintain rewarding activities which can activate their sources of day-to-day reinforcement and modify their experience avoidance patterns. BA appears to be a practical intervention which may improve social and role functioning and the emotional state of cancer patients during chemotherapy treatment.

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

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

A systematic narrative review of the effectiveness of behavioural smoking cessation interventions in selected disadvantaged groups (2010-2017)

INTRODUCTION

Tobacco remains the key modifiable risk factor for the development of a number of diseases, including cardiovascular disease, cerebrovascular disease, lower respiratory infections, chronic obstructive pulmonary disease, tuberculosis and cancer. Among priority populations, smoking prevalence remains high, smokers tend to relapse more often and earlier and fewer are able to sustain quit attempts. This systematic review provides an update on the literature. Areas covered: Twenty-four randomized controlled trials published from 2010-2017, in English language, were identified after searching on Medline, Ovid, Embase and PsycINFO databases. Studies reported on the effectiveness of smoking cessation interventions among six disadvantaged groups known to have high smoking rates: (i) homeless, (ii) prisoners, (iii) indigenous populations, (iv) at-risk youth, (v) people with low income, and (vi) those with a mental illness. Narrative review and assessment of methodological quality of included papers was undertaken. Expert commentary: There is a growing evidence base of methodologically robust studies evaluating a variety of behavioural smoking cessation interventions for priority populations. Multi-component interventions and those examining behavioural interventions incorporating mindfulness training, financial incentives, motivational interviewing and extended telephone-delivered counseling may be effective in the short-term, particularly for smokers on low incomes and people with a mental illness.

Physical activity and sedentary behavior in people with major depressive disorder: A systematic review and meta-analysis

BACKGROUND

Low levels of physical activity (PA) and sedentary behavior (SB) are independent risk factors for cardiovascular disease and premature mortality in people with major depressive disorder (MDD).

AIMS

Investigate levels of PA and SB and their predictors in people with MDD.

METHODS

Electronic databases were searched from inception till 04/2016 for articles measuring PA and SB with a self-report questionnaire (SRQ) or objective measure (e.g. accelerometer) in people with MDD. Random-effects meta-analyses and meta-regression analyses were conducted.

RESULTS

Twenty-four eligible studies were identified including 2901 people with MDD (78.4% female, mean age=54 years; range: 21-77 years). People with MDD spent 126.0min (95%CI=91.9-160.1) per day engaging in all types of PA and spent 8.5hours (95%CI=7.51-9.62) during their waking day being sedentary. Compared to controls, people with MDD spent less time in total PA (SMD=-0.25, 95%CI=-0.03 to 0.15) and moderate to vigorous PA (SMD=-0.30, 95%CI=-0.40 to 0.21) and engaged in higher levels of SB (SMD=0.09, 95%CI=0.01-0.18). The proportion of people with MDD not meeting the recommended PA guidelines was 67.8% (n=13 studies), which was higher in studies relying on objective versus self-report measures (85.7% v 62.1%, p=0.04). People with MDD were more likely than controls to not meeting the recommended PA guidelines (OR = 1.50, 95%CI = 1.10–2.10).

LIMITATIONS

Heterogeneity was evident in most analyses.

CONCLUSIONS

Adults with MDD engage in low levels of PA and high levels of SB. PA and SB are independent predictors of mortality, therefore, future lifestyle interventions targeting both the prevention of SB and adoption and maintenance of PA are warranted.

The Role of Physical Activity Enjoyment on the Acute Mood Experience of Exercise among Smokers with Elevated Depressive Symptoms

PROBLEM

Depressive symptoms are consistently shown to be related to poor smoking cessation outcomes. Aerobic exercise is a potential treatment augmentation that, given its antidepressant and mood enhancing effect, may bolster cessation outcomes for smokers with elevated depressive symptoms. Lower enjoyment of physical activity may inhibit the acute mood enhancing effects of aerobic exercise. The current study investigated the associations between depressive symptoms, physical activity enjoyment and the acute mood experience from exercise among low-active smokers with elevated depressive symptoms.

METHOD

Daily smokers with elevated depressive symptoms (N=159; Mage = 45.1, SD = 10.79; 69.8% female) were recruited for a randomized controlled exercise-based smoking cessation trial. Participants self-reported levels of depressive symptoms, physical activity enjoyment, and rated their mood experience (assessed as "mood" and "anxiety") before and after a standardized aerobic exercise test.

RESULTS

Hierarchical regression analysis revealed that depressive symptom severity accounted for significant unique variance in physical activity enjoyment (R2 =.041, t = -2.61, p = .010), beyond the non-significant effects of gender and level of tobacco dependence. Additionally, physical activity enjoyment was a significant mediator of the association between depressive symptom severity and acute mood experience ("mood" and "anxiety") following the exercise test.

CONCLUSIONS

Physical activity enjoyment may explain, at least in part, how depressive symptom severity is linked to the acute mood experience following a bout of activity. Interventions that target increasing physical activity enjoyment may ultimately assist in enhancing the mood experience from exercise, and therefore improve smoking cessation likelihood, especially for smokers with elevated depressive symptoms.

Factors associated with study attrition in a pilot randomised controlled trial to explore the role of exercise-assisted reduction to stop (EARS) smoking in disadvantaged groups

Background

Study attrition has the potential to compromise a trial’s internal and external validity. The aim of the present study was to identify factors associated with participant attrition in a pilot trial of the effectiveness of a novel behavioural support intervention focused on increasing physical activity to reduce smoking, to inform the methods to reduce attrition in a definitive trial.

Methods

Disadvantaged smokers who wanted to reduce but not quit were randomised (N = 99), of whom 61 (62 %) completed follow-up assessments at 16 weeks. Univariable logistic regression was conducted to determine the effects of intervention arm, method of recruitment, and participant characteristics (sociodemographic factors, and lifestyle, behavioural and attitudinal characteristics) on attrition, followed by multivariable logistic regression on those factors found to be related to attrition.

Results

Participants with low confidence to quit, and who were undertaking less than 150 mins of moderate and vigorous physical activity per week at baseline were less likely to complete the 16-week follow-up assessment. Exploratory analysis revealed that those who were lost to follow-up early in the trial (i.e., by 4 weeks), compared with those completing the study, were younger, had smoked for fewer years and had lower confidence to quit in the next 6 months. Participants who recorded a higher expired air carbon monoxide reading at baseline were more likely to drop out late in the study, as were those recruited via follow-up telephone calls. Multivariable analyses showed that only completing less than 150 mins of physical activity retained any confidence in predicting attrition in the presence of other variables.

Conclusions

The findings indicate that those who take more effort to be recruited, are younger, are heavier smokers, have less confidence to quit, and are less physically active are more likely to withdraw or be lost to follow-up.

Supervised, Vigorous Intensity Exercise Intervention for Depressed Female Smokers: A Pilot Study

INTRODUCTION

Few studies have evaluated exercise interventions for smokers with depression or other psychiatric comorbidities. This pilot study evaluated the potential role of supervised vigorous exercise as a smoking cessation intervention for depressed females.

METHODS

Thirty adult women with moderate-severe depressive symptoms were enrolled and randomly assigned to 12 weeks of thrice weekly, in person sessions of vigorous intensity supervised exercise at a YMCA setting (EX; n = 15) or health education (HE; n = 15). All participants received behavioral smoking cessation counseling and nicotine patch therapy. Assessments were done in person at baseline, at the end of 12 weeks of treatment, and at 6 months post-target quit date. Primary end points were exercise adherence (proportion of 36 sessions attended) and biochemically confirmed 7-day point prevalence abstinence at Week 12. Biomarkers of inflammation were explored for differences between treatment groups and between women who smoked and those abstinent at Week 12.

RESULTS

Treatment adherence was high for both groups (72% for EX and 66% for HE; p = .55). The Week 12 smoking abstinence rate was higher for EX than HE (11/15 [73%] vs. 5/15 [33%]; p = .028), but no significant differences emerged at 6-month follow-up. Interleukin-6 levels increased more for those smoking than women abstinent at Week 12 (p = .040).

CONCLUSIONS

Vigorous intensity supervised exercise is feasible and enhances short-term smoking cessation among depressed female smokers. Innovative and cost-effective strategies to bolster long-term exercise adherence and smoking cessation need evaluation in this population. Inflammatory biomarkers could be examined in future research as mediators of treatment efficacy.

IMPLICATIONS

This preliminary study found that vigorous intensity supervised exercise is feasible and enhances short-term smoking cessation among depressed female smokers. This research addressed an important gap in the field. Despite decades of research examining exercise interventions for smoking cessation, few studies were done among depressed smokers or those with comorbid psychiatric disorders. A novel finding was increases in levels of a pro-inflammatory biomarker observed among women who smoked at the end of the intervention compared to those who did not.