Smoking cessation intervention for smokers with past major depression:

a randomized controlled trial

Warsaw, ENQ meeting, May 2008

Regina M. van der Meer MPH, Marc C. Willemsen PhD,

Pim Cuijpers PhD, Filip Smit PhD, Gerard M. Schippers

PhD

Major depression?

Major depression?

Having a very bad hair day

Major depression (DSM–IV)

Five or more of the following symptoms have been

present during the same 2-week period and

represent a change from previous functioning;

At least one of the symptoms is:

• Depressed mood or• Loss of interest or pleasure

Major depression (DSM–IV)

• Significant weight loss or decrease or increase in

appetite• Insomnia or hypersomnia• Psychomotor agitation or retardation• Fatigue or loss of energy• Feelings of worthlessness or guilt• Diminished ability to think or concentrate, or

indecisiveness• Recurrent thoughts of death

Past major depression

Lifetime major depression,

but not

within the last month

Smoking & past major depression

Smoking and depression are strongly associated

• Smokers are more likely to have past major

depression than non-smokers

&• Persons with past major depression are more

likely to be smokers than non-smokers (Glassman, 1993; Kalman et al., 2005)

Smoking & past major depression

A recent study from Wiesbeck and colleagues in

Neuropsychobiology support the evidence that

smoking is linked to depression.

They found the highest rate of lifetime depression

in current smokers (23,7%), the lowest rate in

never smokers (6,2%) and the rate of those who

had quit smoking was 14,6.

Smoking cessation & past major depression

Hughes (2007) found in a recent review that

smokers with a past major depression clearly have

an increased risk for a new depression after quit

smoking when compared with smokers without a

past major depression.

This might explain why it is more difficult for

smokers with past major depression to quit.

Smoking cessation & past major depression

An often mentioned underlying mechanism is the self-

medication assumption:

Smokers use cigarettes as a form of self-medication

for coping with depressive symptoms

Smokers with past major depression may quit more

easily if they have learned to better manage their

mood without needing cigarettes.

Smoking cessation & past major depression

This self-medication assumption has resulted in

several studies examining smoking cessation

interventions that include strategies for managing

depressive symptoms. (Hall et al., Brown et al)

But non of these interventions consisted out of

telephonic counselling and most of these studies

were very small.

I can handle the world, smokefree!

Aim of study

To assess whether the Mood Management intervention:

1. Produces higher abstinence rates compared to control intervention

2. Helps to prevent and reduce depressive symptoms compared to control intervention

Control (C)

Telephone counselling• 8 sessions (1st: 30 minutes;

quitdate; 2nd – 8th: 12 min.)• by a trained coach of STIVORO

Content Smoking cessation skills:• social support• increasing self-efficacy• self-rewarding• relapse prevention

Mood Management (MM)

Telephone counselling• 10 sessions (1st: 30 minutes;

2nd – 3rd: 15 min; quit date;4th – 10th: 15 min)

• by a trained coach of STIVORO&

Quit smoking mood management manual• Self help manual with exercises

for reading and practicing at home between the sessions

Mood Management (MM)

Content

Smoking cessation skills:• social support• increasing self-efficacy• self-rewarding• relapse prevention

Mood management skills:• Increasing pleasant events• Relaxation• Cognitive skills• Social skills

Based on cognitive behavioural therapy

Study design (RCT)

1. Recruitment – open population

advertisements, articles, website, flyers etc.

(n=4008 received information package)

2. Screening 1 & Informed consent

(n=1875 gave their informed consent)

(n=706 were invited for CIDI interview)

Study design(RCT)

3. Screening 2 (CIDI)

Assessment of past major depression

according to DSM-IV (exclusion of current

depression, current alcohol disorder)

(n=531 met inclusion criteria)

4. Baseline measurement T0

5. Randomisation

(n=485)

Study design (RCT)

6. MM or C intervention

(MM: n=243; C: n=242)

10 Counsellors gave MM and C intervention

7. Follow up T1 (6 months after T0)

Response (MM: 81.0%; C: 83.5%)

8. Follow up T2 (12 months after T0)

Response (MM: 77.0%; C: 76.4%)

Participants• Past major depression• No current major depression• Preparator or contemplator• No current alcohol disorder

Outcomes • Prolonged abstinence• Point prevalence

Study design (RCT)

BaselineCharacteristics

MM group(n=243)

C group(n=242)

Sign.

Male, % 23.0 24.0 NS

Age, mean SD 43.3 9.9 44.2 10.2

NS

Cigarettes, mean SD 21.4 8.9 21.8 9.7 NS

FTND, mean SD 5.1 2.2 5.1 2.4 NS

Stages of change, %-Preparation-Contemplation

71.628.4

72.327.7

NS

BaselineCharacteristics

MM group(n=243)

C group(n=242)

Sign.

Education %- Low- Medium- High

12.037.350.6

11.242.646.3

NS

Quit attempts, mean SD 6.2 11.5 5.8 10.2 NS

Self-efficacy, mean SD 3.0 10.6 5.1 10.6 .03

BaselineCharacteristics

MM group(n=243)

C group(n=242)

Sign.

Depressive symptoms (CES-D), mean SD 18.1 7.6 17.8 8.0 NS

Alcohol-problem drinkers, % 22.2 23.1 NS

Anxiety, mean SD 46.7 9.6 46.1 10.3

NS

BaselineCharacteristics

MM group(n=243)

C group(n=242)

Sign.

Past depression %

- single, light- single, mild- single, severe- recurrent, light- recurrent, mild- recurrent, severe

12.8

10.7

19.8

24.8

15.3

16.5

14.1

13.7

22.4

18.7

19.1

12.0

NS

Results - 6 months follow up

OR Adjusted for self-efficacy and past depression

* Significant

Smoking Cessation

MM(n=243)

C(n=242)

OR unadj.95% CI

OR adjust.95% CI

Point prevalence

37.4 %n=91

31.0 %n=75

1.33(0.9–1.9)

1.33(0.9–2.0)

Prolongedabstinence

30.5 %n=74

22.3 %n=54

1.52*(1.01- 2.3)

1.48(0.98–2.2)

Results - 12 months follow up

OR Adjusted for self-efficacy and past depression

* Significant

Smoking Cessation

MM(n=243)

C(n=242)

OR unadj.95% CI

OR adjust.95% CI

Point prevalence

27.6 %n=67

24.0 %n=58

1.21(0.8–1.8)

1.17(0.8–1.8)

Prolongedabstinence

23.9 %n=58

14.0 %n=34

1.92*(1.2–3.1)

1.86*(1.2–3.0)

Results – 6/12 months follow up

a Adjusted for self-efficacy and past depression

*Significant

Depressive symptoms(CES-D)

MM(n=243)Mean(SD)

C(n=242)Mean (SD)

t-test(P-value)

ANCOVAa

(P-value)

6 months 15.4 (10.5)

14.7 (10.4)

-.71(.48)

.09(.77)

12 months 14.8(9.8)

14.6(10.4)

-.21(.84)

.14(.71)

Conclusion

Overall more smokers quit smoking with the

Mood Management intervention when

compared with the control intervention.

Although there are no significant differences on

point prevalence abstinence.

Prolonged abstinence however does show

significant differences.

Conclusion

It seems that the differences in smoking

abstinence between Mood management

intervention and control intervention can not be

explained by differences in depressive

symptoms

Mood Mangement intervention combined with

telephone counselling seems to increase success

rates for smokers with past major depression

How does the MM interventionworks in practice?

Carl Simons

Many thanks for your attention!

rvandermeer@stivoro.nl