As smoking rates fall in the United States, mentally ill individuals comprise a larger percentage of people who continue to light up.
Smoking cessation interventions that are effective in the general population also help for depressed smokers, suggests a study of outpatients at four mental health clinics. Dr. Sharon Hall and colleagues at the University of California, San Francisco; the University of Rhode Island; and Kaiser Permanente Northern California found that depressed smokers who were treated with a combination of motivational counseling, nicotine patches, and behavioral therapy were more likely than their counterparts who did not receive the interventions to be smoke-free at 12- and 18-month assessments.
"Patients in our study mirrored the general population of smokers in their readiness to quit, acceptance of treatment, and cessation outcomes—findings that surprised me and my colleagues," says Dr. Hall, lead investigator of the study. Further, patients with severe symptoms of depression both accepted the interventions and benefited from them. "Our findings suggest that clinicians should offer depressed outpatients nicotine addiction treatment and should start with available smoking cessation interventions. They need not be overly concerned about patients' levels of depression," says Dr. Hall.
The investigators recruited 322 men and women from a university-based clinic and three sites of a health maintenance organization who were being treated for depression and smoked daily. Most of the volunteers (79 percent) were taking psychiatric medication for moderate depression. On average, they had smoked for 24 years, smoked 15 cigarettes a day, and had tried to quit six times.
At the start of the study, the participants provided information on their depression severity and treatment, smoking behavior (confirmed by expired air carbon monoxide measurements), nicotine dependence level, readiness to quit smoking, previous quit attempts, and commitment to abstinence. They repeated these self-reports 3, 6, 12, and 18 months later.
The active intervention in the study was Staged Care Intervention (SCI). At the outset and months 3, 6, and 12, participants assigned to SCI answered a computerized questionnaire about smoking, its advantages and disadvantages, triggers for smoking-related thoughts and behaviors, and ways to change these thoughts and behaviors. The computer provided an individualized feedback report that the patients and counselors reviewed together in a 15-minute session. The report classified each patient's readiness to quit based on the Stages of Change model, compared his or her responses with those of others in the program, showed changes from earlier reports, and identified triggers for smoking and strategies to move to the next stage. If the patient expressed a desire to quit, he or she began an 8-week cessation treatment. Each participant in the control group received a self-help guide to smoking cessation and a list of programs in the area, but no therapeutic contact or advice about smoking cessation.
Opportunity to Engage
About one-third (34 percent) of SCI participants entered cessation treatment. They received nicotine patches (7, 14, or 21 mg, depending on level of smoking and week of study) and six 30-minute counseling sessions. The focus of counseling was immediate and complete cessation at an agreedupon date. During sessions, patients developed a commitment to abstinence, established a quit plan, identified reasons for smoking, reviewed the benefits of quitting, and received information on nutrition and exercise. Patients who did not attain abstinence with nicotine patches were prescribed bupropion if their mental health care provider deemed it medically appropriate.
The researchers included all SCI participants, including those who did not enter cessation treatment, in their data analysis. At the 12-month assessment, 20 percent of participants in the SCI group and 13 percent in the control group had verified 7-day tobacco abstinence. The SCI group's advantage persisted at the 18-month assessment (25 percent versus 19 percent). More SCI (44 percent) than control group participants (34 percent) endorsed permanent abstinence—an attitude the researchers say predicts success in changing behavior. The intervention was particularly effective for heavy smokers: Among participants who smoked more than a pack of cigarettes a day, those assigned to SCI were about twice as likely as controls to report a quit attempt during the study.
"The findings of Dr. Hall and her colleagues suggest that, even among severely depressed smokers who are not motivated to quit, the SCI increases abstinence rates compared with a standard control," says Ms. Debra Grossman of NIDA's Division of Clinical Neuroscience and Behavioral Research. The finding adds to the justification for American Psychiatric Association and Agency for Health Care Research and Quality recommendations to offer smoking cessation therapy to people with mental disorders.
"The high prevalence of smoking in mental health clinics presents an opportunity to engage people with depression in smoking cessation," says Dr. Hall. She adds that one advantage to doing so is the supportive environment of such settings: if cessation worsens depression, then patients can obtain additional help. Dr. Hall notes that the treatment benefits seen among the study population of mostly employed patients enrolled in a health maintenance organization might not apply to depressed people who are disadvantaged or in treatment at publicly funded hospitals. Dr. Hall's team plans to conduct a cost-effectiveness analysis of the intervention to help clinic directors decide on resource allocation.
Computer Feedback Nurtures Change
Excerpts from two feedback reports illustrate indivualized care:
Feedback for a person who has no immediate intention to stop smoking: Your answers on the last survey show that you need to begin to change the way you look at yourself as a smoker. You can do this by thinking more about your attitudes and beliefs about your smoking.
- If you think smoking could be bad for your health, be specific about how smoking is affecting you. (For example: Cigarettes give me a sore throat—or cause my cough—or make me feel tired all the time.)
- How would your life change if you quit? (For example: I would set a better example for others—or I'd have more money to spend on things I enjoy.)
- What might be difficult if you quit? Can you plan in advance how you will handle those difficulties? (For example: I could get more exercise so I won't gain weight.)
Feedback for a person who intends to quit in the next 6 months: You seem to be well aware of the risks of smoking... you're doing as well as others who have used this program to help themselves quit smoking! To make more progress:
- Weigh the "pros" and "cons" of smoking;
- Learn more about quitting; and
- Keep thinking of how you're doing.
Hall, S.M., et al. Treatment for cigarette smoking among depressed mental health outpatients: a randomized clinical trial. American Journal of Public Health 96(10):1808-1814, 2006. [Abstract]