Smoking cessation and the course of major depression: a follow-up study.

BACKGROUND: Smokers with a history of major depression who attempt to stop smoking have a higher risk of failure than non-depressed smokers. Anecdotal and post-hoc data suggest that those who successfully abstain are at increased risk of depression compared with individuals who continue to smoke. However, these studies confound effects of abstinence and history of depression. We aimed to assess whether there is an increased risk of depression and for how long that increase lasts. METHODS: We enrolled 100 smokers (>1 pack per day) with a history of major depression, but who were currently free from major depression and had not been on antidepressant medicine for at least 6 months, in a 2-month smoking-cessation trial. The primary outcome was recurrence of major depression, which we assessed by structured clinical interviews 3 and 6 months after the end of treatment. We verified smoking status by serum-sample cotinine concentrations. FINDINGS: 76 participants (42 successful abstainers, 34 smokers) were followed up. 13 abstainers and two smokers had an episode of major depression (odds ratio 7.17 [95% CI 1.5-34.5]; Kaplan-Meier survival curve, log-rank statistic 9.11 [p=003]). Risk of major depression was similar between the first and second 3 months of follow-up. INTERPRETATIONS: Smokers with a history of depression who abstain from smoking are at significantly increased risk of developing a new episode of major depression. This risk remains high for at least 6 months.

Advances in non-nicotine pharmacotherapy for smoking cessation.

Progress in understanding the pharmacological nature of tobacco addiction, along with the modest success rates achieved by the nicotine replacement therapies, has provided the major impetus for the development of non-nicotine drugs as smoking cessation aids. This article reviews evidence from controlled trials of several non-nicotine medications for the treatment of nicotine dependence. Clonidine was the first non-nicotine medication to show efficacy for smoking cessation in multiple studies, but its effect was found to be limited at best. Positive results across several trials have been consistently demonstrated for amfebutamone (bupropion). Encouraging results have also been observed for nortriptyline and moclobemide. Studies of combined treatments using non-nicotine medications (amfebutamone, mecamylamine, oral dextrose) with nicotine replacement therapy suggest increased efficacy relative to treatments using one or the other treatment strategy alone. Thus, available evidence indicates that non-nicotine drug treatments offer a promising panoply of therapeutic strategies for the addicted smoker.

Tobacco cessation among patients with depression.

This article summarizes the research evidence on the association between smoking and depression. Across multiple studies and clinical and population-based samples, it has been demonstrated that, compared with nondepressed individuals, persons with depression are more likely to be smokers, to be dependent smokers, to have difficulty stopping smoking, and to experience more severe withdrawal symptoms. Further, they may be at risk of experiencing severe depression once they have stopped smoking. Based on the author's experience with this population of smokers, recommendations for assessing smokers' vulnerability to depression, their level of nicotine dependence, and psychological and pharmacological aids for smokers are offered.

Naltrexone effects on short-term and long-term smoking cessation.

OBJECTIVES: This study examined the efficacy of naltrexone, a long-acting opiate antagonist, as a smoking cessation aid in a double-blind placebo-controlled randomized trial. It was hypothesized that naltrexone would result in higher quit rates at the end of treatment and six months later. METHODS: Subjects were 68 smokers aged 18 to 65 who smoked at least 20 cigarettes daily and wished to stop smoking. They took naltrexone or placebo daily for four weeks and were seen weekly for individual smoking cessation therapy. RESULTS: A statistical trend towards a higher overall cessation rate (cotinine < 15 ng/mL) at end-of-treatment was observed among subjects treated with naltrexone than placebo (46.7% vs. 26.3%, respectively, odds ratio = 2.5, p < .10); however, this difference was attenuated at six months (27% vs. 15%, respectively, odds ratio = 1.9, p = ns). Stratified analysis indicated the usefulness of naltrexone primarily for female smokers and those with a history of major depression. These effects remained six months later. CONCLUSION: These results provide, at best, mild promise for naltrexone as a smoking cessation drug and provide another instance of a differential response to nicotine dependence treatment according to gender and depression history.

Cigarette smoking and major depression.

The authors review recent literature that has demonstrated an association between cigarette smoking behavior and major depression. Persons with major depression are more likely to smoke and to have difficulty when they try to stop. When they manage to succeed in stopping, such persons are at increased risk of experiencing mild to severe states of depression, including full blown major depression. The period of vulnerability to a new depressive episode appears to vary from a few weeks to several months after cessation. This knowledge suggests a relationship between smoking and depression that is complex, pernicious, and potentially life-long. It is recommended that cessation treatments incorporate screening procedures that will identify those patients with a propensity to depression and monitor the emergence of postcessation depression, particularly in those with a history of depression.

Major depression following smoking cessation.

OBJECTIVE: The authors examined the incidence and predictors of major depression following successful smoking cessation treatment, with special attention to the influence of past major depression. METHOD: Three-month follow-up data were obtained from 126 subjects who successfully completed a 10-week smoking cessation program. RESULTS: The 3-month incidence of new major depression following treatment for nicotine dependence was 2%, 17%, and 30% among subjects with histories of no major depression, single major depression, and recurrent major depression, respectively. A history of major depression and persistent withdrawal symptoms independently predicted posttreatment major depression. CONCLUSIONS: Continued patient care beyond the 2-4-week period associated with the nicotine withdrawal syndrome is indicated when abstinence is attempted by smokers with prior major depression.

Depression after smoking cessation: case reports.

BACKGROUND: Cigarette smokers with a history of major depression are at risk for developing depressive mood when they attempt cessation. Whether cessation can also provoke more severe depressions, however, has not been well documented. METHOD: Six case reports of severe depressive episodes after smoking cessation are described. RESULTS: Four cases occurred among smokers with a history of major depression but who were not depressed at the time of cessation. Two cases involved smokers with no previous history of major depression. Variability in both the timing and the outcome of the postcessation depressions was observed. CONCLUSION: The risk that depressive states may emerge or be exacerbated after smoking cessation, particularly in patients with a history of major depression, must be kept in mind in the treatment of nicotine dependence.

Smoking cessation, clonidine, and vulnerability to nicotine among dependent smokers.

OBJECTIVE: This study examines the efficacy of clonidine in smoking cessation and the influence of gender, history of major depression, and measures of nicotine dependence. METHODS: The study was designed as a 10-week double-blind randomized comparison stratified for gender and major depression. Three hundred subjects who smoked cigarettes heavily were enrolled in the study. Abstinence from smoking was evaluated by self-report and verified by serum cotinine levels. RESULTS: Gender, major depression recurrent type, and measures of nicotine addiction were risk factors for treatment failure. There was no clonidine effect in men, but there was a modest effect in women (odds ratio, 2.01; 95% confidence interval, 1.00 to 4.10) that was most pronounced (odds ratio, 8.5; 95% confidence interval, 1.67 to 43.62) among women with the highest risks. CONCLUSION: Measures of addiction and major depression predict treatment failure. Together they are stronger predictors of outcome than drug. Clonidine is a limited aid in cessation, and drug effects come primarily from women at high risk for treatment failure. An increased risk for psychiatric complications after smoking cessation was apparent among smokers with histories of major depression, particularly bipolar disease.

Effect of history of alcoholism or major depression on smoking cessation.

The authors examined the influence of a history of alcoholism or major depression on smoking cessation for 220 subjects. The success rate of recovering alcoholics was comparable to that of nonalcoholics, comorbidity of alcoholism and major depression exerted a detrimental effect, and smoking cessation did not precipitate an alcoholic relapse.

Cigarette smoking and occupational status: 1977 to 1990.

OBJECTIVES: In this study we examined the relationship between occupational status and smoking habits in men and women during the period from 1977 to 1990. METHODS: Cigarette smoking and occupational history were obtained from 8045 men and women who served as controls for a hospital-based study of tobacco-related diseases. RESULTS: There was an association between increasing occupational status and tobacco exposure in men, but not in women. The quit rate increased over time in all sex-occupational groups except for male laborers, whose quit rate remained constant. Nicotine-dependent smokers are likely to find it difficult to quit. Male nicotine-dependent smokers were consistently found in greater numbers among blue collar workers throughout the study period. Initially, female nicotine-dependent smokers were more often found among blue collar workers, but in recent years became more frequent among white collar workers. CONCLUSION: These trends provide clues to the future epidemiological distribution of lung cancer and other tobacco-related diseases. An understanding of gender differences in the occupational profile of cigarette smokers can provide guidelines for effective antismoking interventions.

A meta-analysis of double-blind placebo-controlled trials of clonidine for smoking cessation.

Combined data from nine double-blind placebo-controlled trials (total n = 813), showed a smoking quit rate with clonidine that was significantly greater than with placebo. Further analysis suggested a potentiating influence of individual behavior therapy, and it appeared that clonidine may be more helpful for female than male smokers. Future trials are needed to determine long-term efficacy, and to clarify the effects of gender, other subject characteristics and various treatment conditions on the usefulness of clonidine as a smoking cessation aid.

Depressive mood, the single-parent home, and adolescent cigarette smoking.

The association between depressive mood and cigarette smoking among adolescents was examined within a multivariate model. Subjects were 205 eleventh graders (123 boys and 82 girls) enrolled in a Northeast metropolitan public high school for science-oriented students. Logistic regression analysis showed an independent relation of depressive mood, friends' smoking behavior, and living in a single-parent home with cigarette smoking. Depression scores correlated with the number of cigarettes smoked. These associations suggest that depressive mood and stress may contribute to the onset of smoking.

Smoking, smoking cessation, and major depression.

A relationship between cigarette smoking and major depressive disorder was suggested in previous work involving nonrandomly selected samples. We conducted a test of this association, employing population-based data (n = 3213) collected between 1980 and 1983 in the St Louis Epidemiologic Catchment Area Survey of the National Institute of Mental Health. A history of regular smoking was observed more frequently among individuals who had experienced major depressive disorder at some time in their lives than among individuals who had never experienced major depression or among individuals with no psychiatric diagnosis. Smokers with major depression were also less successful at their attempts to quit than were either of the comparison groups. Gender differences in rates of smoking and of smoking cessation observed in the larger population were not evident among the depressed group. Furthermore, the association between cigarette smoking and major depression was not ubiquitous across all psychiatric diagnoses. Other data are cited indicating that when individuals with a history of depression stop smoking, depressive symptoms and, in some cases, serious major depression may ensue.

Depression and depressive symptoms in smoking cessation.

Previous findings from a smoking cessation trial showed that smokers with a history of major depression had lower success rates than smokers without a depression history. In an attempt to explain the worse outcome observed for smokers with a history of depression, postcessation data obtained from subjects randomly assigned to the placebo condition were examined further. It was observed that in the first week of a behaviorally oriented treatment program, the frequency and intensity of psychological symptoms, particularly depressive mood, were higher among smokers with past depression, and that this discomfort was related to treatment outcome. Interventions designed to prevent dysphoric symptoms during the acute withdrawal period may improve smoking cessation outcome for smokers with a history of major depression.

Heavy smokers, smoking cessation, and clonidine. Results of a double-blind, randomized trial.

Seventy-one heavy smokers who had failed in previous attempts to stop smoking participated in a randomized clinical trial to test the efficacy of clonidine as an aid in smoking cessation. The success rate in clonidine-treated subjects (verified by serum cotinine concentration) was more than twice that in the placebo-treated subjects. When the data were stratified by gender, a strong effect present in women was not apparent in men. After six months, cessation rates remained significantly higher among smokers treated with clonidine than those receiving placebo. The data also revealed an unexpectedly high prevalence (61%) of a history of major depression in this sample and a significant negative effect of such a history on cessation regardless of treatment. These findings, highly suggestive of an important role of clonidine in smoking cessation, warrant further studies to establish the long-term (greater than or equal to 12 months) efficacy of this drug and to replicate the association between nicotine dependence and depression.

Epidemiologic patterns in lung cancer by histologic type.

Three thousand and ninety-seven lung cancer patients interviewed in different U.S. hospitals in 1977-1984 were classified into Kreyberg I and Kreyberg II categories. In both sexes, Kreyberg II patients were found to be younger and more frequently Jewish; among the male patients only, Kreyberg II cases were higher in educational and occupational level. These differences remained when the effect of cigarette smoking was controlled. Study data showed an increase in the frequency of Kreyberg II cases over time, and significantly, a decrease with younger age of the Kreyberg I:Kreyberg II ratio in both sexes. It is concluded that the observed secular increase in Kreyberg II is real and not merely due to changes in diagnostic methodology. On the basis of demographic differences noted, possible etiologic factors that may have contributed to the recent changes in lung cancer distribution by cell type are suggested.

Smoking habits in a hospitalized population: 1970-1980.

The smoking habits of 23,953 hospitalized men and women aged 20 to 80, interviewed in nine United States cities between 1970 and 1980, were examined. Comparisons were made of age-adjusted smoking rates in 1970-1975 vs 1976-1980, stratified by sex, race, and educational level. An overall decrease in smoking exposure between the time periods studied was observed: a decline in rates of current cigarette smokers and an increase in use of cigarettes containing less than or equal to 12 mg tar. Nevertheless, among current smokers, there was no reduction in the proportions of those who smoke 31+ cigarettes daily. An enhancing effect of higher education on rates of smoking cessation and use of cigarettes containing less than or equal to 12 mg tar was observed. In both time periods, proportionately more Black than White men were smokers, although the difference was smaller in college educated groups. These findings point up the limited effectiveness of public health education about smoking in lower socioeconomic groups, and suggest that in the future, lung cancer and other diseases for which smoking is a major factor will be increasingly social class related diseases.