Smoking cessation interventions for patients with depression: a systematic review and meta-analysis

Abstract

Objectives: We conducted a systematic literature review of smoking cessation interventions for patients with histories of depressive disorders or current significant depressive symptoms. We examined the comparative effectiveness of smoking cessation strategies on abstinence rates, differential effects of cessation strategies by depression status (i.e., history positive vs. current depression), and differential effects by gender.

Data sources: Peer-reviewed literature in MEDLINE, Embase, PsycINFO, and Cochrane Library.

Study eligibility criteria, participants, and interventions: Randomized controlled trials or secondary analysis of RCT data comparing two or more smoking cessation interventions or intervention to control, and reporting cessation outcomes in adults with depression.

Study appraisal and synthesis methods: Two trained researchers screened articles for inclusion. When possible, we estimated pooled risk ratios with 95% confidence intervals by using a random effects model with the Mantel-Haenszel method. We synthesized other studies qualitatively. We classified each intervention as antidepressants, nicotine replacement therapy (NRT), brief smoking cessation counseling, smoking cessation behavioral counseling, or behavioral mood management.

Results: We identified 16 unique RCTs, of which, only three trials recruited participants with current depression. Meta-analysis demonstrated a small, positive effect of adding behavioral mood management (RR = 1.41, 95% CI 1.01-1.96). All included antidepressant trials showed small, positive effects, but risk ratio summary was not significant (RR = 1.31, 95% CI 0.73-2.34). Three NRT trials demonstrated small, positive effects on smoking cessation rates. We found insufficient evidence to examine gender and depression status moderator effects.

Limitations: Few RCTs exist that test smoking cessation interventions among adults with depression. To make meaningful comparisons, we created broad intervention categories that contained heterogeneity.

Conclusions and implications of key findings: Few trials enrolled smokers with current depression. Most of data identified were from subgroup analyses of patients history-positive for depression. However, several promising interventions exist. Healthcare providers should consider encouraging their patients with significant depressive symptoms or depression histories to seek smoking cessation services that include NRT and behavioral mood management.

Figure 1

Study flow diagram.

Figure 2

Risk of smoking abstinence at least 6 months after start of antidepressant therapy + behavioral counseling compared with placebo + behavioral counseling. *Events = number of participants who achieved smoking abstinence.

Figure 3

Risk of smoking abstinence at least 6 months after start of behavioral mood management + cotreatment compared to active control. *Events = number of participants who achieved smoking abstinence.