Comparative Effectiveness of Smoking Cessation Treatments for Patients with Depression:
A Synthesis of the Evidence

Tobacco smoking is the greatest preventable cause of disease in the United States. Smoking is disproportionately higher among persons with depression than the general population (45% vs. 22%), and smokers with depression may experience more challenges when trying to quit (e.g., higher nicotine dependence). While several evidence-based smoking cessation treatments are effective for the general population of smokers, the comparative effectiveness of these strategies in smokers with depression is uncertain.

Investigators at the VA Evidence-Based Practice Center in Durham, NC conducted a systematic review of smoking cessation studies published through March, 2010 that resulted in 23 reports of 16 unique trials. Investigators reviewed these reports to answer five key questions:

Question #1: For patients with a history of a depressive disorder or current significant depression symptoms, what is the comparative effectiveness of different smoking cessation strategies on smoking abstinence rates?

Answer: Overall, researchers found few trials of smoking cessation interventions for patients with current depression; most studies were with patients with histories of depression.

Results of the literature review support augmenting smoking cessation treatments with the addition of mood management counseling. Evidence also supports adding nicotine replacement therapy (NRT) to behavioral interventions.

Question #2: Are there differential effects of smoking cessation strategies by depression status?

Answer: Only two studies provided information on the differential effectiveness of smoking cessation intervention strategies by depression status. One study showed that adding content on mood management increased the effectiveness of a mailed smoking cessation guide for participants with a history of major depression but not for smokers with current major depression (38% versus 7%). The other study compared adding buproprion to an intervention consisting of behavioral counseling plus NRT. Researchers found no differences by depression status (i.e., depression history vs. current depression).

Question #3: Are there differential effects of smoking cessation strategies by gender?

Answer: There was insufficient evidence to characterize gender differences.

Question #4: Does treatment effectiveness differ by whether smoking cessation/depression treatments are delivered concurrently or sequentially?

Answer: There was insufficient evidence on treatment delivery sequencing.

Question #5: What is the nature and frequency of the adverse effects of smoking cessation treatments in patients with a history of depressive disorder or current significant depressive symptoms?

Answer: There was insufficient evidence to characterize adverse events. However, in two of three studies that evaluated the addition of antidepressants with other smoking cessation treatments, selected adverse events were more common in patients randomized to antidepressants versus placebo.

Conclusions

Smoking and depression are common and frequently co-occur. However, few trials of smoking cessation interventions for patients with current depression were found. Results of this review may be most relevant for patients with histories of depression versus those with current depression.

Results have implications for the VA. Veterans have higher rates of depression and smoking compared to the general population. Healthcare providers should consider encouraging their patients with depression who smoke to seek smoking cessation services that include both NRT and mood management counseling. While this review provides some evidence of effective smoking cessation strategies for smokers with depression histories, trials are needed to determine the most effective combination of smoking cessation treatments for smokers with current depression and to assess if these treatments work equally well for both men and women.

Reference: Gierisch JM, Bastian LA, Calhoun PS, McDuffie JR, Williams JW Jr. Comparative Effectiveness of Smoking Cessation Treatments for Patients With Depression: A Systematic Review and Meta-analysis of the Evidence. VA-ESP Project #09-010; 2010

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