UC San Diego

Epidemiological studies have found that smokers with depression are less likely to quit smoking. Intervention studies for smoking cessation, however, have tended to exclude those with current depression, with the assumption that the smokers' acute mental health problems should be dealt with before quitting smoking. Only in the last five years has the cessation treatment field begun to address the need to work with smokers with current mental health conditions. For example, a recent study at the California Smokers' Helpline (a SAMHSA model program that serves over 30,000 smokers annually) assessed for current depression among its callers and found that 1 in 4 callers met criteria for current major depression. Furthermore, it found smokers with major depression were significantly more likely to relapse after a quit attempt when treated under the quitline's standard counseling protocol. This suggests a need to develop a specialized protocol to improve the quit rate of these depressed smokers. Previous studies have suggested that one way to increase the quit rate of smokers with greater relapse vulnerability is to increase the number of treatment session with added content that targets their particular vulnerability (e.g. depression). The success of such an approach, however, requires that clients be present and responsive to additional treatment sessions. This is no small requirement for those with current major depression, as they often have reduced motivation. The present study tested a proactive telephone counseling protocol in which counselors took the initiative to call the smokers for all the counseling sessions (including the additional ones). It has two aims: (1) To demonstrate that depressed smokers are responsive to the enhanced protocol in that they would participate in a significantly greater number of sessions (compared to the standard protocol) and that they have positive views of the enhanced counseling protocol, (2) There would be an increase in the quit rate associated with the enhanced protocol compared to the standard protocol. For the second aim, it was determined at the outset that a minimum of a 5 percentage point increase in quit rate was necessary for it to be clinically meaningful. It was hypothesized that the protocol would increase the quit rate by 10 percentage points, but the study was not powered at a sample size to demonstrate a statistically significant difference. total of 92 smokers with current major depression were randomized into two groups: 46 to the enhanced treatment and 46 to the standard treatment. The enhanced protocol, which was specifically developed for this study, includes the additional content on mood management and up to 15 counseling sessions over a 2 month period. The standard counseling protocol consists of up to 5 sessions over a 1 month period. Current depression was measured by Patient Health Questionnaire mood module (PHQ-8) at intake when smokers first contacted the California Smokers' Helpline. Participants were followed up for three months, at which point their quitting status as well as their mood were assessed. The results show the smokers in the enhanced protocol received on average 3 counseling sessions more than those in the standard protocol (6.8 vs. 3.6, p<0.01). The average number of sessions for the standard protocol is comparable to what was found in previous quitline studies, which demonstrated its efficacy. Most of the participants in the enhanced protocol condition responded positively to the increased counseling sessions: 84% reported they received just the right number of sessions and most of them were satisfied with the counseling and rated their counselors highly. The participants in the enhanced protocol condition also quit smoking at a higher rate than those in the standard protocol condition. At the three month follow up, the 7-day point prevalence (the most often used measure of quitting) was 29.4% vs. 17.5%, respectively. If measured by 30-day abstinence rate, they quit at 17.7% and 12.5%, respectively. Moreover, fewer of those in the enhanced treatment met criteria for current major depression at follow-up compared to those in the standard protocol (14.7% vs. 28.2%). While none of these differences reached the conventional statistical significance level due to the small sample size, they have met all the goals set out for the study when it was designed. The results of the study show the promise of providing mood management counseling to smokers with current major depression in the context of a state quitline. The 50 U.S. state quitlines currently serve a large number of smokers (> 400,000 annually). The present study helps to further a larger research agenda to establish a tailored telephone counseling protocol to increase the quit rate of smokers with current major depression