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Impact of Depression History on Tobacco Withdrawal and Relapse

Among Female SmokersDavid W. Wetter, Ph.D.

Department of Behavioral Science

Funded by grants from the National Institute on Drug Abuse and the National Cancer Institute.

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CollaboratorsUT M.D. Anderson Cancer Center• Paul Cinciripini• Ludmila Cofta-Gunn

GHC Center for Health Studies• Jennifer McClure

Simon Fraser University• Rachel Fouladi

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Study Purpose• Examine the impact of depression history

on relapse vulnerability among women.• Examine the impact of depression history

on acute tobacco withdrawal during the first postcessation week among women.

• Withdrawal-related constructs were assessed using standard questionnaires and ecological momentary assessments (EMA).

• Preliminary data are from a just completed clinical trial examining the efficacy of a palmtop computer-delivered treatment among women smokers.

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Depression and a History of Depression

Are:• More prevalent among smokers

than nonsmokers.• More tightly linked to dependent

than nondependent smoking.• Associated with a decreased

likelihood of quitting smoking.• More prevalent among women than

men (life-time major depression rates of 10-25% for women and 5-12% for men).

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Tobacco Withdrawal Trajectories as Key Mechanisms/Outcome Variables• Withdrawal trajectories have illuminated NRT

versus placebo effects, gender differences in response to NRT, and differences associated with a history of depression (Wetter and colleagues).

• Differential withdrawal trajectories over the first 1-2 months after quitting smoking are associated with relapse (Piasecki, Baker and colleagues).

• Both negative affect and urge trajectories appear to independently contribute to the prediction of relapse.

• Abstinence is a gross measure of the process of quitting, is easily influenced by acute and unpredictable events, and is insensitive to subtle effects.

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Project WIN “Women’s INtervention”

All women: Receive six weeks of nicotine patch therapy. Receive five smoking cessation counseling

sessions over a two week period (twoprecessation and three postcessation)

Complete ecological momentary assessments(EMA) for one week after they quit.

Randomization occurs following the completion ofthe counseling sessions and EMA procedures.

No Palm-size Computer-Delivered Treatment

(NT): n=151

Palm-size Computer-Delivered Relapse

Prevention (RP): n=151

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Participant Characteristics By Depression History

Depression HistoryNegative (MDD-)

(n=125)

Depression HistoryPositive (MDD+)

(n=75)Age 43.6 (10.7) 42.3 (11.4)

Cigarettes/Day 21.1 (7.3) 20.7 (8.7)

Fagerstrom Test forNicotine Dependence

5.2 (1.8) 5.2 (2.0)

Baseline Depression * 5.9 (5.0) 10.0 (5.9)

Race/Ethnicity (%White)

88% 78%

Education (% >College Degree)

34% 40%

* p<.05

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Percent Abstinence By Depression History

69

79

52

73

50

55

60

65

70

75

80

Day 7 Day 35

Time Since Quit Day

MDD -MDD +

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Potential Mediators/Confounders

• Demographics (age, race, education)

• Nicotine dependence• Smoking outcome expectancies• Self-efficacy• Affect (CES-D, PANAS)• Perceived Stress

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Questionnaire Measures of Withdrawal

• Urge subscale from the Wisconsin Smoking Withdrawal Scale

• Negative Affect subscale from the Wisconsin Smoking Withdrawal Scale

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EMA Procedures and Items• Hardware and software: Casio palmtop computer

running Windows CE and custom EMA software.• Rationale for EMA: Data used to individualize each

woman’s computer-delivered treatment. • Sampling: At random and during temptations/urges

during the first postcessation week.• EMA Items (prefaced with “right now”)

Urge: How strong is your urge to smoke?(no urge, weak, moderate, strong, severe)Negative Mood: My mood is negative.(Definitely NO, Mostly NO, Mostly YES, Definitely YES)

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EMA (continued)• Random assessments:

* 4/day were scheduled* Compliance was 81%* 92% of completed assessments begun within 30 seconds of the initial signal* 98% of completed assessments begun within 5 minutes of initial signal

• Temptation assessments* Completed approximately 3/day

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Data Analytic Approach• Mixed-model regression analyses (PROC MIXED)

predicting questionnaire and EMA items with and without covariates.

• Covariates: treatment, demographics (age, education, race/ethnicity), nicotine dependence (cigs/day, Fagerstrom), affect (PANAS, PSS, CES-D)

• Questionnaire analyses: Tested for main effects of time, depression history; 2-way interaction.

• EMA analyses: Tested for main effects of assessment type (random vs. temptation), time, depression history; all 2-way interactions; 3-way interaction.

• EMA data were not aggregated in the analyses, but were aggregated in the figures to facilitate presentation.

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WSWS Negative Affect

Day 7Day 5Day 3Day -1Day -3

Neg

ativ

e A

ffect

25

24

23

22

21

20

19

18

17

MDD -

MDD +

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WSWS Urge/Craving

Day 7Day 5Day 3Day -1Day -3

Urg

e/C

ravi

ng3.0

2.8

2.6

2.4

2.2

2.0

MDD -

MDD +

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Questionnaire Data Summary

• Women with a positive history of depression exhibited differential withdrawal trajectories compared to women without a history of depression.

• Differences between depression history groups were most apparent during the postcessation period (i.e., the depression history groups exhibited differential responses to quitting).

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Negative Affect (EMA) Negative Affect (EMA)

Post-Quit Day

7654321

Me

an

Dai

ly M

oo

d R

atin

g

2.4

2.2

2.0

1.8

1.6

1.4

Random AssessmentRandom Assessment

Post-Quit Day

7654321

Me

an

Dai

ly M

oo

d R

atin

g

2.4

2.2

2.0

1.8

1.6

1.4

Urge AssessmentUrge Assessment

MDD+ MDD+

MDD-MDD-

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Urge (EMA) Urge (EMA)

Random AssessmentRandom Assessment Urge AssessmentUrge Assessment

MDD+ MDD+

MDD-MDD-

Day of assessment

7654321

Me

an

da

ily u

rge

stre

ng

th

3.9

3.6

3.3

3.0

2.7

2.4

2.1

1.8

1.5

1.2

Day of assessment

7654321M

ea

n d

aily

urg

e st

ren

gth

3.9

3.6

3.3

3.0

2.7

2.4

2.1

1.8

1.5

1.2

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EMA Data Summary • Women with a positive history of depression

exhibited differential withdrawal severity and trajectories compared to women without a history of depression.

• Differences between depression history groups were most apparent during random assessments (i.e., depression history positive and negative women look more similar during urge episodes than they do when examining random moments from their daily lives).

• These effects held after controlling for baseline demographic, nicotine dependence, affect, and stress related variables.

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Conclusions ???

• Women with a history of major depression have lower rates of smoking cessation.

• The impact of depression history on relapse may be mediated by more severe negative reactions to quitting (i.e., less decline in craving and a greater increase in negative affect).

• Depression history effects may be more pronounced in disruptions in daily functioning than in increased severity of urge episodes.

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THE END