Abstract
Introduction
The strong relationship between persistent tobacco use and Major Depressive Disorder (MDD) has motivated clinical trials of specialized treatments targeting smokers with a history of MDD. Meta-analyses suggest positive responses to specialized treatments have been observed consistently among smokers with history of recurrent rather than a single episode of MDD. Approximately 15% of current US smokers have a history of recurrent MDD. Little is known about the risk factors that contribute to persistent smoking and differentiate these at-risk smokers. US.
Methods
The National Comorbidity Survey – Replication (NCS-R) included a survey of 1560 smokers participants aged 18 and older in the United States. Lifetime history of MDD was categorized according to chronicity: No History (No MDD), single episode (MDD-S) and recurrent depression (MDD-R). The relationship between the chronicity of MDD, smoking characteristics, cessation history, nicotine dependence, comorbidity with psychiatric disorders, and current functional impairments were examined.
Results
MDD-R smokers reported fewer lifetime cessation efforts, smoked more cigarettes, had higher levels of nicotine dependence, had higher rates of co-morbid psychiatric disorders and greater functional impairment than smokers with No MDD. MDD-S smokers were not consistently distinguished from No MDD smokers on cessation attempts, level of daily smoking, nicotine dependence or functional impairment indices.
Conclusions
The study highlights the importance of chronicity when characterizing depression related risk of persistent smoking behavior. Although, clinical trials suggest MDD-R smokers specifically benefit from specialized behavioral treatments, these services are not widely available and more efforts are needed to engage MDD-R smokers in efficacious treatments. Abstract Word Count: 249
Keywords: Smoking, Depression, Recurrent Depression, Nicotine Dependence, Item
1. Introduction
Despite the decreasing prevalence in cigarette smoking in the United States (Grant, et al., 2004), rates of smoking remain high among individuals with Major Depressive Disorder (MDD). Risk factors associated with a lifetime history of MDD such as increased nicotine dependence (Grant et al, 2004), higher levels of negative affect (Dalack, 1995; Ginsberg, 1995; Hall, 1994; Covey et al., 1999), higher levels of comorbid psychiatric disorders (Kessler, 2003), and higher incidence of psychosocial impairments (Cassano & Fava, 2002) are likely to interfere with efforts at cessation. The strong relationship between MDD and these risk factors has motivated clinical trials of specialized treatments for depression (Brown et al, 2001; Hall et al, 1994) to ameliorate risks for poor cessation outcomes among smokers with a history of MDD. These trials have yielded mixed results (Hitsman et al, 2003). However, follow-up analyses have supported consistent positive responses to specialized behavioral treatments among smokers with recurrent rather than single episodes of MDD (Brown et al., 2001; Haas et al., 2004). These findings motivate this research, as we were not aware of any studies that describe the relationship between MDD and cessation-related risk factors using a representative sample of current smokers characterized by their history of single episode or recurrent MDD.
The possibility that associations between MDD history and smoking may be largely accounted for by chronic and recurrent MDD (MDD-R) emerges in part from depression research documenting the etiological heterogeneity (Winokur, 1997) of single episodes of MDD and concentration of recurrent MDD at the highest levels of a continuum of depression severity (Kessler, 1997; Judd, 1997). Relative to single episode MDD (MDD-S), MDD-R has been associated with increased rates of comorbidity (e.g., anxiety and substance use disorders), higher incidence of functional impairments (Klein, 2008; Mondimore et al., 2006) and weakened response to depression treatment and other health interventions (Hamilton & Dobson, 2002; Kocsis, 2003; Thase et al., 1994). Among smokers, a limited amount of information about the prevalence of risk factors for poor cessation among recurrent MDD smokers can be gleaned from clinical trials. While few smoking cessation trials specifically report outcomes for smokers with past MDD-R, studies that do allow extrapolation suggest cessation-related risk factors such as increased negative affect and more severe withdrawal may be attributable to those with past MDD-R rather than past MDD-S (Brown et al., 2001; Covey, 1997; Haas et al., 2004, Kahler et al., 2002). While these results suggest reasons for the differential benefit MDD-R smokers receive from specialized depression treatments, these studies do not inform efforts to identify risk factors that may facilitate persistent smoking or risk for poor outcomes in standard cessation treatment among current populations of smokers.
Currently, examinations of risk for poor smoking outcomes associated with MDD-R have been limited to treatment seeking smokers enrolled in clinical trials where a large number of smokers with psychiatric risk factors are excluded. The degree to which these risk factors are distributed disproportionately among smokers with MDD-R in the general population is unknown. We expect that current smokers with a history of MDD-R relative to smokers with MDD-S or No MDD will be characterized by higher levels of smoking, fewer quit attempts, higher levels of nicotine dependence and the concentration of factors such as comorbid psychiatric disorders and greater functional impairment. Further, we expect that self-reports of higher nicotine dependence will be associated specifically with a history of MDD-R and not to depression-related negative bias (Dierker, et al., 2008) or comorbidity with other psychiatric disorders. Given the expectation for higher rates of comorbidity with psychiatric disorders associated with increased functional impairment and difficulty quitting smoking (e.g., anxiety, substance use disorders; Dierker, et al., 2008; Glassman, 1993), we also expect that MDD-R smokers will have greater functional impairment after taking into account comorbidity histories.
2. Method
2.1. Sample
A full description of the field procedures for the nationally representative face-to-face household survey conducted by the NCS-R can be found in Kessler et al., 2004. The current study draws from the 5,692 respondents who completed both Part I and the smoking-specific questions from Part II of the survey (Kessler et al., 2004). Participants who endorsed being current smoker were included if they reported at least 1 day of smoking in the past year, and had smoked at least 1 cigarette on that day in the past year (n = 1560).
2.2 Measures
2.2.a. NCS-R Sociodemographics and Smoking characteristics
Table 1 shows the sociodemographic and smoking characteristics for this population of current smokers.
Table 1.
No MDD (n=1083) |
MDD-S (n=128) |
MDD-R (n=337) |
||||
---|---|---|---|---|---|---|
Mean | SD | Mean | SD | Mean | SD | |
Demographics: | ||||||
Race | ||||||
White | 73.47% | 76.06% | 76.76% | |||
Black | 10.76% | 10.95% | 7.84% | |||
Hispanic | 11.68% | 7.38% | 7.44% | |||
Other | 4.1% | 5.61% | 7.96% | |||
Female | 47.0% | 53.39% | 62.56%* | |||
Age | 41.14 | 15.96 | 49.31* | 13.86 | 38.77 | 12.83 |
Household Income | 49985.73 | 43056.31 | 59464.77 | 53887.24 | 44943.92 | 40096.36 |
Smoking Characteristics: | ||||||
Average cigarettes each day | 15.79 | 11.99 | 16.96 | 10.12 | 18.57** | 11.46 |
Age of first TBD symptoms | 27.55 | 13.25 | 27.94 | 10.69 | 26.67 | 10.46 |
Years smoked | 20.61 | 15.11 | 20.65 | 14.25 | 19.38 | 13.04 |
Number of quit attempts | 6.82 | 47.54 | 4.64 | 10.98 | 3.42* | 7.25 |
Number of quits >3 months | 2.91 | 4.71 | 2.39 | 2.66 | 2.99 | 5.51 |
Use of cessation aid | 27.1% | 30.5% | 33.5% |
Note: TBD: DSM-IV Tobacco Dependence; Use of cessation aid includes nicotine patch, other pharmacotherapy, nicotine-free cigarettes, behavioral counseling. Statistical tests compare MDD-R and MDD-S to No MDD smokers.
p<0.05;
p<0.01
2.2.b. DSM-IV symptoms of Nicotine Dependence
Responses to nicotine dependence-related questions were recoded to correspond with symptoms that are considered for a diagnosis of nicotine dependence in the DSM IV-TR (http://www.hcp.med.harvard.edu/ncs/diagnosis.php). The NCS-R uses skip-outs after a person has met diagnosis for nicotine dependence after the first three questions in this section (n = 345 current smokers). Overall, of the 1,560 current smokers included in this study 22.1% (n = 344) met the full NCS-R criteria for nicotine dependence, and 77.9% (n = 1216) did not.
2.2.c. History of Major Depressive Disorder
Depression history was recoded into no depression history (No MDD) or a single major depressive episode (MDD-S), based on an NCS-R diagnosis of lifetime history of depression. If the participant had multiple lifetime episodes or 2 or more separate years with a major depressive episode, they were categorized as recurrent major depression (MDD-R). Of the 1560 current smokers, 12 did not provide information on depressive disorder and were not included in the final analyses of 1548 smokers. Of these respondents, 1,083 in the No-MDD category were current smokers; along with 128 in the MDD-S and 337 in the MDD-R categories.
2.2.d History of anxiety and substance use disorders
We adopted the diagnostic algorithms described in the NCS-R documentation to identify current smokers meeting DSM-IV criteria for comorbid anxiety and substance use disorder. A history of an anxiety disorder was present if current smokers reported a lifetime history of agoraphobia, generalized anxiety disorder, panic disorder, post-traumatic stress disorder, or social phobia. Substance use disorder was coded as present if smokers ever met full DSM-IV criteria for alcohol abuse, alcohol dependence, drug abuse, or drug dependence.
2.2.e Impairment in Functioning
The NCS-R interview inquired about recent impairment in functioning using a primary question that asked “How many days in the past 30 were you limited at all in carrying out your normal daily activities because of problems with your physical health, mental health, or substance use?” Answers were provided continuously and ranged from 0 to 30.
2.3. Data analyses
2.3.1. Establishing a continuous index for Nicotine Dependence (ND)
To construct our primary dependent variable, a continuous score was generated to reflect ND severity. Several studies support the validity of a unidimensional continuous index of ND (Muthen & Asporov, 2003; Strong et al., 2007; 2009). With skip-out rules a simple sum of symptoms was not possible and we used an item response model to generate our continuous index of ND. With planned missing data among sets of symptom questions, responses within sets of questions shared a methodological relationship. This relationship can be accommodated statistically, by adding a random effect to a standard unidimensional item response model that is common to the group of questions or ‘testlets’ (Thissen, 1993; Wainer, Bradlow, & Wang 2007; Wainer, 2007). The testlet model (SCORIGHT; Wang, et al., 2005) we employed uses Bayesian methods (Gelman, et al., 1995) for obtaining estimates of statistical parameters that reflect the level of ND for each respondent (mean = 0; SD = 1) along with parameters describing the relative level of ND and discriminative power associated with each DSM-IV symptom (a = discrimination; b = ND severity). The focus of the SCORIGHT method is on obtaining samples from the posterior distribution of each of the model parameters using two separate Markov chains (Markov chain Monte Carlo: MCMC). To generate evidence for convergence of the Gibbs sampler before drawing inferences, we allowed 100,000 iterations (Sinharay, 2004) and compared resulting outputs using the F-test convergence criterion of less than 1.2 to indicate reasonable convergence (Gelman & Rubin, 1992).
2.3.1.a. Evaluating depression-related bias in self-reports of Nicotine Dependence
One advantage of MCMC methods is the ability to obtain separate samples of symptom parameters from groups of smokers with No MDD, MDD-S, and MDD-R smokers who have been equated for their level of ND (Wang, Bradlow, Wainer, & Muller, 2008). This approach allows direct comparisons of depression-related bias in each symptom of ND and uses a series of models in which the discrimination and severity of each symptom is evaluated separately for each group of smokers using the remaining 6 symptoms as the anchor (c.f. Thissen, Steinberg, & Wainer, 1988). We established a priori that the magnitude of bias in the severity of symptoms must exceed 0.25 (a small effect) before we attributed clinically significant differences in symptom performance (Steinberg and Thissen, 2000). Differences in discrimination were evaluated using a visual inspection of item response curves to determine the potential impact on observed levels of ND.
2.3.2. Relationship between MDD history, Nicotine Dependence (ND), and impairment in functioning
Linear regressions were used to estimate the association between a lifetime history of depression (MDD-R, MDD-S, No MDD) and the continuous index of ND with sequential control for a) sociodemograhic factors (age, gender, race, household income) and b) current quantity of smoking. After entering sets of control variables (a, b), the relationship between depression history and ND was captured in two dummy codes comparing No MDD to MDD-S and No MDD to MDD-R. A final multivariable model included the sets of covariates along with dummy codes for MDD, ANX, and SUD. Two-way interactions were included as a block after all other terms to test whether the relationship between ND and each of the covariates was similar for those with different histories of MDD. We conducted the same series of models to evaluate impairment in functioning in the last 30 days. For the analyses of recent impairment in functioning, we attempted to control for the acute effects of current psychiatric disorders by excluding smokers who met criteria for a current MDD (n=92), current ANX (n=268) or current SUD (n=68) in the past 30 days. Regression models were fit using the appropriate sample weights to accommodate the complex survey design using the ‘survey’ package (Lumley, 2004) developed for R data analysis software (R Development Core Team, 2008).
3. Results
3.1.a Sample characteristics
Among smokers, weighted prevalence of depression history subgroups was 15.2 % (SE = 0.01), 5.6% (SE = 0.01), and 79.1% (SE = 0.01) for current smokers with MDD-R, MDD-S, and No MDD histories, respectively. Relative to smokers with no history of MDD, there were similar numbers of women in the MDD-S group (β = 0.06, SE = 0.12, t = 0.50, p < 0.62) and there were significantly more women in the MDD-R group (β = 0.63, SE = 0.16, t = 4.05, p < 0.001). There was an unequal racial distribution across MDD groups (Rao and Scott adjusted χ2: F = 2.31, ndf = 5.61, p < 0.03). Relative to smokers with No MDD, smokers with MDD-S were slightly older (β = 0.17, SE = 0.08, t = 2.170, p < 0.03). Level of household income did not differ across MDD history groups.
3.1.b. Smoking characteristics
When compared to No MDD, smokers with MDD-R had higher average cigarettes each day (β= 2.77, SE = 0.80, p < 0.001). Average cigarettes each day were not significantly different for MDD-S and No MDD smokers (β= 1.17, SE = 1.06, p < 0.27). When compared to No MDD, both MDD-S and MDD-R smokers reported experiencing their first symptoms of Nicotine Dependence at a similar age and reported a similar number of years smoking (p′s > .10). Using generalized linear poisson models, MDD-S smokers reported a similar number of quit attempts to smokers with No MDD (β= −0.38, SE = 0.38, p < 0.31) and MDD-R smokers reported fewer lifetime attempts to quit smoking (β = −0.69, SE = 0.33, p < 0.04). Smokers with MDD-S (β = −0.20, SE = 0.30 p < 0.52) and MDD-R (β = 0.03, SE = 0.29, p < 0.92) did not differ in the number of quit attempts that lasted 3 months or more. In logistic regression, among those who attempted to quit, MDD-S (β = 0.17, SE = 0.23, p < 0.46) and MDD-R (β = 0.31, SE = 0.16, p < 0.06) smokers did not differ in the likelihood of using smoking cessation aids.
3.1.c. Psychiatric comorbidity
Rates of comorbid anxiety disorders were 60.4% (SE = 0.03), 41.8% (SE = 0.05), and 24.5% (SE = 0.01) for smokers with MDD-R, MDD-S, and no MDD history, respectively. Smokers with a history of MDD-R or MDD-S had significantly higher odds of reporting a history of an anxiety disorder even after adjusting for sociodemographic covariates, with adjusted odds ratios of 4.22 (95CI = 3.01 – 5.91, p < 0.001) and 2.11 (95CI = 1.29 – 3.45, p < 0.002), respectively. Rates of comorbid substance use disorders were 40.1% (SE = 0.03), 37.0% (SE = 0.05), and 28.1% (SE = 0.02) for smokers with MDD-R, MDD-S, and no MDD history respectively. MDD-R and MDD-S smokers had significantly higher rates of SUD than smokers with no MDD history and the adjusted odds ratios were 2.04 (95CI = 1.43 – 2.89, p < 0.001) and 1.73 (95CI = 1.01 – 2.97, p < 0.05), respectively.
3.1.d. Establishing a Continuous index for Nicotine Dependence
Evaluation of convergence estimates supported SCORIGHT model results for ND parameters with estimates ranging from 1.0 – 1.05. The mean level of ND was 0.45 (SD = 0.38) and −0.24 (SD = 0.73) for respondents with and without a DSM-IV diagnosis of ND. The observed differences in means (sample mean = 0, SD = 1) and difference in the variability (i.e. SD) of continuous scores of ND among respondents with and without a diagnosis of DSM-IV ND suggested a potential advantage of a continuous rather than categorical diagnostic indicator of ND. The correlation of smoking rate and level of ND was significant statistically and reflected a small and significant relationship (r = 0.19, p < 0.001).
3.1.d.1. Evaluating depression-related bias in self-reports of Nicotine Dependence
We compared samples of severity and discrimination parameters for each subgroup of MDD-R and MDD-S and No MDD smokers. To compare parameters, we repeatedly computed the difference of 10,000 independent random draws from posterior distributions obtained for each subsample and then counted the frequency of differences > 0 (Wang, Bradlow, Wainer, & Muller, 2008). Three items evidenced differences > 0 in symptom parameters across >95% of comparisons. Smokers with a history of MDD-R on average had lower severity estimates than other smokers for both Tolerance (bMDD-R = −1.57; SE = 0.42; bNo-MDD = −0.84; SE = 0.13; d = 0.73) and Withdrawal (bMDD-R = −0.67; SE = 0.12; bNo-MDD = −0.40; SE = 0.06; d = 0.27) symptoms suggesting increased likelihood of reporting these symptoms at lower levels of nicotine dependence. Time spent smoking also was found to be less discriminating among smokers with MDD-R than among other smokers. When compared to No MDD (a=1.04, SE =0.20), the symptom appeared to become less discriminating across MDD-S (a=0.82, SE=0.34) smokers and was consistently less discriminating among MDD-R smokers (a=0.51, SE=0.19).
3.1.d.2. Relationship between single and recurrent MDD history and Levels of Nicotine Dependence
A series of linear regressions was used to first estimate the association between level of ND first with a block (a) of sociodemographic indices (age, gender, race, household income) and then with (b) the current quantity of smoking after controlling for sociodemographic indices (see Table 2). After controlling for levels of smoking, Hispanic smokers had lower levels of ND than White smokers (d = 0.64, p < 0.001) and women reported slightly higher levels of ND than men (d = .15; p < 0.03). Among smokers with MDD-R and MDD-S and No MDD smokers, respectively, the mean levels of ND were 0.14 (SD = 0.65), −0.01 (SD = 0.70), −0.17 (SD = 0.73). The adjusted univariate associations suggested smokers with lifetime MDD-R had significantly higher levels of ND than smokers with No MDD (d = 0.33, p < .001). Levels of ND were not significantly higher for smokers with MDD-S (d = 0.16; p > 0.11). Both a lifetime history of ANX (d = 0.52; p < 0.001) and a history of SUD (d = 0.30; p < 0.001) were related to higher levels of ND. In the multivariable model that controlled for sociodemographic and smoking levels, MDD-R (p < 0.05), ANX (p < 0.001), and SUD (p < .05) each were uniquely related to higher levels of ND. We evaluated all two-way interactions of psychiatric disorders with sociodemographic and smoking levels. Results suggested that the relationship between MDD-R and ND was not significantly different across sociodemographic groups and was not significantly different among men and women (β = −0.06, SE = 0.10, p < 0.54). We did observe that the relationship between ANX and ND was stronger among men then women. After removing all non-significant interactions, the effect remained significant statistically (β = −0.20, SE = 0.08, p < 0.03) although the magnitude of this effect was small (d = 0.14).
Table 2.
Nicotine Dependence (n=1548) | Days of Impairment In Functioning (n=1228) | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Univariate | Multivariable | Univariate | Multivariable | |||||||||
β | SE | p | β | SE | p | β | SE | p | β | SE | p | |
Demographics | ||||||||||||
Age | −0.02 | 0.02 | 0.383 | −0.01 | 0.02 | 0.681 | −0.02 | 0.11 | 0.884 | −0.09 | 0.10 | 0.378 |
Female | 0.11 | 0.05 | 0.021 | 0.11 | 0.05 | 0.021 | 0.70 | 0.21 | 0.002 | 0.78 | 0.22 | 0.001 |
Race | ||||||||||||
HispanicA | −0.45 | 0.01 | 0.001 | −0.33 | 0.09 | 0.000 | −0.81 | 0.32 | 0.012 | −0.86 | 0.33 | 0.011 |
BlackA | −0.17 | 0.07 | 0.025 | −0.10 | 0.08 | 0.222 | −0.24 | 0.34 | 0.476 | −0.22 | 0.36 | 0.545 |
OtherA | 0.17 | 0.09 | 0.067 | 0.11 | 0.09 | 0.131 | 0.23 | 0.44 | 0.607 | −0.09 | 0.46 | 0.839 |
Household Income | 0.02 | 0.02 | 0.457 | 0.03 | 0.02 | 0.187 | −0.05 | 0.11 | 0.633 | −0.08 | 0.12 | 0.500 |
Average Daily Cigarettes | 0.12 | 0.04 | 0.004 | 0.08 | 0.04 | 0.021 | −0.04 | 0.09 | 0.680 | 0.08 | 0.11 | 0.481 |
MDD History | ||||||||||||
MDD-SB | 0.01 | 0.08 | 0.102 | 0.04 | 0.07 | 0.546 | −0.08 | 0.40 | 0.837 | 0.12 | 0.39 | 0.756 |
MDD-RB | 0.24 | 0.05 | 0.001 | 0.10 | 0.05 | 0.044 | 0.85 | 0.30 | 0.005 | 1.21 | 0.29 | 0.001 |
Comorbidity | ||||||||||||
ANXC | 0.38 | 0.04 | 0.001 | 0.34 | 0.05 | 0.001 | 0.93 | 0.24 | 0.001 | 1.16 | 0.22 | 0.001 |
SUDC | 0.22 | 0.05 | 0.001 | 0.15 | 0.05 | 0.001 | 0.57 | 0.23 | 0.015 | 0.73 | 0.23 | 0.001 |
Note: MDD=Major Depressive Disorder. ANX=Anxiety Disorder. SUD=Substance Use Disorder. Impairment index was log transformed to correct for positive skewness and analyses exclude smokers with a current depressive episode in the past 30 days. All continuous variables were scaled to a mean of 0 (SD=1).
Compared to White smokers;
Compared to no MDD history;
Compared to no comorbidity.
3.1.e. Relationship between single and recurrent MDD history and functional impairment
Prior to regression analysis of group differences, we applied a log transformation of the reported days of impairment (range = 0–30; median = 0; skew = 2.9) given the beneficial effect on normalizing residuals from the models. We mirrored the above procedures in modeling the relationships with the level of reported functional impairment in the past 30 days (see Table 2). In univariate analyses controlling for sociodemographic variables and smoking level, MDD-R (d = 0.38; p < 0.001), ANX (d = 0.36; p < 0.001), and SUD (d = 0.23; p < 0.002) were each related to higher levels of impairment in the past month. MDD-S was not related to levels of impairment (d = 0.04; p > 0.84). In multivariable models that controlled for comorbidity with other disorders, MDD-R (d = 0.27; p < 0.05), ANX (d = 0.29; p < 0.001), and SUD (d = 0.18; p < 0.05) each had unique and additive associations with increasing levels of impairment in the past 30 days.
4. Discussion
Using a representative sample of current smokers in the United States, the current study supported the hypothesis that depression related risk for higher levels of smoking, higher levels of ND and the concentration of factors such as comorbid psychiatric disorders and greater functional impairment that may lead to poor cessation outcomes may be found primarily among MDD-R smokers. Smokers with MDD-S did not differ from No MDD smokers on smoking characteristics, levels of ND, or levels of functional impairment. Careful examination of differential symptom functioning suggested that observed differences in overall levels of ND are not likely to arise from depression-related biases in responding to the symptom questions (Dierker and Donny, 2008). Although rates of comorbidity with psychiatric disorders that also convey risk for poor cessation outcomes were substantial, analyses suggested that a history of MDD-R continued to convey significant risk for higher ND and higher functional impairment that was independent of comorbid disorders. Given the disproportionately high rates of smoking, evidence supporting a concentration of cessation-related risk factors, and evidence for differential efficacy of specialized treatments, research efforts are needed to better identify and deliver targeted interventions to increase quit attempts and facilitate access to specialized cessation programs for smokers with MDD-R.
Although MDD-R smokers evidence higher levels of ND and reported fewer lifetime attempts to quit smoking than other smokers, these smokers did not appear to have a more chronic smoking history. The onset of nicotine dependence symptoms and number of years smoking did not differ significantly across depression history groups. Depression history was not related to the effectiveness of quitting given similar reports of quit attempts that were sustained for three months or more and a similar rate of using smoking cessation aids during quit attempts. A recent US survey reported that while middle-aged and older adulthood is developmentally the period associated with the majority of quit attempts, depressive disorders were related to persistent smoking during this period (Agrawal et al, 2008). Thus it may not be the chronicity of smoking or decreased capacity for quitting alone, but the chronic and recurrent features of depressive disorders that reduce the likelihood of initiating attempts and increase probability of relapse.
MDD-R smokers were characterized by more frequent days of impairment in functioning as a result of their physical health, mental health, or substance use. There is a strong link between day-to-day functioning (Manning, et al., 2005), stress (Kassel et al., 2003) and increased smoking (Shiffman et al., 2008). These effects may be particularly strong among those with a history of MDD-R who may be prone to experience more frequent stressful events (Hammen, 1991) and after stressful events, suffer greater decreases in self-efficacy and greater increases negative affect than individuals without a history of depressive disorder (Maciejewski, et al., 2000). The expected higher frequency of stressors associated with increased incidence of functional impairment among MDD-R smokers may sustain smoking in this population by both decreasing confidence in the ability to quit successfully and convey risk for relapse after quit attempts.
We did not observe a difference in the strength of association between the MDD history and levels of nicotine dependence among men and women. Previous studies have documented gender differences in the strength of relationships between MDD and smoking (Grant et al, 2004; Husky et al, 2008). However, each study included different classifications of smokers with regard to both MDD and smoking status when examining the relationship between MDD and nicotine dependence. A combination of decreasing gender-related effects within the range of nicotine dependence examined in the current study and our reduced sample size relative to previous studies may have left the current study underpowered to detect gender differences among current smokers.
There are limitations to the data presented. First, while the NCS-R data allowed us to evaluate smoking characteristics, quitting histories, and functional impairment in a representative sample from the United States, these data do not allow for sequencing of events over time and data are subject to bias inherent in retrospective self-reports. Given the potential for depression-related recall bias, these smokers may also under identify smoking-related events. Although research on this phenomenon is limited, available longitudinal work among young adults (Stanton et al, 2007) suggested that biased recall may increase with severity of depression, and thus respondents in the current survey classified as MDD-R may be more likely to be underreport their smoking history. Second, the NCS-R survey by design did not require all smokers respond to all of the ND criteria questions and we imputed continuous scores using methods based in IRT.
In summary, results from a nationally representative sample of current smokers extend previous investigations by clarifying risk factors for persistent smoking associated with a history of chronic rather than single episodes of major depressive disorder. Although clinical trials have suggested differential benefit of cessation treatments for smokers with MDD-R that include mood management along with behavioral or pharmacological treatments for nicotine dependence (Brown et al, 2001; Haas et al. 2004), this study uniquely examined differential prevalence of risk factors that may impede cessation efforts among current smokers with MDD-R. Future research is needed to better identify opportunities to engage this population of smokers in specialized cessation treatments targeting this high-risk population that are cost-effective and easily disseminated.
Footnotes
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