Combined treatment effective for stopping smoking, anxiety and depression

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A randomised control trial by researchers at the department of psychiatry, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, department of psychology, University of Houston, department of behavioural sciences, The University of Texas MD Anderson Cancer Centre, Houston, department of psychology, University of Texas at Austin, department of psychology & neuroscience, Duke University, Durham, North Carolina, department of psychological & brain sciences, Boston University, department of psychiatry, SUNY Stony Brook School of Medicine, Stony Brook, New York and department of psychology, Southern Methodist University, Dallas, found that an integrated cognitive-behavioural treatment approach aiming to target smoking cessation as well as anxiety and depressive symptoms in people with HIV was more effective than a standard smoking cessation intervention conducted in isolation.

This is of particular interest considering that the prevalence of smoking is three times higher in people with HIV than in the general population. HIV-positive smokers are less likely to adhere to treatment regimens, are likely to experience virologic failure sooner than non-smokers with HIV, and are at an increased risk of developing disease and premature death due to the increased risks of smoking combined with HIV infection.

Additionally, anxiety and depressive symptoms are more common among smokers and may be twice as high in people living with HIV. Anxiety and depression often contribute to failed attempts at smoking cessation and thus, the authors wanted to explore the benefits of an integrated treatment approach.

For the current study, the researchers aimed to expand upon preliminary evidence from an earlier pilot. They randomly assigned participants to intervention and control groups between March 2013 and February 2015, with a follow-up six months later. A total of 53 HIV-positive participants smoking at least five cigarettes daily were randomised: 26 to an intervention group receiving integrated treatment consisting of nine weekly sessions of cognitive behavioural therapy for smoking cessation as well as anxiety and depression, and 27 to a control group receiving four brief weekly check-in sessions as part of standard smoking-cessation treatment. Both groups received nicotine replacement therapy and one educational session prior to randomisation.

The intervention group received a hybrid intervention which aims to target different conditions by attending to underlying or common causes of anxiety as well as barriers to success when it comes to smoking cessation. Thus, while they received the standard smoking cessation cognitive behavioural therapy along with nicotine replacement therapy (also received by the control group), they also received cognitive behavioural therapy specifically aimed at treating anxiety and depression. This consisted of six treatment modules aimed at cognitive restructuring, exposure therapy and problem solving.

Participants ranged in age from 30 to 64 years, 85% were male with most having some college education (65%); they were recruited from HIV primary care clinics and Massachusetts General Hospital in Boston. All participants had to express a moderate level of willingness to stop smoking in order to participate in the study. No inclusion criteria were specified for anxiety and depression symptoms in order to allow for a maximally representative sample. However, a number of participants met the diagnostic criteria for illnesses such as panic disorder, social phobia, major depressive disorder and alcohol dependence. There were no significant differences between the intervention and control groups.

The primary outcome measure was abstinence from smoking; this was defined as absolutely no smoking in the seven days prior to any assessment. Abstinence was measured using self-reported smoking status as well as an objective measure in the form of expired carbon monoxide in order to verify self-reported data at every assessment. Secondary outcome measures consisted of both interviewer-rated and self-reported measures of anxiety and depression symptom severity.

All participants were asked to quit smoking during the study; for the intervention group, this was done after their seventh session. The control group received four post-quit short sessions to check in with them, provide nicotine replacement and measure outcomes. Both groups were compared at the end of the treatment period and again at a six month follow-up. The primary goal was to increase the number who were abstinent at both these time points.

Results revealed that the proportion of those remaining abstinent at the end of treatment was significantly higher in the intervention group (59%) than the control group (9%); abstinence decreased during the follow-up period in the intervention group but was still significantly higher at the six-month follow-up (46% for the intervention group and 5% for the control group).

Multivariate analyses used to measure the secondary outcomes of anxiety and depressive symptoms also revealed lower symptom severity in the intervention group at the end of treatment (b = 0.46, 95% CI: 0.09-0.84) as well as at the six-month follow-up (b = 0.37, 95% CI: 0.05-0.69).

It is important to note that the study had a high drop-out rate, with 21% dropping out before the end of treatment and another 15% dropping out during follow-up. Total drop-outs were significantly higher in the intervention group overall (13 of the 26 vs 6 of the 27 in the control group). This suggests problems with the acceptability of the intervention and willingness of participants to complete the full treatment. However, the authors assert that the pattern of results was not altered by missing data. Another limitation is that most participants were men and thus, the researchers were unable to test sex differences regarding the intervention.

The authors conclude that their results are promising for the use of combined interventions for smoking cessation, anxiety and depression specifically tailored for people living with HIV. This type of intervention could potentially address the unique needs of smokers with HIV and may offer a novel treatment option in clinical settings.

Abstract
Objective: Among people living with HIV, cigarette smoking rates are higher than among the general population, and anxiety, depression, and their disorders are common and associated with smoking and poorer outcomes during cessation. This study evaluated the efficacy of an integrated smoking cessation intervention, developed to target anxiety, depression, and smoking cessation concurrently among people living with HIV.
Method: Smokers living with HIV who reported at least moderate motivation to quit smoking were randomized into a novel 9-week integrated intervention (QUIT), consisting of 1 psychoeducation (prerandomization) session and 9 weekly 1-hour sessions of cognitive behavioral therapy for smoking cessation and anxiety/depression plus nicotine replacement therapy, or a 9-week enhanced standard smoking intervention (ETAU), consisting of 1 psychoeducation session (prerandomization) and 4 brief weekly check-in sessions plus nicotine replacement therapy. All were instructed to make a quit attempt at week 6.
Results: Seventy-two participants were enrolled, and 53 were randomized. 41/53 participants completed the active treatment phase of the study. 7-day point-prevalence abstinence, verified with expired carbon monoxide, was significantly higher among those in the integrated intervention than those in the enhanced standard intervention both end-of-treatment {[MQUIT = 59%, METAU = 9%; b = 5.60, 95% confidence interval: (2.64 to 8.56), t(332) = 3.72, P < 0.001]} and 6-months post-quit date {[MQUIT = 46%, METAU = 5%; b = 7.69, 95% confidence interval: (4.60 to 10.78), t(332) = 4.90, P < 0.001]}. Consideration of patterns of missingness did not alter the significance of these findings.
Conclusions: The integrated intervention was associated with substantially higher short-term and long-term abstinence rates than the enhanced standard intervention. These data provide promising initial evidence supporting the benefits of an integrated anxiety-depression/smoking cessation program specifically tailored for people living with HIV.

Authors
OʼCleirigh C, Zvolensky MJ, Smits JAJ, Labbe AK, Coleman JN, Wilner JG, Stanton AM, Gonzalez A, Garey L, Regenauer KS, Rosenfield D

Aidsmap material
Journal of Acquired Immune Deficiency Syndrome abstract


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