Research article
Current Major Depression Among Smokers Using a State Quitline

https://doi.org/10.1016/j.amepre.2010.09.030Get rights and content

Background

Smokers seeking treatment to quit smoking are generally not assessed for current depression, yet depression among smokers may influence quitting outcome.

Purpose

This study aims to formally assess current major depression among smokers calling a state tobacco quitline.

Methods

A total of 844 smokers calling the California Smokers' Helpline in 2007 were screened for depression by the mood module of the Patient Health Questionnaire (PHQ-9). The Social Functioning Questionnaire (SFQ) also was administered to these callers. Two months after the screening, follow-up evaluations were conducted to assess cessation outcome.

Results

In all, 24.2% of smokers met criteria for current major depression and 16.5% reported symptoms indicating mild depression. Callers with current major depression were more likely to be heavy smokers and on Medicaid. Moreover, 74.0% of smokers with current major depression had substantial social and occupational functioning deficits. Two months later, those with major depression at baseline were significantly less likely to have quit smoking (18.5% vs 28.4%).

Conclusions

Almost one in four smokers who called the California Smokers' Helpline met criteria for current major depression. More than 400,000 smokers call state quitlines in the U.S. for help with quitting each year, which means that as many as 100,000 smokers with serious depressive symptoms are using these services annually. The large number of depressed smokers who seek help suggests a need to develop appropriate interventions to help them quit successfully.

Introduction

Epidemiologic studies1, 2 have found that smokers have a higher prevalence of major depression than nonsmokers. National surveys3, 4 indicate that 11%–12% of smokers, compared to 5%–6% of nonsmokers, meet criteria for current major depression. Smokers with current depression are less likely to quit smoking than those without.5, 6, 7 This link to lower levels of quitting success has led to increased interest in examining the impact of depression on quitting in treatment settings.8, 9, 10, 11

It is common in smoking-cessation research,8, 11, 12 both behavioral and pharmacologic, to exclude smokers with acute mental illness unless they are the specific focus of investigation. Although intervention studies often include smokers with a history of major depression or with subclinical symptoms of depression, they usually exclude smokers with severe levels of current depression such as current Major Depressive Episode (MDE). The few treatment studies13, 14 that have included smokers with severe current depression estimate the prevalence to be 11.4%–23.8%, with some indication that level of depression is related to difficulty quitting.

Regardless of the limited data on the impact of severe current depression on cessation, there is ample evidence9, 12, 15, 16 that subclinical depressed mood predicts worse quitting outcomes, which suggests that more severe depression would also be a risk factor for quitting. The present study assesses current major depression among smokers in a treatment setting by sampling callers to a state tobacco quitline, a telephone counseling program that provides free smoking-cessation services to state residents.

Quitlines have become a popular and effective method of delivering behavioral counseling to a large number of smokers who want to quit.17, 18, 19 Currently, every state in the U.S. has an operating quitline; collectively, they serve more than 400,000 smokers annually.20 No state quitline, to our knowledge, has formally assessed for current major depression, although some have asked callers a single question on mood. One study21 found that a high percentage of quitline callers, 46%, endorsed feeling “sad or blue everyday for the last two weeks.”

The present study focuses on the practical application of measuring depression in the context of smoking-cessation treatment programs. The main goals are to determine (1) whether a relatively short questionnaire, administered over the telephone, can be used to identify current major depression and (2) whether depression is predictive of cessation outcome. The Patient Health Questionnaire mood module (PHQ-9) was used to assess for current major depression. Developed as a screening tool, the PHQ-9 has been used extensively as a diagnostic measure for current depression.22, 23, 24, 25, 26, 27 The PHQ-9 is a self-report measure of depressive symptoms and is relatively easy to administer over the phone.28 The Social Functioning Questionnaire (SFQ) also was used to assess the level of impairment in smokers' daily lives.29

Section snippets

Participants and Settings

Participants were recruited from among callers to the ongoing state quitline in California, the California Smokers' Helpline, between August and November 2007. The current study was approved by the Human Research Protections Program at the University of California, San Diego. For increased efficiency in training and monitoring, a decision was made a priori to restrict data collection to staff who typically conduct high numbers of intakes each week; thus, 22 staff members were selected to

Sample Characteristics and Depression Prevalence

Table 1 shows the demographic characteristics of the study participants and callers who met the criteria but were not sampled in the study. There were significantly more female participants compared to nonparticipants during the same time period. There is no significant difference in any other demographic measure.

There were 861 callers who agreed to participate in the current study whereas 12 callers declined to answer the additional intake questions. Of the 861 participants, 17 were excluded

Discussion

The present study uses a formal instrument to assess for current major depression among callers to a large state quitline and it is one of the few studies to assess major depression among smokers seeking cessation treatment.13, 14 Using the PHQ-9, the current study found that almost one of four smokers seeking help through a quitline has current major depression. The study shows that it is feasible to assess depression with the PHQ-9 in the context of a quitline. The PHQ-9 score correlated well

References (44)

  • L. Degenhardt et al.

    The relationship between tobacco use, substance-use disorders and mental health: results from the National Survey of Mental Health and Well-being

    Nicotine Tob Res

    (2001)
  • K. Lasser et al.

    Smoking and mental illness: a population-based prevalence study

    JAMA

    (2000)
  • H.E.R. Morrell et al.

    Cigarette smoking, anxiety, and depression

    J Psychopathol Behav Assess

    (2006)
  • P.M. Cinciripini et al.

    The effects of depressed mood on smoking cessation: mediation by postcessation self-efficacy

    J Consult Clin Psychol

    (2003)
  • R.A. Brown et al.

    Bupropion and cognitive–behavioral treatment for depression in smoking cessation

    Nicotine Tob Res

    (2007)
  • A.L. Haas et al.

    Influences of mood, depression history, and treatment modality on outcomes in smoking cessation

    J Consult Clin Psychol

    (2004)
  • T. Kinnunen et al.

    Depression and smoking cessation: characteristics of depressed smokers and effects of nicotine replacement

    J Consult Clin Psychol

    (1996)
  • R.F. Muñoz et al.

    Toward evidence-based Internet interventions: a Spanish/English website for international smoking cessation trials

    Nicotine Tob Res

    (2006)
  • R.F. Muñoz et al.

    International Spanish/English Internet Smoking Cessation Trial yields 20% abstinence rates at one year

    Nicotine Tob Res

    (2009)
  • I. Berlin et al.

    Pre-cessation depressive mood predicts failure to quit smoking: the role of coping and personality traits

    Addiction

    (2006)
  • S.M. Hall et al.

    Nicotine, negative affect, and depression

    J Consult Clin Psychol

    (1993)
  • E. Lichtenstein et al.

    Smoking cessation quitlines: an underrecognized intervention success story

    Am Psychol

    (2010)
  • Cited by (41)

    • Understanding engagement behaviors and rapport building in tobacco cessation telephone counseling: An analysis of audio-recorded counseling calls

      2022, Journal of Substance Abuse Treatment
      Citation Excerpt :

      Also, as previously noted, this sample demonstrated high rates of anxiety and depression. High anxiety and depression may reflect stress associated with hospitalization when the study obtained survey measures, or reflect higher psychological distress noted among smokers (Hebert et al., 2011; Jamal et al., 2012). Symptoms were likely dynamic over the course of the study in response to additional stressors.

    • Quitline Programs Tailored for Mental Health: Initial Outcomes and Feasibility

      2021, American Journal of Preventive Medicine
      Citation Excerpt :

      Quitlines further questioned whether the MHC population would utilize telephonic services,19 but by 2009, quitlines were reporting that the prevalence of MHC among callers ranged from 19% to 50%.8,20–22 An early study found that a quarter of callers reported current major depression alone.23 An observational study of quitlines across 3 states found that 46% of respondents reported 1 or more MHCs, with the most common conditions being depression, anxiety, and bipolar disorder.24

    • The reinforcement threshold and elasticity of demand for nicotine in an adolescent rat model of depression

      2021, Drug and Alcohol Dependence
      Citation Excerpt :

      For example, depression in adolescents predicts subsequent onset of daily smoking and progression to dependence (Breslau and Peterson, 1996; Karp et al., 2006). Individuals with depression are three to four times more likely to develop nicotine dependence during adolescence (e.g., Kendler et al., 1993; Patton et al., 1998) and comprise 20−30% of adult smokers (e.g., Fond et al., 2015; Hebert et al., 2011; Shahab et al., 2014). Compared to non-depressed smokers, currently depressed smokers were twice as likely to choose smoking over other rewarding activities and reported needing a larger amount of an alternative reinforcer to quit smoking (Spring et al., 2003).

    • The Medi-Cal Incentives to Quit Smoking Project: Impact of Statewide Outreach Through Health Channels

      2018, American Journal of Preventive Medicine
      Citation Excerpt :

      Medi-Cal callers reported high rates of chronic disease and behavioral health issues. Depression was reported by more than 40% of callers; previously, the Helpline described how almost one in four callers met clinical criteria for current major depression.38 More than 1,000 Medi-Cal callers were pregnant women (three quarters of the state's pregnant women who smoke have Medi-Cal),39 and nearly 15,000 Medi-Cal callers live with a young child.

    View all citing articles on Scopus
    View full text