Full length articleEffects of time-varying changes in tobacco and alcohol use on depressive symptoms following pharmaco-behavioral treatment for smoking and heavy drinking
Introduction
The extant literature provides evidence that both smoking cessation and abstinence from alcohol (independently) predict reduced depressive symptoms over time. However, many smokers are unsuccessful in achieving sustained abstinence or are unwilling to commit to complete abstinence in the foreseeable future, e.g. (Begh et al., 2015). Similarly, many heavy drinkers report willingness and motivation to reduce their alcohol consumption but do not intend to be abstinent from alcohol (Marlatt and Witkiewitz, 2002). Whereas the effects of abstinence on depressive symptoms have been studied extensively, the question as to whether or not reducing smoking or alcohol use positively affects depressive symptoms has yet to be examined.
Previous studies examining the link between smoking cessation and depressive symptoms generally show positive effects for those who quit successfully. Smokers who successfully quit and maintain abstinence for one year following treatment have demonstrated significant reductions in depressive symptoms over the assessment period, whereas those who relapsed showed no associated change (Kahler et al., 2002). A second study found similar effects: participants who had stopped smoking successfully reported a significant improvement in depression; those with moderate to severe depression reported the largest improvement (Stepankova et al., 2017). Some research has indicated that smoking cessation may lead to a worsening or re-emergence of depressive symptoms (Aubin, 2009), no change in symptoms (Rodriguez-Cano et al., 2016), or that depression changes post-cessation may depend on medication effects (Cinciripini et al., 2013). Despite some mixed findings, a recent meta-analysis found that smoking cessation (compared to continued smoking) was associated with a significant decrease in depression over time (Taylor et al., 2014). Part of the difficulty of examining the relationship between cessation and depressive symptoms is that baseline depressive symptoms at the time of quit attempt are strongly tied to the outcome; thus, assessing the effect of cessation on subsequent depressive symptoms between individuals carries significant limitations. One study accounted for this limitation by modeling individual-level changes in smoking status over time in relation to depressive symptoms, allowing for transitions between smoking statuses within a participant. Results indicated that being abstinent at a particular time point was associated with lower levels of concurrent depressive symptoms (Kahler et al., 2011).
Several studies have found similar reductions in depression in individuals following treatment and successful abstinence from alcohol. Brown and Schuckit (1988) found that among the 46% of individuals with alcohol dependence who were admitted with clinically significant levels of depression, only 6% had clinically elevated levels of depression following four weeks of abstinence achieved through inpatient treatment (Brown and Schuckit, 1988). A second study found that, regardless of the presence of baseline diagnosis of a depressive disorder, individuals with an alcohol use disorder demonstrated a significant decrease in depressive symptoms as the result of a four to five-week inpatient detoxification program (Liappas et al., 2002). These findings are also in line with studies examining the effects of alcohol abstinence on a broader range of psychological symptoms (Brown et al., 1995, 1991); each showing reductions in symptoms following abstinence.
General and substance-specific theories have been proposed to explain the relationship between abstinence and reduced negative affect. In general, success in attaining a goal of reduced use or abstinence may result in greater positive mood and reduced negative mood regardless of the substance, and increases in perceptions of physical well-being that occur following a successful quit-attempt also may contribute to reduced depression (Carbone et al., 2005; Peters and Hughes, 2009; Stead and Lancaster, 2007). Frequent tobacco use leading to physiologic dependence can result in recurring mood oscillations where negative affect occurs during smoking abstinence and is attenuated by smoking (Parrott, 1994a,b, 2006, 2015). Removing or dampening these daily oscillations in mood through sustained abstinence or reduction in use and dependence may result in less negative affect overall. In regards to alcohol, mood also may improve following abstinence as a result of decreases in negative consequences associated with heavy drinking (problems with relationships, legal issues, financial issues) (Markman Geisner et al., 2004).
Although the literature supports that both smoking cessation and abstinence from alcohol reduce depressive symptoms over time, no studies to our knowledge, have examined the relationship as a function of reduction in use from baseline. Given that successful cessation is likely dependent on a variety of psychological factors, including depression, how any reduction in smoking impacts depression has significant implications for treatment planning. If a reduction in use significantly decreases depressive symptoms, then smoking reduction as a step-down process towards cessation may be indicated in smokers for whom depressive symptoms are a key barrier to cessation. Similar implications may exist for individuals seeking abstinence from alcohol use; or, could serve as a critical motivator for those who seek to moderate their alcohol use.
The current study examined changes in depressive symptoms following a smoking cessation treatment, which also addressed reducing alcohol use, as a function of 1) no significant change in use relative to baseline 2) a 50% or greater reduction in use, and 3) abstinence from use of the substance for each substance independently. Additionally, we examined if continuous measures of smoking and alcohol use, among the group of participants who did not abstain, were associated with depressive symptoms. The theories detailed above regarding the link between change in substance use and depressive symptoms suggest that there may be a linear relationship between the degree of reduction in use and reduction in depressive symptoms due to attainment of a behavior change goal, increase in physical well-being, reduction in dependence, and a reduction in negative consequences associated with use. Therefore, we hypothesize a linear relationship between reductions in use and associated depressive symptoms.
Section snippets
Participants
Participants were 150 heavy drinking smokers recruited in Providence RI, and surrounding communities, through posted advertisement, radio, internet, newspaper and flyers in physicians’ offices and primary care clinics to participate in a randomized controlled trial of naltrexone for reducing alcohol use and improving smoking outcomes in heavy drinkers seeking smoking cessation treatment. Primary inclusion criteria included that participants (i) be ≥18 years old; (ii) have smoked cigarettes
Results
Means and standard deviations for CES-D scores by smoking and alcohol use category, as well as sample percentages, are listed in Table 1. Mean baseline CES-D score was 11.8 (SD = 9.9); mean CES-D did not change significantly over time; Week 2 CES-D = 10.43 (SD = 9.28), Week 8 CES-D = 10.94 (SD = 9.2), Week 16 CES-D = 11.97 (SD = 10.8), Week 26 CESD = 11.49 (SD = 9.78). Smoking and drinking reductions (analyzed as ordinal variables [0, 1, or 2] as described above) were not significantly
Discussion
The current study is the first, to our knowledge, to model depressive symptoms in heavy-drinking smokers making a quit attempt as a function of 1) abstinence from smoking or alcohol use, independently 2) a significant reduction (>50%) in use of either substance and 3) little or no change in use following a smoking cessation and alcohol reduction intervention. In accordance with previous findings, i.e. (Kahler et al., 2011; Mathew et al., 2013; Stepankova et al., 2017), abstinence from smoking
Contributors
WVL conducted primary data analyses with advisement from CWK. WVL conceptualized and wrote the majority of the manuscript text. CWK, NS and PAC aided in conceptualization and contributed significantly to revision. All authors read and approved the final manuscript.
Role of source funding
This study was supported by NIHNIAAA R01-AA01718 (Kahler).
Conflict of interest
No conflict declared.
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