Combined treatment for smoking cessation, anxiety and depression more effective than smoking cessation alone

A randomised control trial published in The Journal of Acquired Immune Deficiency Syndromes by researchers in Boston 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.

O’Cleirigh, C. et al. Integrated treatment for smoking cessation, anxiety, and depressed mood in people living with HIV: a randomized control trial. J Acquir Immune Defic Syndr 79 (2), 2018.