PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Drug Alcohol Depend. Author manuscript; available in PMC 2014 January 1.
Published in final edited form as:
PMCID: PMC3480998
NIHMSID: NIHMS393071

The Relationship of Dysthymia, Minor Depression, and Gender to Changes in Smoking for Current and Former Smokers: Longitudinal Evaluation in the U.S. Population

Abstract

BACKGROUND

Although data clearly link major depression and smoking, little is known about the association between dysthymia and minor depression and smoking behavior. The current study examined changes in smoking over three years for current and former smokers with and without dysthymia and minor depression.

METHODS

Participants who were current or former daily cigarette smokers at Wave 1 of the National Epidemiologic Survey on Alcohol and Related Conditions and completed the Wave 2 assessment were included in these analyses (n=11,973; 46% female). Analyses examined the main and gender-specific effects of current dysthymia, lifetime dysthymia, and minor depression (a single diagnostic category that denoted current and or lifetime prevalence) on continued smoking for Wave 1 current daily smokers and continued abstinence for Wave 1 former daily smokers.

RESULTS

Wave 1 current daily smokers with current dysthymia (OR=2.13, 95% CI=1.23, 3.70) or minor depression (OR=1.53, 95% CI=1.07, 2.18) were more likely than smokers without the respective diagnosis to report continued smoking at Wave 2. Wave 1 former daily smokers with current dysthymia (OR=0.44, 95% CI=0.20, 0.96) and lifetime dysthymia (OR=0.37, 95% CI=0.15, 0.91) were less likely than those without the diagnosis to remain abstinent from smoking at Wave 2. The gender-by-diagnosis interactions were not significant, suggesting that the impact of dysthymia and minor depression on smoking behavior is similar among men and women.

CONCLUSIONS

Current dysthymia and minor depression are associated with a greater likelihood of continued smoking; current and lifetime dysthymia are associated with a decreased likelihood of continued smoking abstinence.

Keywords: Smoking, Cessation, Relapse, Dysthymia, Minor Depression, Gender, Epidemiological Data

1. INTRODUCTION

While a significant amount of research has demonstrated a positive relationship between smoking and depression, most studies have focused on major depressive disorder (MDD). Compared to adults without depression, adults with MDD report higher rates of smoking (Lasser et al., 2000) and appear to have more difficulty quitting smoking (see Ziedonis et al., 2008 for a review). In a national longitudinal U.S. sample, we found that diagnoses of current and lifetime MDD were associated with a reduced likelihood of quitting and higher smoking relapse rates (Weinberger et al., in press). Little is known about the smoking behavior of adults with other depressive disorders like dysthymia and minor depression (Ziedonis et al., 2008).

Dysthymia and minor depression are recurrent mood disorders with important clinical implications that affect a significant number of adults. Dysthymia is marked by a chronic depressed mood that exists for the majority of the time for at least two years along with additional depressive symptoms (e.g., sleep disturbance, low energy; APA, 1994). Dysthymia is less prevalent than MDD (6.8% versus 16.6%; Lasser et al., 2000; Ziedonis et al., 2008) but causes significant impairment and is associated with a more severe course of later MDD (Keller, 1994; Klein and Santiago, 2003).

Minor depression is characterized by at least two weeks of depressed affect and additional depressive symptoms that are fewer than would qualify for an MDD diagnosis (2–4 versus 5 or more symptoms; APA, 2002). Minor depression is included in the DSM-IV-TR (APA, 2002) as a depressive disorder not otherwise specified and is anticipated to be reformulated within the category of depressive disorders, not elsewhere classified with the sub-classification of subthreshold depressive episode with insufficient symptoms in the DSM-5 (APA, 2012). Estimates of the lifetime prevalence of minor depression range from 10 to 24% (Judd et al., 1994; Kessler et al., 1997; Rowe and Rapaport, 2006) and data suggest that minor depression (also referred to as subclinical, subthreshold, or subsyndromal depression; Pincus et al., 1999) results in functional consequences (e.g., work and role impairment) that can reach the same level of severity as MDD (e.g., Howland et al., 2008; Kessler et al., 1997; Lewinsohn et al., 2000; Wagner et al., 2000). Mortality among persons with minor depression is higher than rates in the general population (Carney et al., 2008; Lin et al., 2009). Moreover, adults with dysthymia or minor depression are 2-to-5 times more likely than other adults to develop MDD (Fogel et al., 2006; Horwath et al., 1994; Shankman et al., 2009).

Few studies to date have examined the smoking behavior of adults with dysthymia or minor depression. Current and lifetime dysthymia are associated with higher rates of smoking (Ajdacic-Gross et al., 2009; Lasser et al., 2000; Morris et al., 2006) and current smoking was associated with greater likelihood of minor depression in one study of over 4,000 adults with diabetes (Katon et al., 2004). Lifetime dysthymia has been associated with a lower rate of former smoking in cross-sectional epidemiological data (37% versus 42.5%; Lasser et al., 2000) and pregnant women with current dysthymia and current depressive symptoms exhibit more difficulty quitting smoking (Blalock et al., 2006; Park et al., 2009). Symptoms of depression have been associated with poorer smoking cessation outcomes in some studies (Ziedonis et al, 2008, but see also Kassel et al, 2007; Kinnunen et al, 2006); however, it is not clear if these results generalize to smokers who meet formal diagnostic criteria for minor depression. Clarifying the relationships between dysthymia and minor depression and smoking behavior will help to determine the treatment needs for these smokers.

Women are more likely than men to experience dysthymia (Grant et al., 2004) and minor depression (Kessler et al., 1997) and one study of older adults (>85 years old) in Finland found that minor depression was significantly related to smoking in women but not men (Paivarinta et al., 1999). While a stronger relationship between MDD and smoking has been observed among women (Husky et al., 2008), our research found that the relationship between MDD and changes in smoking over three years did not differ by gender (Weinberger et al., in press). It is not known whether the relationship between changes in smoking behavior and either dysthymia or minor depression differs for adult men and women in the U.S.

The primary aim of this study was to examine the relationship of a diagnosis of current dysthymia, lifetime dysthymia, and minor depression (a single diagnostic category that denoted current and or lifetime prevalence; see Methods) to changes in smoking behavior over a three-year period among a large, nationally representative sample of the adult U.S. population. We hypothesized that: 1) among current smokers, a diagnosis of dysthymia (current and lifetime) and minor depression would be positively associated with continued smoking; and, 2) among former smokers, a diagnosis of dysthymia (current and lifetime) and minor depression would be negatively associated with continued smoking abstinence. Given the absence of research on the relationship between dysthymia and minor depression and smoking behavior, as well as the finding that MDD was not differentially associated with changes in smoking for men and women (Weinberger et al., in press), we did not put forth specific hypotheses regarding gender differences in the relationship between dysthymia and minor depression and changes in smoking.

2. METHODS

2.1. Participants and Procedures

Data for these analyses were taken from two waves of the National Institute on Alcohol Abuse and Alcoholism’s National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; Wave 1, 2001–2002; Wave 2, 2004–2005). During Wave 1, face-to-face personal interviews were conducted with 43,093 non-institutionalized United State civilians in all 50 states and the District of Columbia. Participants were ages 18 and older with an oversampling of African-Americans, Hispanics, and young adults (ages 18–24). Approximately 86% of the eligible Wave 1 sample completed face-to-face Wave 2 interviews (n=34,653). See Grant et al., 2005, 2003b for more details about the NESARC sampling, purpose, and weight procedures.

2.2. Analytic sample

Using similar methods to our prior investigation of MDD and changes in smoking (Weinberger et al., in press), we utilized two, non-overlapping subsamples of the NESARC population: Wave 1 current daily smokers and Wave 1 former daily smokers. Smoking behavior was assessed in Wave 1 and Wave 2 of the NESARC study using the Alcohol Use Disorders and Associated Disabilities Interview Schedule-DSM-IV (AUDADIS-IV; Grant et al., 2001), a structured interview administered by trained lay interviewers which shows good reliability in the assessment of smoking behaviors (ICCs=0.60–0.92; Grant et al., 2003a). Definitions of current and former smoking behavior were consistent with the categories used by the U.S. Department of Health and Human Service’s Centers for Disease Control and Prevention (CDC, 2007) and other NESARC investigations (Dierker and Donny, 2008; Husky et al., 2008).

Wave 1 current daily smokers were defined as individuals who (1) smoked 100 or more cigarettes in their lifetime; (2) smoked cigarettes in the 12 months preceding the Wave 1 assessment; and, (3) currently smoked cigarettes every day. We identified 8,213 individuals who met these criteria. We excluded 1,668 individuals who did not complete the Wave 2 assessment or did not provide valid data for smoking status at Wave 2. The final sample of Wave 1 current daily smokers included 6,545 individuals.

Wave 1 former daily smokers were defined as individuals who (1) smoked 100 or more cigarettes in their lifetime; (2) smoked cigarettes before the 12 months preceding the Wave 1 assessment (but not during those 12 months); and, (3) smoked cigarettes every day in the period when they had last smoked. We identified 6,622 individuals who met these criteria. From this subsample, we excluded 1,194 individuals who did not complete the Wave 2 assessment or did not provide valid data for smoking status at Wave 2. The final sample of Wave 1 former daily smokers included 5,428 individuals.

2.3. Measures

2.3.1. Dependent variables: Changes in Smoking Status

Among Wave 1 current daily smokers, the binary dependent variable of interest was “persistence of smoking” (i.e., continued smoking). Persistence of smoking was defined by whether Wave 1 current daily smokers were still current smokers at Wave 2 (coded as “1”; participants who indicated that they smoked cigarettes in the 12 months preceding the Wave 2 interview; i.e., stable current smokers) or if they had quit smoking at Wave 2 (coded as “0”; participants who had not smoked cigarettes in the 12 months preceding the Wave 2 interview; i.e., quitters).

Among Wave 1 former smokers, the binary dependent variable of interest was “persistence of non-smoking” (i.e., continued smoking abstinence). Persistence of non-smoking was denoted by whether Wave 1 former Smokers remained former smokers at Wave 2 (coded as “1”; participants who indicated that they had not smoked cigarettes in the 12 months preceding the Wave 2 interview; i.e., stable former smokers) or had relapsed to smoking at Wave 2 (coded as “0”; participants who indicated that they smoked cigarettes in the 12 months preceding the Wave 2 interview; i.e., relapsers).

2.3.2. Independent variables

Diagnostic criteria for dysthymia and minor depression were assessed at Wave 1 using the AUDADIS-IV (Grant et al., 2001). Dysthymia was a categorical variable with three mutually-exclusive responses: current (dysthymia was present in the twelve months directly preceding the Wave 1 assessment), lifetime (dysthymia was present prior to the twelve months directly preceding the Wave 1 assessment, but absent during the twelve months directly preceding the Wave 1 assessment), and never (no current or lifetime history of dysthymia).

The authors constructed the binary diagnostic variable for minor depression (ever, never) according to DSM-IV-TR diagnostic criteria (APA, 2002). Participants were classified as having a diagnosis of minor depression if they reported ever having experienced two to four symptoms of depression; one of these symptoms had to be either low mood or a decreased interest in activities. Furthermore, participants with minor depression could not meet criteria for current or lifetime major depression. The nature of these data did not allow for the construction of a variable that differentiated between current and lifetime minor depression.

2.3.3. Covariates

Demographic information was assessed at Wave 1, and included age (18–29, 30–44, 45 and older), race/ethnicity (Non-Hispanic White, Non-Hispanic Black, Non-Hispanic Other, Hispanic), education (Less than High School, High School Graduate, Attended/Completed College), and marital status (Married, Not Married). These categorizations follow the convention of prior work (Grant et al., 2004).

Axis I disorders were assessed using the AUDADIS-IV, which is based on DSM-IV (APA, 1994) diagnostic criteria. The diagnostic variables for all psychiatric disorders were constructed in the same manner; each was a categorical variable with three mutually-exclusive responses: current (disorder was present in the twelve months directly preceding the Wave 1 assessment), lifetime (disorder was present prior to the twelve months directly preceding the Wave 1 assessment, but absent during the twelve months directly preceding the Wave 1 assessment), and never (no current or lifetime history of the disorder). Psychiatric covariates included any manic disorder, anxiety disorder (panic disorder with or without agoraphobia, agoraphobia, social phobia, specific phobia, or generalized anxiety disorder), alcohol abuse/dependence, and drug abuse/dependence. The AUDADIS has demonstrated adequate reliability for assessment of Axis I disorders (κ s=0.40–0.63; Grant et al., 2003a).

2.4. Statistical Analyses

Data were analyzed using SUDAAN (Research Triangle Institute, 2001), a software package that adjusts for characteristics of complex survey sampling designs. NESARC-calculated weights were used to account for nonresponse; attrition; oversampling of African-Americans, Hispanics, and young adults; and to be representative of the U.S. civilian population based on the 2000 decennial census. Statistical significance was determined with the Wald Chi-square test. Statistical tests were two-tailed and differences were considered significant when p<0.05.

PROC CROSSTAB was utilized for descriptive and bivariate analyses. We examined the demographic characteristics of the overall Wave 1 sample. We used PROC CROSSTAB to examine the bivariate association between the independent and dependent variables of interest, overall and according to gender. We presented the unweighted N and weighted prevalence estimates in these analyses.

We then built a series of binary logistic regression models using PROC RLOGIST. These models were constructed separately for Wave 1 current daily smokers and Wave 1 former daily smokers. The dependent variables of interest were persistence of smoking for Wave 1 current daily smokers and persistence of non-smoking for Wave 1 former daily smokers. We ran one set of models for each independent variable (dysthymia, minor depression).

The first model included only the independent variable of interest, generating the main effect of the depressive disorder (either dysthymia or minor depression) as an unadjusted odds ratio (OR) and its associated 95% Confidence Interval (95% CI). The second model examined the gender-specific effect of each depressive disorder, and thus included the main effects of the depressive disorder, gender, and the depressive disorder*gender interaction term. For these analyses, we calculated the unique effects of each depressive disorder among women and among men (gender-specific ORs and their associated 95% CIs), as well as the interaction ORs. The interaction OR is the ratio of the gender-specific effects; in other words, it is effect of the depressive disorder among women divided by the effect of that depressive disorder among men (Interaction OR= ORwomen/ORmen). An interaction was considered to be statistically significant when the 95% CI of the interaction OR did not include 1.0 (the corresponding p-value is less than 0.05). Additional models were analyzed that controlled for other psychiatric disorders (including depressive disorders that were not the independent variable of interest) and substance use disorders. For persistence of smoking, the significant covariates for the analysis for dysthymia were drug abuse/dependence, MDD, and minor depression while the significant covariates for the analysis of minor depression were drug abuse/dependence and MDD. For persistence of non-smoking, the significant covariates for the analysis for dysthymia were drug abuse/dependence and manic disorders while the significant covariates for the analysis of minor depression were alcohol abuse/dependence, drug abuse/dependence, and manic disorders.

3. RESULTS

3.1. Demographics

Overall, approximately half of the sample included in these analyses (n=11,973) was female (46%), 45 years old or older (57.0%), and attended or completed college (48.5%). The majority of the sample reported being married (64.2%) and identified as Caucasian, Non-Hispanic (79.1%). Compared to Wave 1 former daily smokers, Wave 1 current daily smokers were more likely to be female (47.3% versus 43.9%; p<0.01) and less likely to be 45 years or older (40.1% versus 77.5%; p<0.001), Caucasian (76.3% versus 82.6%, p<0.001), married (55.5% versus 74.8%; p<0.001), and to have attended or completed college (43.4% versus 54.8%; p<0.001). Wave 1 current daily smokers reported smoking ~17 cigarettes per day (M=17.3, SEM=0.08) and an average smoking onset of ~16 years of age (M=15.7; SEM=0.03). Wave 1 former Daily Smokers reported a similar age of smoking onset (M=16.2, SEM=0.03) and smoked a pack of cigarettes per day when they were smokers (M=20.3, SEM=0.13).

3.2. Prevalence of dysthymia and minor depression by Gender at Wave 1

The prevalence of current and lifetime dysthymia was approximately two times higher for women than men. Among Wave 1 current daily smokers, the prevalence of current dysthymia and lifetime dysthymia was 4.6% and 5.0% among women, and 2.2% and 3.0% among men, respectively (p<0.0001). Among Wave 1 former daily smokers, the prevalence of current dysthymia and lifetime dysthymia was 2.3% and 4.6% among women, and 1.1% and 1.9% among men, respectively (p<0.0001). The prevalence of minor depression was not associated with gender among Wave 1 current daily smokers (women, 7.8%; men, 7.3%; p=0.54) or Wave 1 former daily smokers (women, 8.3%; men, 7.5%; p=0.42).

3.3. Persistence of smoking (i.e., continued smoking) among Wave 1 current daily smokers

3.3.1. The Main Effects of dysthymia and minor depression on continued smoking (Table 1)

Compared to participants without the respective diagnosis, participants with current dysthymia were 113% (p<0.01) more likely and participants with minor depression were 53% (p<0.05) more likely to continue to smoke at Wave 2. Lifetime dysthymia was not significantly associated with continued smoking (p=0.34).

Table 1
The Relationship of Current Dysthymia, Lifetime Dysthymia, and Minor Depression to Changes in Smoking for Wave 1 Current Daily Smokers.

3.3.2. The Gender-Specific Effects of dysthymia and minor depression on continued smoking (Table 1)

The effect of current dysthymia on continued smoking remained statistically significant among women, but not among men. However, the interaction odds ratios were not statistically significant for either current or lifetime dysthymia, suggesting that gender did not modify the association between dysthymia and continued smoking. The interaction term for minor depression was non-significant, indicating that gender did not modify the association between minor depression and continued smoking.

Analyses that controlled for significant covariates as listed in the Statistical Analysis section resulted in a similar pattern of main- and gender-specific results for continued smoking.

3.4. Persistence of non-smoking (i.e., continued abstinence) among Wave 1 former daily smokers

3.4.1. The Main Effects of dysthymia and minor depression on continued abstinence (Table 2)

Compared to participants with no history of dysthymia, participants with current dysthymia and lifetime dysthymia were 56% (p<0.05) and 63% (p<0.05), respectively, less likely to be stable former smokers at Wave 2. Minor depression was not significantly associated with continued abstinence at Wave 2 (p=0.87).

Table 2
The Relationship of Current Dysthymia, Lifetime Dysthymia, and Minor Depression to Changes in Smoking for Wave 1 Former Daily Smokers.

3.4.2. The Gender-Specific Effects of dysthymia and minor depression on continued abstinence (Table 2)

No gender-specific effects or interaction terms were statistically significant, indicating that gender did not modify the association between dysthymia or minor depression and continued abstinence.

Analyses that controlled for significant covariates as listed in the Statistical Analysis section resulted in a similar pattern of main- and gender-specific results for continued abstinence.

4. DISCUSSION

The current study used longitudinal data from a nationally representative sample of the U.S. adult population to examine changes in smoking over three years in adults with and without dysthymia and minor depression. Diagnoses of current dysthymia and minor depression were associated with greater persistence of smoking (i.e., lower smoking cessation) in daily smokers, and diagnoses of current dysthymia and lifetime dysthymia were associated with less persistence of non-smoking (i.e., greater smoking relapse) in former smokers.

A comparison with the results of our study of MDD (Weinberger et al., in press) suggests that the relationship of current dysthymia to continued smoking was greater in magnitude than the relationship between current MDD and continued smoking (OR=1.38, 95% CT=1.03, 1.85) and the relationship of current dysthymia to continued abstinence was similar to the relationship of current MDD to continued abstinence (OR=0.44; 95% CI=0.26, 0.76). Lifetime dysthymia was not significantly associated with continued smoking, contrary to expectations and the findings for lifetime MDD (OR=1.52, 95% CT=1.15, 2.01). Lifetime dysthymia showed a greater relationship with continued abstinence than lifetime MDD (OR=0.71; 95% CI=0.39, 1.24). A diagnosis of minor depression, using DSM-IV-TR criteria, was significantly related to greater continued smoking consistent with research showing a relationship between symptoms of depression and decreased smoking cessation (Ziedonis et al., 2008). Our research suggests that minor depression exerts a similar impact on continued smoking as MDD (Weinberger et al., in press). While current MDD and current dysthymia were associated with both smoking cessation and smoking relapse, lifetime dysthymia and minor depression were significantly associated with either smoking cessation or relapse but not both. Different factors impact the ability of current smokers to quit and former smokers to avoid relapse (e.g., Zhou et al., 2009) and more research is needed to understand the specific ways that dysthymia and minor depression relate to these two different aspects of smoking behavior.

Compared to men, women reported higher rates of current and lifetime dysthymia, consistent with past research (Grant et al., 2004; Kessler et al., 1997), and similar rates of minor depression. Women appear to have more trouble quitting smoking than men (Perkins, 2001; Perkins and Scott, 2008; Wetter et al., 1999) and depression has been suggested to play a role in this difficulty (Perkins, 2001; Reynoso et al., 2004). However, the relationship of dysthymia and minor depression to changes in smoking did not differ by gender, similar to the findings for MDD (Weinberger et al., in press) and a meta-analysis of smoking cessation treatment outcomes (e.g., Hitsman et al., 2003). Interestingly, gender differences in the relationship of depression to smoking cessation have been found for certain pharmacological agents (e.g., Covey et al., 1999; Glassman et al., 1993; Hall et al., 1998) suggesting that gender differences exist at the level of specific treatments. Smoking treatment studies rarely examine outcomes by gender (Dickerson et al., 2009; Piper et al., 2001) and it is critical that research continue working to identify variables that can be used to help women quit smoking.

The majority of research on depression and smoking cessation treatment has focused on MDD (Gierisch et al., 2012; Ziedonis et al., 2008) and the few studies of dysthymia and minor depression have examined specific samples (e.g., pregnant smokers, smokers with cardiovascular disease; Blalock et al., 2006; Trockel et al., 2008). It is not yet understood how smokers with dysthymia and minor depression respond to specific treatments. Smokers with depression report greater tobacco withdrawal (Breslau et al., 1992; Weinberger et al., 2010), cue reactivity (Pomerleau et al., 2005; Weinberger et al., 2012), and smoking reward (Spring et al., 2003). Further, neurobiological findings related to the common pathways of nicotine and depression through the nicotinic acetylcholine receptor system also suggest that smokers with depression would experience greater cravings to smoke when attempting to quit (Benowitz, 2008; Mineur et al., 2010; Picciotto et al., 2002). Additional research is needed to understand how these variables can be incorporated into cessation efforts for smokers with depressive disorders. Clinically, smokers with current dysthymia and minor depression may benefit from smoking cessation interventions that target these variables including pharmacological and behavioral treatments that target cravings. Smokers with current and past dysthymia may also need longer monitoring after smoking cessation to catch and intervene early in relapse situations.

Several limitations of the current study must be noted. The sample included noninstitutionalized adults who were at least 18 years old and living in the U.S. Further, the majority of the sample identified as Caucasian. Additional research would be needed to determine whether these results generalize to other groups of smokers. While the NESARC study collected information about smoking status at Wave 1 and Wave 2, the dataset is limited with regard to information about the number and length of quit attempts and the methods of smoking cessation treatment utilized by participants between waves. It would be useful for future research to examine these variables, as well as how the course and severity of dysthymia and minor depression impacts smoking cessation and relapse. Another limitation is the determination of smoking abstinence by self-report alone. Smokers may underreport their tobacco use (Gorber et al., 2009) and biochemical measures should be used to verify smoking status when possible (Benowitz et al., 2002). Finally, dysthymia and depression symptoms are associated with higher rates of nicotine dependence (Grant et al., 2004; Hu et al., 2006; see also Dierker and Donny, 2008) and nicotine dependence was found to relate to the relationship of smoking and anxiety and mood diagnoses in data from Wave 1 of the NESARC (Grover et al., 2012). Further, nicotine dependence is associated with increased smoking persistence (Breslau et al., 2001) and difficulty abstaining from or quitting smoking (Pomerleau et al., 2005; Sienkiewicz-Jarosz et al., 2009). While the low rates of dysthymia and minor depression did not allow us to examine the role of nicotine dependence in the relationship of non-MDD depressive disorders and smoking, it would be important for future studies with larger samples of adults with these disorders (e.g., clinical samples) to examine this important question.

Our findings suggest that current dysthymia and minor depression are associated with a decreased likelihood of quitting smoking, and current and lifetime dysthymia are associated with a greater likelihood of smoking relapse. Further, the relationship of dysthymia and minor depression to changes in smoking appears to be at least equal to the impact of MDD on smoking. The smoking behavior of adults with dysthymia and minor depression has been an understudied area of research. Additional research on smokers with depressive disorders other than MDD is needed to understand how to best provide appropriate levels of care in assisting these smokers to quit smoking and remain abstinent.

Acknowledgments

Role of Funding Source

Funding for this study was provided by the National Institutes of Health grants R03-DA027052 (to AHW), K12-DA000167 (to AHW), and RL1-DA024857 (to SAM); NIMH training grant: 5-T32-MH014235-37 (to CEP); Women’s Health Research at Yale; the Yale Cancer Center; and the State of Connecticut, Department of Mental Health and Addiction Services. The NIH, NIMH, Women’s Health Research at Yale, the Yale Cancer Center, and the State of Connecticut, Department of Mental Health and Addiction Services had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

Footnotes

Contributors

Dr. Weinberger helped to design the study, managed the literature searches and summaries of previous work, and wrote the first draft of the manuscript. Drs. Pilver and Desai undertook the statistical analyses. Drs. McKee and Mazure helped to design the study and provided feedback on drafts of the paper. All authors contributed to and approved the final manuscript.

Conflict of Interest

Drs. Weinberger, Pilver, Desai, Mazure, and McKee have no conflicts of interest to report.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

References

  • Ajdacic-Gross V, Landolt K, Angst J, Gamma A, Merikangas KR, Gutzwiller F, Rossler W. Adult versus adolescent onset of smoking: how are mood disorders and other risk factors involved? Addiction. 2009;104:1411–1419. [PMC free article] [PubMed]
  • APA. Diagnostic and Statistical Manual of Mental Disorders. 4. American Psychiatric Association; Washington DC: 1994. (DSM-IV)
  • APA. Diagnostic and Statistical Manual of Mental Disorders. 4. American Psychiatric Association; Washington, DC: 2002. text revision (DSM-IV-TR)
  • APA. D 07 Depressive Disorder Not Elsewhere Classified. [Accessed on May 13, 2012];2012 Retrived from http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=47.
  • Benowitz NL. Neurobiology of nicotine addiction: implications for smoking cessation treatment. Am J Med. 2008;121:S3–S10. [PubMed]
  • Benowitz NL, Jacob P, III, Ahijevich K, Jarvis MJ, Hall S, LeHouzec J, Lichenstein E, Henningfield J, Tsoh J, Hurt RD, Velicer W. Biochemical verification of tobacco use and cessation. Report from the SRNT Subcommittee on Biochemical Verification. Nicotine Tob Res. 2002;4:149–159. [PubMed]
  • Blalock JA, Robinson JD, Wetter DW, Cinciripini PM. Relationship of DSM-IV-based depressive disorders to smoking cessation and smoking reduction in pregnant smokers. Am J Addict. 2006;15:268–277. [PubMed]
  • Breslau N, Johnson EO, Hiripi E, Kessler R. Nicotine dependence in the United States: prevalence, trends and smoking persistence. Arch Gen Psychiatry. 2001;58:810–816. [PubMed]
  • Breslau N, Kilbey MM, Andreski P. Nicotine withdrawal symptoms and psychiatric disorders: findings from an epidemiologic study of young adults. Am J Psychiatry. 1992;149:464–469. [PubMed]
  • Carney RM, Freedland KE, Steinmeyer B, Blumenthal JA, Berkman LF, Watkins LL, Czajkowski SM, Burg MM, Jaffe AS. Depression and five year survival following acute myocardial infarction: a prospective study. J Affect Disord. 2008;109:133–138. [PMC free article] [PubMed]
  • CDC. Cigarette smoking among adults - United States, 2006. MMWR. 2007;56:1157–1161. [PubMed]
  • Covey LS, Glassman AH, Stetner F. Naltrexone effects on short-term and long-term smoking cessation. J Addict Dis. 1999;18:31–40. [PubMed]
  • Dickerson DL, Leeman RF, Mazure CM, O’Malley SS. The inclusion of women and minorities in smoking cessation clinical trials: a systematic review. Am J Addict. 2009;18:21–28. [PMC free article] [PubMed]
  • Dierker L, Donny E. The role of psychiatric disorders in the relationship between cigarette smoking and DSM-IV nicotine dependence among young adults. Nicotine Tob Res. 2008;10:439–446. [PMC free article] [PubMed]
  • Fogel J, Easton WW, Ford DE. Minor depression as a predictor of the first onset of major depressive disorder over a 15-year follow-up. Acta Psychiatr Scand. 2006;113:36–43. [PubMed]
  • Gierisch JM, Bastian LA, Calhoun PS, McDuffiee JR, Williams JW., Jr Smoking cessation interventions for patients with depression: a systematic review and meta-analysis. J Gen Intern Med. 2012;27:351–360. [PMC free article] [PubMed]
  • Glassman AH, Covey LS, Dalack GW, Stetner F, Rivelli SK, Fleiss J, Cooper TB. Smoking cessation, clonidine, and vulnerability to nicotine among dependent smokers. Clin Pharmacol Ther. 1993;54:670–679. [PubMed]
  • Gorber SC, Schofield-Hurwitz S, Hardt J, Levasseur G, Tremblay M. The accuracy of self-reported smoking: a systematic review of the relationship between self-reported and cotinine-assessed smoking status. Nicotine Tob Res. 2009;11:12–24. [PubMed]
  • Grant BF, Dawson DA, Hasin DS. The Alcohol Use Disorders and Associated Disabilities Interview Schedule-Version for DSM-IV (AUDADIS-IV) National Institute on Alcohol Abuse and Alcoholism; Bethesda, MD: 2001.
  • Grant BF, Dawson DA, Stinson FS, Chou PS, Kay W, Pickering R. The Alcohol Use Disorder and Associated Disabilities Schedule (AUDADIS): reliability of alcohol consumption, tobacco use, family history of depression, and psychiatric diagnostic modules in a general population. Drug Alcohol Depend. 2003a;71:7–16. [PubMed]
  • Grant BF, Hasin DS, Chou P, Stinson FS, Dawson DA. Nicotine dependence and psychiatric disorders in the United States. Arch Gen Psychiatry. 2004;61:1107–1115. [PubMed]
  • Grant BF, Kaplan KD. Source and Accuracy Statement: The Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) National Institute on Alcohol Abuse and Alcoholism; Rockville, MD: 2005.
  • Grant BF, Moore TC, Shepard J, Kaplan K. Source and Accuracy Statement for Wave 1 of the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) National Institute on Alcohol Abuse and Alcoholism; Bethesda, MD: 2003b.
  • Grover KW, Goodwin RD, Zvolensky MJ. Does current versus former smoking play a role in the relationship between anxiety and mood disorders and nicotine dependence? Addict Behav. 2012;37:682–685. [PubMed]
  • Hall SM, Reus VI, Munoz RF, Sees KL, Humfleet G, Hartz DT, Frederick S, Triffleman E. Nortriptyline and cognitive-behavioral therapy in the treatment of cigarette smoking. Arch Gen Psychiatry. 1998;55:683–690. [PubMed]
  • Hitsman B, Borrelli B, McChargue DE, Spring B, Niaura R. History of depression and smoking cessation outcome: a meta-analysis. J Consult Clin Psychol. 2003;71:657–663. [PubMed]
  • Horwath E, Johnson J, Klerman GL, Weissman MM. What are the public health implications of subclinical depressive symptoms? Psychiatr Q. 1994;65:323–337. [PubMed]
  • Howland RH, Schettler PJ, Rapaport MH, Mischoulon D, Schneider T, Fasiczka A, Delrahiem K, Maddux R, Lightfood M, Nierenberg AA. Clinical features and functioning of patients with minor depression. Psychother Psychosom. 2008;77:384–389. [PubMed]
  • Hu MC, Davies M, Kandel DB. Epidemiology and correlates of daily smoking and nicotine dependence among young adults in the United States. Am J Public Health. 2006;96:299–308. [PubMed]
  • Husky MM, Mazure CM, Paliwal P, McKee SA. Gender differences in the comorbidity of smoking behavior and major depression. Drug Alcohol Depend. 2008;93:176–179. [PMC free article] [PubMed]
  • Judd LL, Rapaport MH, Paulus MP, Brown JL. Subsyndromal symptomatic depression: a new mood disorder? J Clin Psychiatry. 1994;55:18–28. [PubMed]
  • Kassel JD, Yates M, Brown RA. Baseline reaction time predicts 12-month smoking cessation outcome in formerly depressed smokers. Psychol Addict Behav. 2007;21:415–419. [PubMed]
  • Katon W, von Korff M, Ciechanowski P, Russo J, Lin E, Simon G, Ludman E, Walker E, Bush T, Young B. Behavioral and clinical factors associated with depression among individuals with diabetes. Diabetes Care. 2004;27:914–920. [PubMed]
  • Keller MB. Dysthymia in clinical practice: course, outcome and impact on the community. Acta Psychiatr Scand Suppl. 1994;383:24–34. [PubMed]
  • Kessler RC, Zhao S, Blazer DG, Swartz M. Prevalence, correlates, and course of minor depression and major depression in the National Comorbidity Survey. J Affect Disord. 1997;45:19–30. [PubMed]
  • Kinnunen T, Haukkala A, Korhonen T, Quiles ZN, Spiro A, 3rd, Garvey AJ. Depression and smoking across 25 years of the Normative Aging Study. Int J Psychiatry Med. 2006;36:413–426. [PubMed]
  • Klein DN, Santiago NJ. Dysthymia and chronic depression: introduction, classification, risk factors, and course. J Clin Psychol. 2003;59:807–816. [PubMed]
  • Lasser K, Boyd JW, Woolhander S, Himmelstein DU, McCormick D, Bor DH. Smoking and mental illness: a population-based prevalence study. JAMA. 2000;284:2606–2610. [PubMed]
  • Lewinsohn PM, Solomon A, Seeley JR, Zeiss A. Clinical implications of “subthreshold” depressive symptoms. J Abnorm Psychol. 2000;109:345–351. [PubMed]
  • Lin EH, Heckbert SR, Rutter CM, Katon WJ, Ciechanowski P, Ludman EJ, Oliver M, Young BA, McCulloch DK, Von Korff M. Depression and increased mortality in diabetes: unexpected causes of death. Ann Fam Med. 2009;7:414–421. [PubMed]
  • Mineur YS, Picciotto MR. Nicotine receptors and depression: revisiting and revising the cholinergic hypothesis of depression. Trends Pharmacol Sci. 2010;31:580–586. [PMC free article] [PubMed]
  • Morris CD, Giese AA, Turnbull JJ, Dickinson M, Johnson-Nagel N. Predictors of tobacco use among persons with mental illnesses in a statewide population. Psychiatr Serv. 2006;57:1035–1038. [PubMed]
  • Paivarinta A, Verkkoniemi A, Niinisto L, Kivela SL, Sulkava R. The prevalence and associates of depressive disorders in the oldest-old Finns. Soc Psychiatry Psychiatr Epidemiol. 1999;34:352–359. [PubMed]
  • Park ER, Chang Y, Quinn V, Regan S, Cohen L, Viguera A, Psaros C, Ross K, Rigotti N. The association of depressive, anxiety, and stress symptoms and postpartum relapse to smoking: a longitudinal study. Nicotine Tob Res. 2009;11:707–714. [PMC free article] [PubMed]
  • Perkins KA. Smoking cessation in women: special considerations. CNS Drugs. 2001;15:391–411. [PubMed]
  • Perkins KA, Scott J. Sex differences in long-term smoking cessation rates due to nicotine patch. Nicotine Tob Res. 2008;10:1245–1251. [PubMed]
  • Picciotto MR, Brunzell DH, Caldarone BJ. Effect of nicotine and nicotinic receptors on anxiety and depression. NeuroReport. 2002;13:1097–1106. [PubMed]
  • Pincus HA, Davis WW, McQueen LE. ‘Subthreshold’ mental disorders. A review and synthesis of studies on minor depression and other ‘brand names’ Br J Psychiatry. 1999;174:288–296. [PubMed]
  • Piper ME, Fox BJ, Welsch SK, Fiore MC, Baker TB. Gender and racial/ethnic differences in tobacco-dependence treatment: a commentary and research recommendations. Nicotine Tob Res. 2001;3:291–297. [PubMed]
  • Pomerleau OF, Pomerleau CS, Mehringer AM, Snedecor SM, Ninowski R, Sen A. Nicotine dependence, depression, and gender: characterizing phenotypes based on withdrawal discomfort, response to smoking, and ability to abstain. Nicotine Tob Res. 2005;7:91–102. [PubMed]
  • Reynoso J, Susabda A, Cepeda-Benito A. Gender differences in smoking cessation. J Psychopathol Behav Assess. 2004;27:227–234.
  • Rowe SK, Rapaport MH. Classification and treatment of sub-threshold depression. Curr Opin Psychiatry. 2006;19:9–13. [PubMed]
  • Shankman SA, Lewinsohn PM, Klein DN, Small JW, Seeley JR, Altman SE. Subthreshold conditions as precursors for full syndrome disorders: a 15-year longitudinal study of multiple diagnostic classes. J Child Psychol Psychiatry. 2009;50:1485–1494. [PMC free article] [PubMed]
  • Sienkiewicz-Jarosz H, Zatorski P, Baranowska A, Ryglewicz D, Bienkowski P. Predictors of smoking abstinence after first-ever ischemic stroke: a 3-month follow-up. Stroke. 2009;40:2592–2593. [PubMed]
  • Spring B, Pingitore R, McChargue DE. Reward value of cigarette smoking for comparably heavy smoking schizophrenic, depressed, and nonpatient smokers. Am J Psychiatry. 2003;160:316–322. [PubMed]
  • Trockel M, Burg M, Jaffe A, Barbour K, Taylor CB. Smoking behavior postmyocardial infarction among ENRICHD trial participants: cognitive behavior therapy intervention for depression and low perceived social support compared with care as usual. Psychosom Med. 2008;70:875–882. [PubMed]
  • Wagner HR, Burns BJ, Broadhead WE, Yarnall KSH, Sigmon A, Gaynes BN. Minor depression in family practice: functional morbidity, co-morbidity, service utilization and outcomes. Psychol Med. 2000;30:1377–1390. [PubMed]
  • Weinberger AH, Desai R, McKee SA. Nicotine withdrawal in U.S. smokers with current mood, anxiety, alcohol, and substance use disorders. Drug Alcohol Depend. 2010;108:7–12. [PMC free article] [PubMed]
  • Weinberger AH, McKee SA, George TP. Smoking cue reactivity in adult smokers with and without depression: a pilot study. Am J Addiction. 2012;21:136–144. [PMC free article] [PubMed]
  • Weinberger AH, Pilver CE, Desai R, Mazure CM, McKee SA. The relationship of major depressive disorder and gender to changes in smoking for current and former smokers: longitudinal evaluation of the U.S. population. Addiction in press. [PMC free article] [PubMed]
  • Wetter DW, Kenford SL, Smith SS, Fiore MC, Jorenby DE, Baker TB. Gender differences in smoking cessation. J Consult Clin Psychol. 1999;67:555–562. [PubMed]
  • Zhou X, Nonnemaker J, Sherrill B, Gilsenan AW, Coste F, West R. Attempts to quit smoking and relapse: factors associated with success or failure from the ATTEMPT cohort study. Addict Behav. 2009;34:365–373. [PubMed]
  • Ziedonis D, Hitsman B, Beckham JC, Zvolensky M, Adler LE, Audrain-McGovern J, Breslau N, Brown RA, George TP, Williams J, Calhoun PS, Riley WT. Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report. Nicotine Tob Res. 2008;10:1691–1715. [PubMed]