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Intervenciones de abandono del hábito de fumar para los fumadores con depresión actual o anterior

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Resumen

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Antecedentes

Los individuos con depresión actual o anterior suelen ser fumadores que presentan más dependencia de nicotina, más probabilidades de sufrir cambios negativos en el estado de ánimo después del síndrome de abstinencia nicotínica, y más probabilidades de recaer en el hábito de fumar después del abandono que la población en general, lo cual contribuye a un aumento de la morbilidad y la mortalidad por enfermedades relacionadas con el hábito de fumar. Aún no se conoce qué intervenciones pueden ayudarlos a abandonar el hábito de fumar.

Objetivos

Evaluar la efectividad de las intervenciones de abandono del hábito de fumar, con y sin componentes específicos de manejo del estado de ánimo, en fumadores con depresión actual o anterior.

Métodos de búsqueda

En abril de 2013, se realizaron búsquedas en el Registro Cochrane Central de Ensayos Controlados (CENTRAL), MEDLINE, EMBASE, PsycINFO, otras revisiones y se solicitó información sobre ensayos a expertos.

Criterios de selección

Los criterios para la inclusión de estudios en esta revisión fueron que debían ser ensayos controlados aleatorios (ECA) que compararan intervenciones de abandono del hábito de fumar en fumadores adultos con depresión actual o anterior. La depresión se definió como depresión o síntomas depresivos graves. Se incluyeron estudios en los que se identificaron subgrupos de participantes con depresión, ya sea declarada de forma previa o post hoc. El resultado fue la abstinencia del hábito de fumar después de un seguimiento de seis meses o mayor. Se prefirió la abstinencia prolongada o continua y la abstinencia validada bioquímicamente cuando estaban disponibles.

Obtención y análisis de los datos

De ser posible, se calcularon los cocientes de riesgos (CR) agrupados con el método de Mantel‐Haenszel (modelo de efectos fijos). También se realizaron análisis de subgrupos por duración del seguimiento, medición de la depresión, grupo de depresión en estudio, uso de antidepresivos, datos publicados o no publicados, formato de la intervención, nivel del apoyo conductual, tratamiento farmacológico adicional, tipo de medicación antidepresiva y tratamiento de reemplazo de nicotina (TRN) adicional.

Resultados principales

Se incluyeron cuarenta y nueve ECA de los cuales 33 ensayos investigaron intervenciones de abandono del hábito de fumar con componentes específicos de manejo del estado de ánimo para la depresión. En los fumadores con depresión actual, el metanálisis mostró un efecto positivo significativo del agregado del manejo psicosocial del estado de ánimo a una intervención estándar de abandono del hábito de fumar en comparación con la intervención estándar de abandono del hábito de fumar sola (11 ensayos, N = 1844; CR 1,47; IC del 95%: 1,13 a 1,92). En los fumadores con depresión anterior se encontró un efecto similar (13 ensayos, N = 1496; CR 1,41; IC del 95%: 1,13 a 1,77). El metanálisis resultó en un efecto positivo, aunque no significativo, para el agregado de bupropión en comparación con placebo en los fumadores con depresión actual (5 ensayos, N = 410; CR 1,37; IC del 95%: 0,83 a 2,27). No hubo datos suficientes en los ensayos para evaluar la efectividad de la fluoxetina y la paroxetina para los fumadores con depresión actual. El bupropión (4 ensayos, N = 404; CR 2,04; IC del 95%: 1,31 a 3,18) podría aumentar de forma significativa el abandono a largo plazo entre los fumadores con depresión anterior comparado con placebo, aunque las pruebas sobre el bupropión son relativamente débiles debido al número pequeño de estudios y a los subgrupos post hoc para todos los estudios. No hubo datos suficientes en los ensayos para evaluar la efectividad de la fluoxetina, la nortriptilina, la paroxetina, la selegilina y la sertralina en los fumadores con depresión anterior.

Veintitrés de los 49 ensayos investigaron intervenciones de abandono del hábito de fumar sin componentes específicos para la depresión. Hubo heterogeneidad entre los ensayos que compararon intervenciones psicosociales con asesoramiento estándar sobre el abandono del hábito de fumar para los fumadores con depresión tanto actual como anterior. Por tanto, no se estimó un efecto agrupado. Un ensayo comparó el tratamiento de reemplazo de nicotina (TRN) versus placebo en fumadores con depresión actual y encontró un efecto positivo, aunque no significativo (N = 196; CR 2,64; IC del 95%: 0,93 a 7,45). El metanálisis también encontró un efecto positivo, aunque no significativo, para el TRN versus placebo en los fumadores con depresión anterior (3 ensayos, N = 432; CR 1,17; IC del 95%: 0,85 a 1,60). Tres ensayos compararon otros tratamientos farmacológicos versus placebo y seis ensayos compararon otras intervenciones en fumadores con depresión actual o anterior. Debido a la heterogeneidad entre las intervenciones de los ensayos incluidos no se calcularon los efectos agrupados.

Conclusiones de los autores

Las pruebas indican que el agregado de un componente psicosocial de manejo del estado de ánimo a una intervención estándar de abandono del hábito de fumar aumenta las tasas de abandono a largo plazo en los fumadores con depresión tanto actual como anterior en comparación con la intervención estándar sola. Los resultados agrupados de cuatro ensayos indican que la administración de bupropión puede aumentar el abandono a largo plazo en los fumadores con depresión anterior. No se encontraron pruebas sobre la administración de bupropión en fumadores con depresión actual. No hubo pruebas suficientes para evaluar la efectividad de los otros antidepresivos en fumadores con depresión actual o anterior. Tampoco hubo pruebas suficientes para evaluar el grupo de ensayos que investigaron intervenciones sin componentes específicos de manejo del estado de ánimo para la depresión, incluido el TRN y las intervenciones psicosociales.

Resumen en términos sencillos

¿Existen intervenciones efectivas para ayudar a los individuos con depresión a abandonar el hábito de fumar?

Los pacientes con depresión muy a menudo son grandes fumadores. Se deseaba saber si los tratamientos para ayudar a los pacientes a abandonar el hábito de fumar son efectivos para los pacientes con depresión actual o con antecedentes de depresión. En esta revisión, los tratamientos se dividieron en los que incluyen atención específica para el manejo de la depresión y los que no. Se encontró que los tratamientos para abandonar el hábito de fumar con atención específica en el manejo de la depresión ayudaron a los fumadores que sufrían de depresión a abandonar el hábito de fumar. Las intervenciones psicosociales para el “manejo del estado de ánimo”, en las que los participantes aprenden cómo manejar los síntomas depresivos con técnicas psicológicas, fueron efectivas en los pacientes con depresión actual y con antecedentes de depresión. Se ha demostrado que el bupropión, una medicación antidepresiva para ayudar a dejar de fumar, es efectivo para el abandono del hábito de fumar en los fumadores sanos. Los hallazgos indican que el bupropión también puede beneficiar a los fumadores con antecedentes de depresión. Sin embargo, no se hallaron los mismos datos para los pacientes con depresión actual. Hubo una falta de pruebas sobre la efectividad de otros antidepresivos para ayudar a los fumadores con antecedentes de depresión a dejar de fumar. Tampoco hubo pruebas suficientes sobre la administración de antidepresivos en los fumadores con depresión actual. Aunque se ha demostrado que los tratamientos sin atención específica en el manejo de la depresión, como el tratamiento de reemplazo de nicotina y las intervenciones psicosociales estándar de abandono del hábito de fumar, ayudan a otros grupos de personas a dejar de fumar, no hubo pruebas suficientes para indicar que fueron útiles en los pacientes con antecedentes de depresión o depresión actual.

Authors' conclusions

Implications for practice

Based on the best currently available evidence, our results support the effectiveness of adding a psychosocial mood management component to a smoking cessation intervention for smokers with current and past depression. Health professionals should consider encouraging their smoking patients with depression to use a smoking cessation intervention that includes a psychosocial mood management component. The results also seem to support the effectiveness of using bupropion for smokers with past depression, although the evidence for bupropion is relatively weak due to the small number of studies that used post hoc subgroups. For interventions without specific mood management components for depression, including NRT and psychosocial interventions, we did not find sufficient convincing evidence to support their use in clinical practice for smokers with depression.

Implications for research

Evidence for the effectiveness of interventions for smoking cessation in depression is restricted to a limited number of mostly small studies without adequate power to detect reasonable treatment effects. Further trials with an inclusion criterion of smokers with past depression, or especially current depression, would be informative.

In addition, the following areas should be considered for future research for smokers with current or past depression:

1. the effectiveness of antidepressants for smoking cessation;

2. the effectiveness of a combination of a psychosocial mood management and an antidepressant for smoking cessation;

3. the effectiveness of interventions without specific components for depression, including NRT, varenicline, psychosocial interventions, and the essential component(s) for the effectiveness of the intervention.

Summary of findings

Open in table viewer
Summary of findings for the main comparison. Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or longer follow‐up

Psychosocial mood management versus control for smokers with current depression. Abstinence at 6 m or longer follow‐up

Patient or population: smokers with current depression1
Intervention: Psychosocial mood management

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Psychosocial mood management

Smoking cessation
Biochemical validation (minority) and self report
Follow‐up: 6 ‐ 12 months

88 per 10002

130 per 1000
(100 to 170)

RR 1.47
(1.13 to 1.92)

1844
(11 studies)

⊕⊕⊝⊝
low3,4

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Smokers with past depression evaluated separately see Summary of findings table 3; Summary of findings table 4.
2 Baseline control risk calculated as average across included studies.
3 The Risk of Bias has been downgraded as most of the studies included under this outcome contained unclear or high risks, especially where blinding or incomplete outcome data were concerned.
4 Total number of events fewer than 300.

Open in table viewer
Summary of findings 2. Bupropion versus control for smokers with current depression. Abstinence at six months or longer follow‐up

Bupropion vs control for smokers with current depression. Abstinence at 6 m or longer follow‐up

Patient or population: smokers with current depression
Intervention: Bupropion

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Bupropion

Bupropion versus placebo
All biochemically validated
Follow‐up: 6 ‐ 12 months

112 per 10001

153 per 1000
(93 to 253)

RR 1.37
(0.83 to 2.27)

410
(5 studies)

⊕⊕⊝⊝
low2,3,4

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Baseline risk calculated as average across all control groups.
2 The Risk of Bias has been downgraded as all of the studies included under this outcome contained some unclear risks.
3 There were no differences across two subgroups for Bupropion use (1) without additional NRT; 2) with NRT across both control and intervention). Taking NRT did not change the overall effect.
4 Number of events is fewer than 300, and the confidence intervals encompass both negative and positive outcomes.

Open in table viewer
Summary of findings 3. Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or longer follow‐up

Psychosocial mood management versus control for smokers with past depression. Abstinence at 6 months or longer follow‐up.

Patient or population: patients with smokers with past depression
Intervention: Psychosocial mood management

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Psychosocial mood management

Smoking cessation
Biochemical validation (majority) and self report
Follow‐up: 6‐12 months

142 per 10001

201 per 1000
(161 to 252)

RR 1.41
(1.13 to 1.77)

1496
(13 studies1)

⊕⊕⊝⊝
low2,3

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Baseline control risk calculated as average across included studies.
2 The Risk of Bias has been downgraded as most of the studies included under this outcome contained unclear or high risks, especially where allocation concealment, blinding or incomplete data were concerned.
3 Total number of events fewer than 300.

Open in table viewer
Summary of findings 4. Bupropion versus control for smokers with past depression. Abstinence at six months or longer follow‐up

Bupropion for smokers with past depression

Patient or population: patients with smokers with past depression
Intervention: Bupropion

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Bupropion

Bupropion versus placebo
Biochemical validation (majority) and self report
Follow‐up: 6‐12 months

123 per 10001

251 per 1000
(161 to 391)

RR 2.04
(1.31 to 3.18)2

404
(4 studies)

⊕⊕⊝⊝
low3,4

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Baseline control risk calculated as average across included studies.
2 There were no differences across two subgroups for Bupropion use (1) without additional NRT; 2) with NRT across both control and intervention). Taking NRT did not change the overall effect.
3 The risk of bias has been downgraded as all the studies included under this outcome contained unclear or high risks, mainly where blinding or incomplete outcome data were concerned.
4 Total number of events fewer than 300.

Background

As smokers are not an homogeneous group, it may be important to develop tailored smoking cessation interventions for specific groups such as those with depression (Borrelli 2010; Ranney 2006). Subsequently, smokers with depression need standard smoking cessation treatment strategies that are supported by evidence of effectiveness in their population (Evins 2012; Hall 2007; Hitsman 2009).

Smoking and depression are strongly associated. People with depression are about twice as likely to be smokers than individuals who are not depressed (Hall 2009; Kalman 2005; Lasser 2000; Ziedonis 2008). This relationship between depression and smoking usually starts in adolescence (Brown 1996). The literature describes a number of possible mechanisms for the association between smoking and depression (Mendelsohn 2012), shared genetic factors (Kendler 1993), shared environmental influences (Kendler 1993), bidirectional causality (Breslau 1998; Markou 2002), and self‐medication (Fergusson 2003).

Several studies have shown that attempts to quit smoking are more likely to fail in smokers with depression than in those without (Covey 1999; Glassman 1993; Hitsman 2012; Weinberger 2012). Some evidence suggests that people with current depression are less likely to successfully quit smoking when compared to those with past depression (Weinberger 2012).

Furthermore, compared to people in the general population who smoke, those with depression are more nicotine dependent, more likely to suffer from negative mood changes after nicotine withdrawal, more likely to relapse to smoking after quitting, and have a greater risk for smoking‐related morbidity and mortality (Bolam 2011; Gierisch 2011; Torres 2010; Weinberger 2013). Hence for people with depression standard smoking cessation interventions may be less effective than shown in the general population.

It is often thought that smokers with depression do not want to quit smoking but several studies show the contrary (Hall 2007; Haukkala 2000; Siru 2009). However, they are not often encouraged by health professionals to quit smoking because many of the latter believe that quitting may exacerbate depressive symptoms (Hall 2009; Hitsman 2009; Prochaska 2010), although evidence suggests that quitting smoking may improve rather than exacerbate depressive symptoms in those who are able to remain abstinent (Blalock 2008; Kahler 2002; Prochaska 2008; Thorsteinsson 2001; Tsoh 2000).

Smoking cessation interventions for smokers with depression can be divided into interventions with and without specific components for handling depression. The assumption that smoking and smoking cessation relapse are linked to a high incidence of current and past depression has resulted in several studies examining smoking cessation interventions that include an antidepressant for smoking cessation, or a psychosocial mood management component for managing depressive symptoms above and beyond standard smoking cessation counselling (Brown 2001; Hall 1994; Hall 1996; Patten 1998; Van der Meer 2010). Among the psychosocial mood management interventions, cognitive behavioural therapy (CBT) in particular, has been examined. There are also many smoking cessation interventions without specific components for handling depression. The effectiveness of these interventions is mostly studied in the general group of smokers. Smokers with past depression, and in particular smokers with current depression, have often been excluded from these trials.

Objectives

To evaluate the effectiveness of smoking cessation interventions, with and without specific mood management components, in smokers with current or past depression.

Methods

Criteria for considering studies for this review

Types of studies

We examined randomised controlled trials (RCTs).

Types of participants

We included adult smokers with current or past depression. Current depression was defined as current major depression (according to the DSM‐IV criteria) or depressive symptoms (use of multi‐item scales as measures of depression, for example Beck Depression Inventory or Center for Epidemiologic Studies Depression Scale, or use of a single item question as a measure of depression). Past depression was defined as past major depression (according to the DSM‐IV criteria) or depressive symptoms (use of multi‐item scales as measures of depression or use of a single item question as a measure of depression).

Studies with subgroups (pre‐stated stratification or post hoc) of participants with current or past depression were also included when separate data were available. By 'pre‐stated', we mean that researchers explicitly state, a priori, that they want to analyse the effectiveness of the smoking cessation intervention for the depression subgroup. By 'post hoc', we mean that the researchers did not explicitly state this analysis a priori.

Types of interventions

RCTs were included when the effectiveness of any pharmacological or psychosocial intervention, or a combination of both types, was assessed as an aid to smoking cessation in smokers with current or past depression.

Comparisons investigated (separately for smokers with past or current depression) the following.

Interventions with specific mood management components for depression

  • Psychosocial mood management versus control

  • Antidepressants for smoking cessation versus placebo

Psychosocial mood management was defined as: group or individual counselling, self help or exercise, or hypnosis intended to influence negative mood and improve depression symptoms above and beyond standard smoking cessation counselling.

Interventions without specific mood management components for depression

  • Psychosocial interventions versus standard smoking cessation counselling

  • Nicotine replacement therapy (NRT) versus placebo

  • Other pharmacotherapy (no antidepressants or NRT) versus placebo

  • Other interventions (smoking cessation interventions that did not fit within one of the other comparisons)

Types of outcome measures

The primary outcome was smoking status at a minimum of six months from the quit day. We used sustained cessation rates in preference to point prevalence, where available. By sustained cessation we meant either continuous abstinence from quit date or prolonged abstinence (continuous abstinence following a short period of grace in which lapses are not regarded as treatment failure) (Hughes 2003). We used biochemically validated cessation in preference to self‐reported quitting. The strictest definition of smoking cessation reported was used in the meta‐analysis. We examined types of abstinence (continuous, prolonged, point prevalence) and levels of verification (biochemical, self report) as potential modifiers of outcome. Participants lost to follow‐up were assumed to be continuing smoking.

Search methods for identification of studies

Electronic searches

We identified studies from the Tobacco Addiction Group Specialised Register using the search terms 'depression or depressive or antidepress* or mood or affective or dysthymi* or bipolar' in the title, abstract, or keyword field. At the time of the search of the Register it included the results of searches of the Cochrane Central Register of Controlled trials (CENTRAL) (2012, Issue 7); MEDLINE (via Ovid) (to update 20120907); EMBASE (via Ovid) (to week 201240); PsycINFO (via Ovid) (to update 20120625). See the Tobacco Addiction Group Module in The Cochrane Library for full search strategies and the list of other resources searched.

Studies were also identified from CENTRAL with the following search terms: (depress* and (smok* or tobacco)) in title, abstract and keyword field (April 2013). Furthermore, we searched MEDLINE, EMBASE, and PsycINFO using the search strategies recommended by the Cochrane Tobacco Addiction Group and the Cochrane Depression, Anxiety and Neurosis Group. These search terms were: (depress* [all] and (smok* or tobacco [all])) (July 2011) and (depress* [all] and smoking cessation [title]) (April 2013).

Searching other resources

We checked the reference lists of relevant reviews and asked experts in the tobacco control and depression field if they were aware of other studies not yet included.

Data collection and analysis

Selection of studies

Two authors (RvdM and MW) independently screened the titles and abstracts identified by the search and decided on the possible publications to be included. Full text publications of all potentially relevant trials were obtained and examined by both authors to decide whether the studies fulfilled the inclusion criteria. Any disagreement between the authors was resolved through discussion. All studies excluded at this stage were reported in the 'Characteristics of excluded studies' section.

Data extraction and management

Data from the included studies were extracted by one author (RvdM) and checked by a second (MW).

We recorded the following information in the 'Characteristics of included studies' table.

  • Methods: study design, current and past depression, subgroup (pre‐stated or post hoc) if applicable, setting, country, and method of recruitment.

  • Participants: number of participants per intervention group, definition of depression, mean age, per cent female, mean score on the Fagerstrom Test of Cigarette Dependence (FTCD), mean number of cigarettes per day (CPD), important exclusion criteria for review.

  • Interventions: description of the interventions and format, intensity of psychosocial interventions, type of pharmacotherapy.

  • Outcomes: definition of abstinence and length of follow‐up, biochemical validation, published or unpublished abstinence outcome data.

  • Notes: including information on the analysis.

In the Characteristics of excluded studies table, we listed studies that did not meet the inclusion criteria along with the reasons for exclusion. We attempted to contact the authors of studies where there were any uncertainties. Any disagreement between the authors was resolved through discussions or consultation with the other two authors (FS or PC).

Assessment of risk of bias in included studies

During data extraction, one author (RvdM) assessed each trial for risk of bias according to the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2008). We recorded random sequence generation, allocation concealment, blinding, and completeness of outcome data (including use of intention‐to‐treat (ITT) analysis). Each trial was categorised as low, uncertain, or high risk of bias for each domain, based on the standards described in the Cochrane Handbook for Systematic Reviews of Interventions. We attempted to contact the authors of the studies if there were uncertainties.

Measures of treatment effect

We calculated summary statistics from the extracted data. Results for dichotomous outcomes were expressed as risk ratios (RRs). RR was calculated from the: (number of participants who quit smoking in the intervention group/number of participants randomised to intervention group) divided by (number of participants who quit smoking in control group/number of participants randomised to the control group). An RR greater than one favoured the experimental group.

Dealing with missing data

We attempted to contact the authors of the primary studies for unreported data. For data synthesis, where no additional information was available we assumed any missing data as failure to achieve the desired outcome. The potential impact of the missing data was also addressed in the 'Risk of bias' table for each study.

Assessment of heterogeneity

We examined statistical heterogeneity among trials with the Cochran's Q test and by calculating the I2 statistic. The I2 statistic describes the percentage of the variability in the summary estimate due to systematic heterogeneity rather than random chance stemming from sample error alone (Higgins 2003). Values over 50% suggested moderate heterogeneity and values over 75% suggested substantial heterogeneity.

Data synthesis

Where appropriate, we performed meta‐analysis of the included trial data. For dichotomous outcomes, we calculated the summary estimates using the Mantel‐Haenszel fixed‐effect model method and reported the 95% confidence intervals (CI) of the RR.

Subgroup analysis and investigation of heterogeneity

We conducted subgroup analyses separately for smokers with current depression or past depression. Within the psychosocial mood management versus control comparison, we analysed length of follow‐up (abstinence at six months versus 12 months follow‐up), measurement of depression (major depression versus multi‐item scale depressive symptoms versus one item question on depressive symptoms), depression group in study (depression inclusion criteria versus subgroup pre‐stated versus subgroup post hoc), publication source (published data versus unpublished data), antidepressant use by participant (antidepressant use an exclusion criterion versus not an exclusion criterion), intervention format (group versus individual versus telephone versus self help, etc.), level of behavioural support (multi‐session behavioural support versus no behavioural support), and additional pharmacotherapy (pharmacotherapy versus no pharmacotherapy).

Within the antidepressants for smoking cessation versus placebo comparison, we separately analysed the type of antidepressant (bupropion, fluoxetine, nortriptyline, paroxetine, selegiline, sertraline). Within the group of bupropion studies we conducted the subgroup analyses bupropion alone versus bupropion and additional NRT separately for smokers with current depression or past depression.

Furthermore, within the psychosocial versus control comparison, we conducted the subgroup analysis of telephone counselling versus self help for current depression. Within the NRT versus placebo comparison, we analysed NRT versus placebo for past depression.

Results

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of ongoing studies; Characteristics of studies awaiting classification

Results of the search

We identified 5220 reports from the electronic search of the databases (482 reports from the Tobacco Addiction Group Specialised Register, 581 from CENTRAL, 1281 from MEDLINE, 1373 from EMBASE, and 1503 from PsycINFO). See Figure 1 for a summary of the process for identifying trials for inclusion. We identified 33 reports by checking the reference lists of relevant reviews and through communication with experts in the tobacco control and depression field. After screening, we reviewed the full text of 106 trials that were considered potentially eligible. Of these, 45 trials were excluded after reviewing the full text (see Characteristics of excluded studies). Four studies were ongoing and the outcomes are expected in 2013 to 2014 (see Characteristics of ongoing studies). Eight studies are awaiting classification. We asked the authors for additional data, which they have not yet supplied (see Characteristics of studies awaiting classification).


Process of identifying trials for inclusion.

Process of identifying trials for inclusion.

Included studies

The final review includes 49 trials (see Characteristics of included studies table). Many of these trials had a subgroup of participants with current depression and also a subgroup with past depression. Some trials were classified for both smoking cessation interventions with and without components for handling depression.

Thirty‐three of the 49 included trials investigated smoking cessation interventions with specific mood management components for handling depression. Nineteen trials investigated psychosocial mood management versus control: 13 trials for smokers with current depression (Batra 2010; Brown 2007; Carmody 2008; Cinciripini 2010; Duffy 2006; MacPherson 2010; Muñoz 1997; Muñoz 2006a; Muñoz 2006b; Muñoz 2009; Rabius 2007b; Van der Meer 2010; Vickers 2009), and 14 trials for smokers with past depression (Brown 2001; Brown 2007; Carmody 2008; Cinciripini 2010; Hall 1994; Hall 1996; Hall 1998; Hall 2009; Muñoz 1997; Muñoz 2006a; Muñoz 2006b; Muñoz 2009; Patten 1998; Van der Meer 2010). Sixteen trials investigated antidepressants versus placebo: eight trials with smokers with current depression (Blondal 1999; Brown 2007; Catley 2005; Killen 2000; Levine 2010; Saules 2004; Schnoll 2010; Thorndike 2008), and 11 trials with smokers with past depression (Brown 2007; Covey 2002; Hall 1998; Hall 2002; Hayford 1999; Killen 2000; Piper 2009; Saules 2004; Smith 2003; Spring 2007; Weinberger 2010).

Twenty‐three of the 49 trials investigated smoking cessation interventions without specific components for depression. Twelve trials investigated psychosocial interventions versus standard smoking cessation counselling: 10 trials for smokers with current depression (Catley 2003; Hayes 2010; Killen 2008; Levine 2003; Levine 2010; McAlister 2004; Muñoz 2009; Rabius 2007a; Rabius 2007b; Rabius 2008), and five trials for smokers with past depression (Kahler 2008; Killen 2008; Levine 2003; Muñoz 2009; Swan 2010).

Five trials investigated NRT versus placebo: one trial for smokers with current depression (Kinnunen 2008), and four trials for smokers with past depression (Hall 1996; Hall 2009; Piper 2009; Smith 2003). Three trials investigated other pharmacotherapy versus placebo: one trial for smokers with current depression (Walsh 2008), and two trials for smokers with past depression (Covey 1999; Piper 2009). Five trials investigated other interventions: four trials for smokers with current depression (Hall 2006; Kodl 2008; McFall 2010; Wewers 2009), and two trials for smokers with past depression (Hall 2009; McFall 2010).

I. Interventions with specific components for depression
1. Psychosocial mood management for smokers with current depression
Study and participant characteristics

There were 13 trials in this category; eight trials were conducted in the USA, three were conducted internationally, one trial was conducted in Germany, and one in the Netherlands. Four trials recruited participants from the community and a clinical setting, three trials recruited online, three from the community, two from a clinical setting, and one from a university and community setting. Participants had current major depression in five trials (Cinciripini 2010; Muñoz 1997; Muñoz 2006a; Muñoz 2006b; Muñoz 2009); depressive symptoms according to a multi‐item scale in seven trials (Batra 2010; Brown 2007; Carmody 2008; Duffy 2006; MacPherson 2010; Van der Meer 2010; Vickers 2009); and depressive symptoms according to a single item question in one trial (Rabius 2007b). Current major depression was an exclusion criterion in five trials (Batra 2010; Brown 2007; Duffy 2006; MacPherson 2010; Van der Meer 2010). Vickers 2009 and MacPherson 2010 had an inclusion criterion of current depression and the other 11 trials had subgroups of participants with current depression.

Interventions

In most trials, the psychosocial mood management component of the experimental intervention consisted of a format of (cognitive) behavioural therapy for depression (Batra 2010; Brown 2007; Duffy 2006; MacPherson 2010; Muñoz 1997; Muñoz 2006a; Muñoz 2006b; Muñoz 2009; Rabius 2007b; Van der Meer 2010). In one trial the psychosocial mood management component consisted of a cognitive behavioural analysis system of psychotherapy (Cinciripini 2010), in one trial of hypnosis skills (Carmody 2008), and in one trial of exercise counselling (Vickers 2009). The interventions of all of four of Muñoz's trials (Muñoz 1997; Muñoz 2006a; Muñoz 2006b; Muñoz 2009) had a self‐help format, one trial had a group counselling format (Brown 2007), two trials had an individual counselling format (Cinciripini 2010; Vickers 2009), two trials had an individual plus telephone counselling format (Carmody 2008; Duffy 2006), one trial had a telephone counselling format (Rabius 2007b), one had a telephone counselling plus self‐help format (Van der Meer 2010), and one had a group plus self‐help format (MacPherson 2010). All trials except the four conducted by Muñoz had interventions with multi‐session behavioural support. Seven trials (Batra 2010; Brown 2007; Carmody 2008; Cinciripini 2010; MacPherson 2010; Muñoz 1997; Vickers 2009) had time‐matched comparisons. Three trials (Carmody 2008; MacPherson 2010; Vickers 2009) had additional pharmacotherapy in both arms, and six trials had no additional pharmacotherapy in both arms (Cinciripini 2010; Muñoz 1997; Muñoz 2006a; Muñoz 2006b; Muñoz 2009; Rabius 2007b).

Outcomes

Six trials validated abstinence biochemically (Batra 2010; Brown 2007; Carmody 2008; MacPherson 2010; Van der Meer 2010; Vickers 2009), and the other seven trials did not. Most of the abstinence outcome data were unpublished and made available by the authors. Four trials had published abstinence outcome data (Duffy 2006; MacPherson 2010; Muñoz 1997; Vickers 2009).

2. Psychosocial mood management for smokers with past depression
Study and participant characteristics

There were 13 trials in this category: nine were conducted in the USA, three internationally, and one in the Netherlands. Two trials recruited participants from the community and a clinical setting, three trials recruited online, three from the community, three from a clinical setting, and two from the university setting. In almost all trials the participants had past major depression according to DSM‐IV criteria, except in the trial of Carmody 2008. Here the participants had a past depression according to a single item question. Current major depression and use of antidepressants were exclusion criteria in seven trials (Brown 2001; Brown 2007; Hall 1996; Hall 1998; Hall 2009; Patten 1998; Van der Meer 2010). Three trials had an inclusion criterion of past depression (Brown 2001; Patten 1998; Van der Meer 2010), eight trials had pre‐stated subgroups of participants with past depression (Cinciripini 2010; Hall 1996; Hall 1998; Hall 2009; Muñoz 1997; Muñoz 2006a; Muñoz 2006b; Muñoz 2009), and three trials had post hoc subgroups of participants with past depression (Brown 2007; Carmody 2008; Hall 1994).

Interventions

In almost all trials the psychosocial mood management component of the experimental intervention consisted of a format of (cognitive) behavioural therapy for depression. In one trial the psychosocial mood management component consisted of a cognitive behavioural analysis system of psychotherapy (Cinciripini 2010), and in one trial of hypnosis skills (Carmody 2008). The interventions of all of the four trials of Muñoz had a self‐help format, five trials had a group counselling format (Brown 2007; Hall 1994; Hall 1996; Hall 1998; Patten 1998), one trial had a group counselling plus self‐help format (Brown 2001), one trial had an individual counselling format (Cinciripini 2010), one trial had an individual plus telephone counselling format (Carmody 2008), one trial had a telephone counselling plus self‐help format (Van der Meer 2010), and one trial had a group and individual counselling and self‐help format (Hall 2009). All of the trials except the four trials conducted by Muñoz had interventions with multi‐session behavioural support. Six trials (Brown 2001; Brown 2007; Carmody 2008; Cinciripini 2010; Hall 1996; Patten 1998) had time‐matched comparisons. Three trials (Hall 1994; Carmody 2008; Hall 2009) had additional pharmacotherapy in both arms and seven trials had no additional pharmacotherapy in both arms (Brown 2001; Cinciripini 2010; Muñoz 1997; Muñoz 2006a; Muñoz 2006b; Muñoz 2009; Patten 1998).

Outcomes

Nine trials validated abstinence biochemically (Brown 2001; Brown 2007; Carmody 2008; Hall 1994; Hall 1996; Hall 1998; Hall 2009; Patten 1998; Van der Meer 2010), while the other five trials did not. Seven trials had unpublished abstinence outcome data, which were made available by the authors (Brown 2007; Carmody 2008; Cinciripini 2010; Hall 2009; Muñoz 2006a; Muñoz 2006b; Muñoz 2009). The other seven trials had published abstinence outcome data.

3. Antidepressants for smokers with current depression
Study and participant characteristics

There were eight trials in this category; seven trials were conducted in the USA and one in Iceland. Three trials recruited participants from the clinical setting, two trials recruited from the community setting, one from the community and university setting, one from the community and hospital setting, and one from the clinical and at home settings. In all trials the participants had depressive symptoms according to a multi‐item scale. Current major depression was an exclusion criterion in six trials (Brown 2007; Killen 2000; Levine 2010; Saules 2004; Schnoll 2010; Thorndike 2008). Use of antidepressants was an exclusion criterion in all of the trials except the trial of Thorndike 2008. Two trials had pre‐stated subgroups of participants with current depression (Brown 2007; Schnoll 2010), and the other six trials had post hoc subgroups of participants with current depression.

Interventions

Five trials studied the effect of bupropion (Brown 2007; Catley 2005; Levine 2010; Schnoll 2010; Thorndike 2008) compared with placebo, two trials studied fluoxetine (Blondal 1999; Saules 2004) compared with placebo, and one trial studied paroxetine (Killen 2000) compared with placebo. Four trials (Blondal 1999; Killen 2000; Saules 2004; Schnoll 2010) had additional NRT in both arms, and the other four trials did not.

Outcomes

All trials validated abstinence biochemically. Schnoll 2010 had published abstinence outcome data. The other trials had unpublished abstinence outcome data, which were made available by the authors.

4. Antidepressants for smokers with past depression
Study and participant characteristics

There were 11 trials in this category and they were all conducted in the USA. Two trials recruited participants from the community setting, two trials recruited from the university setting, two from the clinical and community settings, one from the community and university setting, one from the clinical and university settings, one from the community and hospital settings, and two from the clinical setting. In all trials, the participants had past major depression according to the DSM‐IV criteria. Current major depression was an exclusion criterion in all the trials except in the trial of Piper 2009. Use of antidepressants was an exclusion criterion in all trials. One trial had an inclusion criterion of past depression (Covey 2002), four trials had pre‐stated subgroups of participants with past depression (Hall 1998; Hall 2002; Saules 2004; Spring 2007), and six trials had post hoc subgroups of participants with past depression (Brown 2007; Hayford 1999; Killen 2000; Piper 2009; Smith 2003; Weinberger 2010).

Interventions

Four trials studied the effect of bupropion (Brown 2007; Hayford 1999; Piper 2009; Smith 2003) compared to placebo, two trials studied fluoxetine (Saules 2004; Spring 2007), one trial studied paroxetine (Killen 2000), one trial studied selegiline (Weinberger 2010), one trial studied sertraline (Covey 2002), and one trial studied nortriptyline (Hall 1998) compared with placebo. One trial studied nortriptyline versus bupropion (Hall 2002). Three trials had additional NRT (Killen 2000; Saules 2004; Smith 2003) in both arms, and the other trials did not (Brown 2007; Covey 2002; Hall 1998; Hall 2002; Hayford 1999; Piper 2009; Smith 2003; Spring 2007; Weinberger 2010).

Outcomes

All trials validated abstinence biochemically. Five trials had unpublished abstinence outcome data, which were made available by the authors (Brown 2007; Killen 2000; Piper 2009; Saules 2004; Weinberger 2010). The other trials (Covey 2002; Hall 1998; Hall 2002; Hayford 1999; Smith 2003; Spring 2007) had published abstinence outcome data.

II. Interventions without specific components for depression
5. Psychosocial interventions for smokers with current depression
Study and participant characteristics

There were 10 trials in this category and they were all conducted in the USA except the trial of Muñoz 2009, which was a multi‐country trial. Seven trials recruited participants from the community, one trial recruited online, one trial from the clinical setting, and one from the home healthcare setting. Participants had current major depression in one trial (Muñoz 2009), depressive symptoms according to a multi‐item scale in six trials (Catley 2003; Hayes 2010; Killen 2008; Levine 2003; Levine 2010), and depressive symptoms according to a single item question in four trials (McAlister 2004; Rabius 2007a; Rabius 2007b; Rabius 2008). Current major depression was an exclusion criterion in the trials of Killen 2008; Levine 2003; Levine 2010. Use of antidepressants was an exclusion criteria in two trials (Killen 2008; Levine 2010). Ten trials had subgroups of participants with current depression: one trial had a pre‐stated subgroup (Muñoz 2009) and all the other trials had post hoc subgroups.

Interventions

There was a lot of diversity between the interventions of the included trials. Two trials had a group counselling format (Levine 2003; Levine 2010), two trials had a self‐help website format (Muñoz 2009; Rabius 2008), two trials had a telephone counselling format (Rabius 2007a; Rabius 2007b), two trials had telephone counselling plus a self‐help format (Catley 2003; McAlister 2004), one trial had individual counselling plus telephone counselling format (Killen 2008), and one trial had an individual plus telephone counselling plus self‐help format (Hayes 2010). All of the trials except the trials of Muñoz 2009 and Rabius 2008 had interventions with multi‐session behavioural support. Three trials (Catley 2003; Levine 2003; Levine 2010) had time‐matched comparisons. Two trials (Catley 2003; Killen 2008) had additional pharmacotherapy in both arms and seven trials had no additional pharmacotherapy in either arm (Hayes 2010; Levine 2003; McAlister 2004; Muñoz 2009; Rabius 2007a; Rabius 2007b; Rabius 2008).

Outcomes

Five trials validated abstinence biochemically (Catley 2003; Hayes 2010; Killen 2008; Levine 2003; Levine 2010) and the other five trials did not. Most of the abstinence outcome data were unpublished and made available by the authors. Only one trial had published abstinence outcome data (Rabius 2008).

6. Psychosocial interventions for smokers with past depression
Study and participant characteristics

There were five trials in this category: one trial was a multi‐country trial (Muñoz 2009), and the other trials were conducted in the USA. Three trials recruited participants from the community, one trial recruited online, and one from an university setting. In almost all trials the participants had past major depression according to DSM‐IV criteria, except in the trial of Swan 2010. In this study the participants had past depression according to a singe item question. Current major depression was an exclusion criterion in three trials (Kahler 2008; Killen 2008; Levine 2003), and use of antidepressant in one trial (Killen 2008). One trial had a pre‐stated subgroup of participants with past depression (Muñoz 2009) and four trials had post hoc subgroups of participants with past depression (Kahler 2008; Killen 2008; Levine 2003; Swan 2010).

Interventions

Also for this category of trials there was a lot of diversity between the interventions. One trial had a group counselling format (Levine 2003), one trial had a self‐help website format (Muñoz 2009), one trial had an individual counselling format (Kahler 2008), one trial had abself‐help plus telephone counselling format (Swan 2010), and one had an individual counselling plus telephone counselling format (Killen 2008). All of the trials except the trials of Muñoz 2009 had interventions with multi‐session behavioural support. Two trials (Kahler 2008; Levine 2003) had time‐matched comparisons. Three trials had additional pharmacotherapy in both arms (Kahler 2008; Killen 2008; Swan 2010), while the other two did not.

Outcomes

Three trials validated abstinence biochemically (Kahler 2008; Killen 2008; Levine 2003) while the other two did not. All of the trials had unpublished abstinence outcome data and these were made available by the authors.

7. Nicotine replacement therapy (NRT) for smokers with current or past depression
Study and participant characteristics

Five trials investigated NRT versus placebo: one trial for smokers with current depression (Kinnunen 2008), and four trials for smokers with past depression (Hall 1996; Hall 2009; Piper 2009; Smith 2003). All trials were conducted in the USA. Two trials recruited participants from the community setting, one from the clinical setting, one from the university setting, and one from the community and clinical settings. In all trials the participants had past major depression according to the DSM‐IV criteria (Hall 1996; Hall 2009; Piper 2009; Smith 2003). In the trial of Kinnunen 2008, the participants had depressive symptoms according to a multi‐item scale. Current major depression was an exclusion criterion in the trials of Hall 1996; Hall 2009; and Smith 2003. Use of antidepressants was an exclusion criterion in all of the trials.Two trials had pre‐stated subgroups of participants with past depression (Brown 2007; Schnoll 2010), and the other three trials had post hoc subgroups of participants with past depression (Piper 2009; Smith 2003) or current depression (Kinnunen 2008).

Interventions

Three trials studied the effect of NRT gum (Hall 1996; Hall 2009; Kinnunen 2008), and one trial studied the effect in three comparisons: (1) NRT patch versus placebo, (2) NRT lozenge versus placebo, and (3) NRT patch and lozenge versus placebo (Piper 2009). One trial studied the effect of NRT patch in two comparisons: (1) NRT patch versus placebo, and (2) NRT patch plus bupropion versus placebo plus bupropion (Smith 2003). Two trials (Hall 2009; Smith 2003) had additional bupropion in both arms while the others (Hall 1996; Hall 2009; Kinnunen 2008; Smith 2003) did not.

Outcomes

All trials validated abstinence biochemically. Two trials had unpublished abstinence outcome data (Hall 2009; Piper 2009), which were made available by the authors. The other trials (Hall 1998; Kinnunen 2008; Smith 2003) had published abstinence outcome data.

8. Other pharmacotherapy (no antidepressants or NRT) for smokers with current or past depression
Study and participant characteristics

Three trials investigated other pharmacotherapy versus placebo: one trial for smokers with current depression (Walsh 2008), and two trials for smokers with past depression (Covey 1999; Piper 2009). All trials were conducted in the USA. One trial recruited participants from the clinical setting, one from the university, and one from the community setting.

In all past depression trials the participants had past major depression according to the DSM‐IV criteria (Covey 1999; Piper 2009). In the trial of Walsh 2008 the participants had depressive symptoms according to a multi‐item scale. Current major depression was an exclusion criterion in the trials of Covey 1999 and Walsh 2008. Use of antidepressants was an exclusion criterion in two of the four trials (Piper 2009; Walsh 2008). All trials had post hoc subgroups of participants with depression.

Interventions

Two trials studied the effect of naltrexone, which is an opioid antagonist (Covey 1999; Walsh 2008), and one trial studied the effect of bupropion and NRT lozenges together (Piper 2009). The trial of Walsh 2008 had an additional NRT patch in both arms; the other did not have additional pharmacotherapy.

Outcomes

Two trials validated abstinence biochemically (Piper 2009; Walsh 2008) while Covey 1999 did not. We used published data from the trial of Covey 1999. From the other trials we used unpublished data.

9. Other interventions for smokers with current or past depression
Study and participant characteristics

Five trials investigated other interventions: four trials for smokers with current depression (Hall 2006; Kodl 2008; McFall 2010; Wewers 2009), and two trials for smokers with past depression (Hall 2009; McFall 2010). All trials were conducted in the USA. Three trials recruited participants from the clinical setting, one trial from the clinical and community settings, and one trial from the mental health outpatient setting.

In the two past depression trials, the participants had past major depression according to the DSM‐IV criteria (Hall 2009; McFall 2010); and in one of the five current depression trials the participants had current major depression according to the DSM‐IV criteria (McFall 2010). In the three trials of Hall 2006; Kodl 2008; and Wewers 2009 the participants had depressive symptoms according to a multi‐item scale. Current major depression and use of antidepressants were both exclusion criteria in the trial of Hall 2009 and not in the other trials. One trial had an inclusion criterion of current depression (Hall 2006), two trials had pre‐stated subgroups of participants with past or current depression (Hall 2009; McFall 2010), and three trials had post hoc subgroups of participants with past or current depression (McFall 2010; Kodl 2008; Wewers 2009).

Interventions

One trial studied the effect of extended NRT and extended cognitive behavioural therapy (CBT) versus standard treatment (Hall 2009), one trial studied integrated smoking cessation care versus referral to a smoking cessation clinic (McFall 2010), one trial studied staged care versus brief contact plus referral (Hall 2006), one trial studied concurrent smoking cessation versus delayed smoking cessation (Kodl 2008), and one trial studied a nurse‐managed lay‐led protocol versus a personalised letter from a physician (Wewers 2009).

Outcomes

All five trials validated abstinence biochemically. We used published data from the trial of Hall 2006 and from the other trials we used unpublished data.

Excluded studies

We listed 45 excluded studies (see Characteristics of excluded studies). Reasons for not meeting the inclusion criteria were: too short follow‐up (N = 19), no outcome data available (N = 6), depression not an inclusion criterion or a variable subgroup analysis (N = 8), no RCT (N = 8), and no smoking cessation intervention (N = 9).

Risk of bias in included studies

A summary of the evaluation of risk of bias for each study is shown in Figure 2, which shows a risk of bias graph with review authors' judgements about each risk of bias item presented as percentages across all included studies.


Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Allocation

All studies described treatment allocation as random, but 15 of the 49 trials (30.6%) did not give details about the method for generating the sequence. Methods for concealing the allocation were also poorly reported: 23 of the 49 trials (46.9%) did not give clear details.

Blinding

It is far easier to provide blinding of patients and care providers for pharmacotherapy than for psychosocial interventions. The criteria with regard to blinding of patients and care providers are difficult to achieve for psychosocial interventions. They might have introduced a bias.

Incomplete outcome data

All trials reported the numbers randomised to each group, so we could use these in the meta‐analysis. Most trials reported findings based on treating all dropouts as continuing smoking although some did not note the number lost to follow‐up, who were assumed to be continuing smokers.

Effects of interventions

See: Summary of findings for the main comparison Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or longer follow‐up; Summary of findings 2 Bupropion versus control for smokers with current depression. Abstinence at six months or longer follow‐up; Summary of findings 3 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or longer follow‐up; Summary of findings 4 Bupropion versus control for smokers with past depression. Abstinence at six months or longer follow‐up

I. Interventions with specific mood management components for depression

1. Psychosocial mood management for smokers with current depression

Thirteen trials with a total of 1949 participants investigated adding psychosocial mood management to a standard smoking cessation intervention compared with the standard smoking cessation intervention alone, for smokers with current depression, on abstinence at six months or longer follow‐up. The meta‐analysis, including 11 trials (N = 1844), showed a positive effect on smoking cessation of adding psychosocial mood management for smokers with current depression (11 trials, RR 1.47, 95% CI 1.13 to 1.92; I² = 0%; Analysis 1.1; Figure 3). Batra 2010 and Duffy 2006 were not included in this analysis because of: different advice for pharmacotherapy in both arms, and psychosocial mood management and pharmacotherapy in the experimental condition alone, respectively. Batra 2010 found an abstinence rate of 30.4% (7/23) for the experimental condition compared with 11.1% (2/18) in the control condition (RR 2.74, 95% CI 0.65 to 11.62). Duffy 2006 showed abstinence rates of 51.4% (18/35) for the experimental condition compared with 17.2% (5/29) in the control condition (RR 2.98, 95% CI 1.26 to 7.05). We also performed a meta‐analysis without Carmody 2008 and Vickers 2009 because their experimental psychosocial mood management component consisted of hypnosis and exercise counselling, compared with a (cognitive) behavioural therapy component in the other trials. The meta‐analysis without Carmody 2008 and Vickers 2009 also showed a positive effect of adding mood management for current depression (9 trials, RR 1.42, 95% CI 1.07 to 1.88; I² = 0%; Analysis 1.2).


Forest plot of comparison: 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up.

Forest plot of comparison: 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up.

We conducted eight subgroup analyses with the 11 included trials. There were no important differences in effect estimates between the five trials reporting abstinence at six months follow‐up and the six with 12‐month outcomes (Analysis 1.3). Estimates were similar across the different ways of measuring depression (Analysis 1.4). There were no important differences in effect estimates between the two trials recruiting only people with depression, the five trials where depression was a pre‐stated subgroup analysis, and the four trials where depression was a post hoc subgroup analysis (Analysis 1.5). Data came from published reports in only three trials (N = 188) and although the point estimate was higher in this group the confidence intervals overlapped with the eight trials (N = 1663) where we obtained subgroup data from the authors (Analysis 1.6). Only three trials excluded people using antidepressants, and there was no evidence of a difference between the subgroups (Analysis 1.7). There were too many formats of intervention categories to make a sensible subgroup analysis (Analysis 1.8). The seven trials (N = 1647) where multi‐session behavioural support was provided to all participants showed a significant benefit from the additional components in the experimental group. There were only 197 participants in trials without this level of support for all participants and the pooled estimate had wide confidence intervals (Analysis 1.9). There was no evidence that the relative effect was different for trials where participants were offered pharmacotherapy and those where they were not (Analysis 1.10). Overall, none of the subgroup analyses detected significant differences between the subgroups.

2. Psychosocial mood management for smokers with past depression

Fourteen trials with a total of 1554 participants investigated adding psychosocial mood management to a standard smoking cessation intervention compared with the standard smoking cessation intervention alone, for smokers with past depression, on abstinence at six months or longer follow‐up. The meta‐analysis, including 13 trials (N = 1496), showed a positive effect for adding psychosocial mood management for past depression (13 trials, RR 1.41, 95% CI 1.13 to 1.77; I² = 23%; Analysis 2.1; Figure 4). Hall 2009 was not included in the meta‐analysis because the differences between the experimental intervention (extended CTB) and control intervention (standard treatment) included more than only the addition of a psychosocial mood management component. This trial found an abstinence rate of 48.3% (14/29) for the experimental condition compared with 27.6% (8/29) in the control condition (RR 1.75, 95% CI 0.87 to 3.52). We also performed a meta‐analysis without Carmody 2008 because the experimental psychosocial mood management component of this trial consisted of hypnosis, compared with CBT components in the other trials. The meta‐analysis without Carmody 2008 also showed a positive effect of adding psychosocial mood management for smokers with past depression (12 trials, RR 1.38, 95% CI 1.09 to 1.74; I² = 25%; Analysis 2.2).


Forest plot of comparison: 2 Psychosocal mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up.

Forest plot of comparison: 2 Psychosocal mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up.

We conducted eight subgroup analyses with the 13 included trials. The effect estimates of the two trials reporting abstinence at six‐month follow‐up was higher than the effect estimate of 11 trials reporting 12‐month outcomes. However, there was no significant difference between the two subgroups (Analysis 2.3). The estimates were not similar across the two different ways of measuring depression, although there was no significant difference between the two subgroups (Analysis 2.4). There were no important differences in effect estimates between the three trials recruiting only people with depressions, the seven trials where depression was a pre‐stated subgroup analysis, and the three trials where depression was a post hoc subgroup analysis (Analysis 2.5). Data from published reports in seven trials showed a higher point estimate than the obtained data from authors in six trials, although the confidence intervals overlapped (Analysis 2.6). There were no important differences in effect estimates between the six trials where antidepressant use was an exclusion criterion and the seven where antidepressant use was not an exclusion criterion (Analysis 2.7). There were too many format intervention categories to make a sensible subgroup analysis (Analysis 2.8). The nine trials (N = 1252) where multi‐session behavioural support was provided to all participants showed a significant benefit from the additional components in the experimental group. In the four trials without this level of support for all participants (N = 244), the confidence intervals overlapped between the two subgroups (Analysis 2.9). There was no evidence that the relative effect was different for the trials where participants were offered pharmacotherapy and those where they were not (Analysis 2.10). Overall, none of the subgroup analyses detected significant differences between the subgroups.

3. Antidepressants for smokers with current depression

Eight trials with a total of 517 participants investigated antidepressants for smoking cessation versus placebo, for smokers with current depression, looking at abstinence at six months or longer follow‐up. Five trials studied the effect of bupropion compared with placebo (Brown 2007; Catley 2005; Levine 2010; Schnoll 2010; Thorndike 2008). These trials only included subgroups of smokers with mild depressive symptoms. Meta‐analysis found a positive effect, although not significant, for the effect of bupropion compared with placebo (5 trials, N = 410, RR 1.37, 95% CI 0.83 to 2.27; I² = 29%; Analysis 3.1; Figure 5).


Forest plot of comparison: 3 Bupropion versus placebo for current depression. Abstinence at six months or greater follow‐up

Forest plot of comparison: 3 Bupropion versus placebo for current depression. Abstinence at six months or greater follow‐up

There was no strong evidence for a difference in relative effect between the four trials using bupropion as sole pharmacotherapy and the trial using bupropion as an adjunct to NRT (Schnoll 2010). There were not enough trial data to evaluate the effectiveness of fluoxetine (2 trials, N = 64, RR 1.02, 95% CI 0.14 to 7.32; I² = 0%; Analysis 4.1; Figure 6) (Blondal 1999; Saules 2004) and paroxetine (1 trial, N = 43, RR 1.09, 95% CI 0.34 to 3.51; Analysis 5.1; Killen 2000), both compared with placebo.


Forest plot of comparison: 6 Bupropion versus placebo for smokers with past depression. Abstinence at six months or greater follow‐up.

Forest plot of comparison: 6 Bupropion versus placebo for smokers with past depression. Abstinence at six months or greater follow‐up.

4. Antidepressants for smokers with past depression

Ten trials with a total of 836 participants investigated antidepressants for smoking cessation versus placebo in smokers with past depression on abstinence at six months or longer follow‐up. Four trials studied the effect of bupropion compared with placebo (Brown 2007; Hayford 1999; Piper 2009; Smith 2003). Meta‐analyses showed a significant positive effect for the use of bupropion for smoking cessation in smokers with past depression (4 trials, RR 2.04, 95% CI 1.31 to 3.18; I² = 44%; Analysis 6.1; Figure 6); although, the strength of the evidence for bupropion was relatively weak due to the small number of studies and the post hoc subgroups for all of the studies.

There was no strong evidence for a difference in relative effect between the four trials using bupropion as sole pharmacotherapy (Brown 2007; Hayford 1999; Piper 2009; Smith 2003) or the trial using bupropion as an adjunct to NRT (Smith 2003). Smith 2003 included four arms: two having additional NRT, and two without additional NRT. All four arms were included in the meta‐analyses. There were not enough trial data to evaluate the long‐term effectiveness of fluoxetine (2 trials, N = 147, RR 1.18, 95% CI 0.47 to 2.93; I² = 0%; Analysis 7.1), nortriptyline (1 trial, N = 65, RR 1.03, 95% CI 0.41 to 2.61; Analysis 8.1) (Hall 1998), paroxetine (1 trial, N = 60, RR 2.03, 95% CI 0.86 to 4.74; Analysis 9.1) (Killen 2000), selegiline (1 trial, N = 26, RR 3.75, 95% CI 0.20 to 71.12; Analysis 10.1) (Weinberger 2010), and sertraline (1 trial, N = 134, RR 0.71, 95% CI 0.30 to 1.64; Analysis 11.1) (Covey 2002) all compared with placebo.

II. Interventions without specific components for depression

5. Psychosocial interventions for smokers with current depression

Ten trials investigated psychosocial interventions versus standard smoking cessation counselling for smoking cessation, in people with current depression, on abstinence at six months or longer follow‐up. Because of the heterogeneity of the interventions, only a meta‐analysis including two trials (McAlister 2004; Rabius 2007a) comparing telephonic counselling versus a self‐help booklet was possible (2 trials, RR 1.36, 95% CI 0.77 to 2.42; I² = 54%; Analysis 12.1). No significant effect was detected. Catley 2003 compared culturally sensitive self help versus standard self help and found abstinence rates of 16.3% (14/86) and 13.2% (12/91) respectively (RR 1.23, 95% CI 0.61 to 2.52). Hayes 2010 compared motivational versus standard care and found abstinence rates of 6.9% (6/87) and 3.3% (3/92) respectively (RR 2.11, 95% CI 0.55 to 8.20). Killen 2008 compared extended CBT versus telephone support and found abstinence rates of 33.3% (5/15) and 8.3% (1/12) respectively (RR 4.0, 95% CI 0.54 to 29.80). Levine 2003 compared CBT weight gain versus standard counselling and found abstinence rates of 10.0% (2/20) and 0% (0/19) respectively (RR 4.76, 95% CI 0.24 to 93.19). Levine 2003 also compared behavioural weight control versus standard counselling and found abstinence rates of 8% (2/25) and 0% (0/19) respectively (RR 3.85, 95% CI 0.20 to 75.71). Levine 2010 compared CBT weight gain versus standard counselling and found abstinence rates of 12.5% (3/24) and 3.4% (1/29) respectively (RR 3.63, 95% CI 0.40 to 32.64). Two arms in the trial of Muñoz 2009 compared additional virtual group website versus without the additional virtual group website and showed abstinence rates of 6.1% (2/33) and 18.2% (6/33) respectively (RR 0.33, 95% CI 0.07 to 1.53). The trial of Rabius 2007b consisted of four arms. We compared standard telephonic counselling plus booster versus standard telephonic counselling and found abstinence rates of 6.7% (17/252) and 7.2% (18/249) respectively (RR 0.93, 95% CI 0.49 to 1.77). We also compared the CBT plus booster versus CBT and found abstinence rates of 10.5% (27/256) and 7.8% (23/294) respectively (RR 1.35, 95% CI 0.79 to 2.29). Rabius 2008 compared a tailored interactive website versus a minimally interactive website and found abstinence rates of 8.1% (133/1648) and 10.2% (32/313) respectively (RR 0.79, 95% CI 0.55 to 1.14). None of the trials showed a significant risk ratio.

6. Psychosocial interventions for smokers with past depression

Five trials investigated psychosocial interventions versus standard smoking cessation counselling, for smokers with past depression, on abstinence at six months or longer follow‐up. Because of the heterogeneity of the interventions, pooling of the data was not possible. Kahler 2008 compared a standard individual smoking cessation treatment incorporating a brief alcohol intervention versus a standard individual smoking cessation treatment and found abstinence rates of 16.2% (6/37) and 11.9% (5/42) respectively (RR 1.36, 95% CI 0.45 to 4.10). Killen 2008 compared extended CBT versus telephone support and found abstinence rates of 42.1% (8/19) and 41.7% (5/12) respectively (RR 1.01, 95% CI 0.43 to 2.37). Levine 2003 compared CBT weight gain versus standard counselling and found abstinence rates of 22.5% (9/40) and 12.5% (4/32) respectively (RR 1.80, 95% CI 0.61 to 5.31). Levine 2003 also compared behavioural weight control versus standard counselling and found abstinence rates of 11.6% (5/43) and 12.5% (4/32) respectively (RR 0.93, 95% CI 0.27 to 3.19). Two arms in Muñoz 2009 compared an additional virtual group website versus without the additional virtual group website and showed abstinence rates of 25.0% (11/44) and 11.9% (5/42) respectively (RR 5.25, 95% CI 1.24 to 22.29). Swan 2010's trial consisted of three arms. We compared website plus telephonic counselling versus website alone and the data showed abstinence rates of 29.1% (58/199) and 30.5% (69/226) respectively (RR 0.95, 95% CI 0.71 to 1.28). We also compared website plus telephonic counselling versus telephonic counselling alone and the data showed abstinence rates of 29.1% (58/199) and 34.7% (82/236) respectively (RR 0.84, 95% CI 0.63 to 1.11).

7. Nicotine replacement therapy (NRT) for smokers with current or past depression

Five trials investigated NRT versus placebo, one trial for smokers with current depression (Kinnunen 2008) and four trials for smokers with past depression (Hall 1996; Hall 2009; Piper 2009; Smith 2003), on abstinence at six months or longer follow‐up. Kinnunen 2008 compared NRT gum versus placebo and found abstinence rates of 15.1% (19/126) and 5.7% (4/70) respectively (RR 2.64, 95% CI 0.93 to 7.45). A meta‐analysis including three trials (Hall 1996; Piper 2009; Smith 2003) showed a positive effect, although not significant, for NRT versus placebo for participants with past depression (three trials, RR 1.17, 95% CI 0.85 to 1.60; I² = 0%; Analysis 13.1). Hall 2009 compared extended NRT (gum) versus standard NRT and found abstinence rates of 17.4% (4/23) and 23.8% (5/21) respectively (RR 0.73, 95% CI 0.23 to 2.36).

8. Other pharmacotherapy (no antidepressants or NRT) for smokers with current or past depression

Three trials investigated other pharmacotherapy versus placebo, one for smokers with current depression (Walsh 2008) and two trials for smokers with past depression (Covey 1999; Piper 2009), on abstinence at six months or longer follow‐up.

Walsh 2008 compared naltrexone versus placebo and found abstinence rates of 14.3% (1/7) and 0% (0/6) respectively (RR 2.63, 95% CI 0.13 to 54.64). Covey 1999 found 28.6% (4/14) and 9.12% (2/22) for the same comparison (RR 3.14, 95% CI 0.66 to 14.95). Piper 2009 compared bupropion plus NRT lozenge versus placebo and found abstinence rates of 30.2% (16/53) and 27.3% (9/33) respectively (RR 1.11, 95% CI 0.55 to 2.21). None of the trials detected a significant difference between the intervention and control groups.

9. Other interventions for smokers with current or past depression

Six trials investigated other interventions, four trials for smokers with current depression (Hall 2006; Kodl 2008; McFall 2010; Wewers 2009) and two trials for smokers with past depression (Hall 2009; McFall 2010), on abstinence at six months or greater follow‐up.

Hall 2006 compared staged care versus brief contact plus referral and showed abstinence rates of 18.4% (30/163) and 13.2% (21/159) respectively (RR 1.39, 95% CI 0.83 to 2.33). Kodl 2008 compared concurrent smoking cessation versus delayed smoking cessation and found abstinence rates of 9.7% (10/103) and 14.8% (13/88) (RR 0.66, 95% CI 0.30 to 1.42). Wewers 2009 compared a nurse managed lay led protocol versus a personalised letter written by a physician and found abstinence rates of 9.1% (7/77) and 0% (0/76) respectively (RR 14.81, 95% CI 0.86 to 254.80). McFall 2010 compared integrated smoking cessation care versus referral to a smoking cessation clinic and showed abstinence rates of 14.6% (30/205) versus 9.8% (19/193) (RR 1.49, 95% CI 0.87 to 2.55) for the current depression group and 26.4% (32/121) and 14.2% (19/134) (RR 1.87, 95% CI 1.12 to 3.11) for the past depression group, showing a significant RR for past depression. Hall 2009 compared extended NRT and extended CBT versus standard treatment and found abstinence rates of 53.6% (15/28) and 27.6% (8/29) respectively (RR 1.94, 95% CI 0.98 to 3.85).

Discussion

Summary of main results

This systematic review is the first to evaluate the effectiveness of smoking cessation interventions separately for smokers with current and past depression. Our evidence suggests that adding a psychosocial mood management component to a standard smoking cessation intervention, compared with standard smoking cessation alone, increases cessation rates for smokers with current depression or past depression (see summary of findings Table for the main comparison for smokers with current depression). Subgroup analyses show that the outcome was not influenced by any of the following: the length of follow‐up, depression measurement, depression group in study, antidepressant use, antidepressant exclusion criteria, published or unpublished data, format of intervention, level of behavioural support, or additional pharmacotherapy.

Bupropion seems to increase long‐term cessation for people with past depression, although the evidence is relatively weak due to the small number of studies and post hoc subgroups for all the studies. We found no strong evidence for long‐term abstinence due to bupropion use in smokers with current depression (summary of findings Table 2 for bupropion use in smokers with current depression). There were not enough trial data to evaluate the effectiveness of the other antidepressants for smoking cessation. There was also not enough evidence for the group of trials which investigated interventions without specific components for handling depression, including NRT and psychosocial interventions.

An alternative explanation for the positive effect of the psychosocial mood management component might be the higher number of sessions in the experimental condition for some of the included studies (Hall 1994; Hall 1998; Rabius 2007b; Van der Meer 2010), as the number of sessions might be associated with a larger effect size in quitting. Three reviews indirectly compared the number of sessions and quitting, for which two reviews did not find an association (Pan 2006; Stead 2006) and one found a positive association (Fiore 2008). Another review looked at the direct evidence by including only studies where participants were randomised to more sessions or fewer sessions, and no effect was found to support the effect of number of sessions on quitting (Lancaster 2005). Given these findings and the modest number of studies that did not control for number of sessions, it seems unlikely that the positive effect of the psychosocial mood management component is the result of a higher number of sessions; but we cannot rule out this possibility.

We have no explanation for why bupropion probably seems to work for smokers with past depression and not for smokers with current depression. This result is counterintuitive, although the strength of the evidence for bupropion is relatively weak due to the small number of studies and the post hoc subgroups for all the studies. More trials are needed to evaluate the effectiveness of bupropion for smokers with current depression and also for smokers with past depression

Quality of the evidence

In this review, we found most evidence for the effectiveness of smoking cessation interventions with a psychosocial mood management component for smokers with current or past depression. Although the number of trials was relatively small, there was no significant heterogeneity among them. There is weak evidence for the effectiveness of bupropion for smokers with past depression, but there aren't enough trials to evaluate the effectiveness of the other antidepressants for smoking cessation.

The evidence for the other interventions without specific components for depression was very limited, despite good evidence of their benefit in other populations of smokers. Hence, it is possible that the lack of efficacy for these interventions is likely due to the lack of evidence rather than to negative results from trials. The effectiveness of these interventions is mostly studied in the general group of smokers, with smokers with depression often being excluded from these trials. In the group of interventions without specific components for depression, only two trials had an inclusion criterion of depression, therefore most of our data came from trials with post hoc subgroups.

Potential biases in the review process

This review has several limitations. One limitation is that few RCTs have been conducted that test smoking cessation interventions for smokers with depression. Therefore, we decided to also include trials with subgroups of depression. Much of the data came from post hoc subgroups and pre‐stated subgroups as only seven trials had an inclusion criterion of depression. Thus the findings for the results should be interpreted cautiously.

Another limitation was that major past depression defined as a dichotomous 'yes or no' variable may have poor predictive power because it does not differentiate between smokers with a single episode or those with multiple episodes of past major depression. Psychosocial mood management interventions might be more effective for recurrent past depression compared with single past depression (Brown 2001). Furthermore, the multi‐item scales such as CES‐D, BDI, and The Hamilton Depression Scale are frequently used in smoking cessation research but are not replacements for clinical diagnosis or semi‐structured clinical interviews (for example DSM‐IV‐TR). In this review self‐reported single item questions and multi‐item scales and clinical diagnosis were taken together for defining depression. Therefore, this review contains heterogeneity among participants classified as depressed.

Because there were almost no trials with an inclusion criterion of depression, we also included subgroups of people with past and current depression. This means that we had to ask many authors for unpublished data that had not been subjected to peer‐review processes, although the studies from which they originated were. We cannot rule out that unpublished data might be a limitation of this review. However, the strength of unpublished data is that the data might decrease the degree of publication bias. Furthermore, subgroup analyses showed that the outcome was not influenced by published or unpublished data.

Finally, the variations in outcome measurements reported by the studies hampered the comparison of the trials. Some trials used point prevalence while other used sustained abstinence (continuous abstinence or prolonged abstinence), and some used both. In this review we preferred sustained abstinence and biochemically validated abstinence, and included the longest follow‐up. The outcome was abstinence from smoking for six months or longer. Thus in the meta‐analysis for some studies we used the point prevalence data when no data on sustained abstinence were available and for other studies we used sustained abstinence. For most trials the point prevalence data and sustained abstinence data did not favour either the experimental or control condition; but this was not always the case. For example in Brown 2001 the continuous abstinence favours the experimental group, as does the point prevalence data.

Agreements and disagreements with other studies or reviews

In a recent systematic review of smoking cessation interventions for patients with depression, Gierisch 2011 showed that adding psychosocial mood management has a positive effect (5 trials, N = 402, RR 1.41, 95% CI 1.01 to 1.96) for smoking cessation. We performed separate analyses for smokers with current depression and past depression and found comparable findings for both groups. Their review also showed a positive but not significant effect for antidepressants (3 trials, N = 255, RR 1.31, 95% CI 0.73 to 2.34). In our review we did not pool different antidepressants for smoking cessation. However, our results appear to show a positive effect for bupropion for both smokers with current and past depression, although we found only a significant effect for past depression. However, as previously described, these latter findings should be interpreted with caution. Gierisch 2011 found three NRT trials that demonstrated small, positive effects, which were not significant, on smoking cessation rates for smokers with depression. We also found positive but not significant effects for the use of NRT when compared with placebo for smokers with current depression and those with past depression.

Process of identifying trials for inclusion.
Figuras y tablas -
Figure 1

Process of identifying trials for inclusion.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figuras y tablas -
Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Forest plot of comparison: 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up.
Figuras y tablas -
Figure 3

Forest plot of comparison: 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up.

Forest plot of comparison: 2 Psychosocal mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up.
Figuras y tablas -
Figure 4

Forest plot of comparison: 2 Psychosocal mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up.

Forest plot of comparison: 3 Bupropion versus placebo for current depression. Abstinence at six months or greater follow‐up
Figuras y tablas -
Figure 5

Forest plot of comparison: 3 Bupropion versus placebo for current depression. Abstinence at six months or greater follow‐up

Forest plot of comparison: 6 Bupropion versus placebo for smokers with past depression. Abstinence at six months or greater follow‐up.
Figuras y tablas -
Figure 6

Forest plot of comparison: 6 Bupropion versus placebo for smokers with past depression. Abstinence at six months or greater follow‐up.

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 1 Psychosocial mood management versus control for smokers with current depression.
Figuras y tablas -
Analysis 1.1

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 1 Psychosocial mood management versus control for smokers with current depression.

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 2 Psychosocial mood management versus control for smokers with current depression (without Carmody 2008 and Vickers 2009).
Figuras y tablas -
Analysis 1.2

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 2 Psychosocial mood management versus control for smokers with current depression (without Carmody 2008 and Vickers 2009).

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 3 Length of follow‐up.
Figuras y tablas -
Analysis 1.3

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 3 Length of follow‐up.

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 4 Current depression measurement.
Figuras y tablas -
Analysis 1.4

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 4 Current depression measurement.

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 5 Depression group in study.
Figuras y tablas -
Analysis 1.5

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 5 Depression group in study.

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 6 Published or unpublished data.
Figuras y tablas -
Analysis 1.6

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 6 Published or unpublished data.

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 7 Antidepressants use participants exclusion criteria.
Figuras y tablas -
Analysis 1.7

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 7 Antidepressants use participants exclusion criteria.

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 8 Format intervention.
Figuras y tablas -
Analysis 1.8

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 8 Format intervention.

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 9 Level of behavioural support.
Figuras y tablas -
Analysis 1.9

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 9 Level of behavioural support.

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 10 Additional pharmacotherapy.
Figuras y tablas -
Analysis 1.10

Comparison 1 Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up, Outcome 10 Additional pharmacotherapy.

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 1 Psychosocial mood management versus control for smokers with past depression.
Figuras y tablas -
Analysis 2.1

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 1 Psychosocial mood management versus control for smokers with past depression.

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 2 Psychosocial mood management versus control for smokers with past depression (without Carmody 2008).
Figuras y tablas -
Analysis 2.2

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 2 Psychosocial mood management versus control for smokers with past depression (without Carmody 2008).

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 3 Length of follow‐up.
Figuras y tablas -
Analysis 2.3

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 3 Length of follow‐up.

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 4 Past depression measurement.
Figuras y tablas -
Analysis 2.4

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 4 Past depression measurement.

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 5 Depression group in study.
Figuras y tablas -
Analysis 2.5

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 5 Depression group in study.

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 6 Published or unpublished data.
Figuras y tablas -
Analysis 2.6

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 6 Published or unpublished data.

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 7 Antidepressants use participants exclusion criteria.
Figuras y tablas -
Analysis 2.7

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 7 Antidepressants use participants exclusion criteria.

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 8 Format intervention.
Figuras y tablas -
Analysis 2.8

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 8 Format intervention.

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 9 Level of behavioural support.
Figuras y tablas -
Analysis 2.9

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 9 Level of behavioural support.

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 10 Additional pharmacotherapy.
Figuras y tablas -
Analysis 2.10

Comparison 2 Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up, Outcome 10 Additional pharmacotherapy.

Comparison 3 Bupropion versus placebo for current depression. Abstinence at six months or greater follow‐up, Outcome 1 Bupropion versus placebo.
Figuras y tablas -
Analysis 3.1

Comparison 3 Bupropion versus placebo for current depression. Abstinence at six months or greater follow‐up, Outcome 1 Bupropion versus placebo.

Comparison 4 Fluoxetine versus placebo for current depression. Abstinence at six months or greater follow‐up, Outcome 1 Fluoxetine versus placebo.
Figuras y tablas -
Analysis 4.1

Comparison 4 Fluoxetine versus placebo for current depression. Abstinence at six months or greater follow‐up, Outcome 1 Fluoxetine versus placebo.

Comparison 5 Paroxetine versus placebo for current depression. Abstinence at six months or greater follow‐up, Outcome 1 Paroxetine versus placebo.
Figuras y tablas -
Analysis 5.1

Comparison 5 Paroxetine versus placebo for current depression. Abstinence at six months or greater follow‐up, Outcome 1 Paroxetine versus placebo.

Comparison 6 Bupropion versus placebo for past depression. Abstinence at six months or greater follow‐up, Outcome 1 Bupropion versus placebo.
Figuras y tablas -
Analysis 6.1

Comparison 6 Bupropion versus placebo for past depression. Abstinence at six months or greater follow‐up, Outcome 1 Bupropion versus placebo.

Comparison 7 Fluoxetine versus placebo for past depression. Abstinence at six months or greater follow‐up, Outcome 1 Fluoxetine versus placebo.
Figuras y tablas -
Analysis 7.1

Comparison 7 Fluoxetine versus placebo for past depression. Abstinence at six months or greater follow‐up, Outcome 1 Fluoxetine versus placebo.

Comparison 8 Nortriptyline versus placebo for past depression. Abstinence at six months or greater follow‐up, Outcome 1 Nortriptyline versus placebo.
Figuras y tablas -
Analysis 8.1

Comparison 8 Nortriptyline versus placebo for past depression. Abstinence at six months or greater follow‐up, Outcome 1 Nortriptyline versus placebo.

Comparison 9 Paroxetine versus placebo for past depression. Abstinence at six months or greater follow‐up, Outcome 1 Paroxetine versus placebo.
Figuras y tablas -
Analysis 9.1

Comparison 9 Paroxetine versus placebo for past depression. Abstinence at six months or greater follow‐up, Outcome 1 Paroxetine versus placebo.

Comparison 10 Selegiline versus placebo for past depression. Abstinence at six months or greater follow‐up, Outcome 1 Selegiline versus placebo.
Figuras y tablas -
Analysis 10.1

Comparison 10 Selegiline versus placebo for past depression. Abstinence at six months or greater follow‐up, Outcome 1 Selegiline versus placebo.

Comparison 11 Sertraline versus placebo for past depression. Abstinence at six months or greater follow‐up, Outcome 1 Sertraline versus placebo.
Figuras y tablas -
Analysis 11.1

Comparison 11 Sertraline versus placebo for past depression. Abstinence at six months or greater follow‐up, Outcome 1 Sertraline versus placebo.

Comparison 12 Psychosocial intervention for current depression. Abstinence at six months or greater follow‐up, Outcome 1 Telephone counselling versus self help.
Figuras y tablas -
Analysis 12.1

Comparison 12 Psychosocial intervention for current depression. Abstinence at six months or greater follow‐up, Outcome 1 Telephone counselling versus self help.

Comparison 13 NRT versus placebo for past depression. Abstinence at six months or greater follow‐up, Outcome 1 NRT versus placebo.
Figuras y tablas -
Analysis 13.1

Comparison 13 NRT versus placebo for past depression. Abstinence at six months or greater follow‐up, Outcome 1 NRT versus placebo.

Summary of findings for the main comparison. Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or longer follow‐up

Psychosocial mood management versus control for smokers with current depression. Abstinence at 6 m or longer follow‐up

Patient or population: smokers with current depression1
Intervention: Psychosocial mood management

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Psychosocial mood management

Smoking cessation
Biochemical validation (minority) and self report
Follow‐up: 6 ‐ 12 months

88 per 10002

130 per 1000
(100 to 170)

RR 1.47
(1.13 to 1.92)

1844
(11 studies)

⊕⊕⊝⊝
low3,4

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Smokers with past depression evaluated separately see Summary of findings table 3; Summary of findings table 4.
2 Baseline control risk calculated as average across included studies.
3 The Risk of Bias has been downgraded as most of the studies included under this outcome contained unclear or high risks, especially where blinding or incomplete outcome data were concerned.
4 Total number of events fewer than 300.

Figuras y tablas -
Summary of findings for the main comparison. Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or longer follow‐up
Summary of findings 2. Bupropion versus control for smokers with current depression. Abstinence at six months or longer follow‐up

Bupropion vs control for smokers with current depression. Abstinence at 6 m or longer follow‐up

Patient or population: smokers with current depression
Intervention: Bupropion

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Bupropion

Bupropion versus placebo
All biochemically validated
Follow‐up: 6 ‐ 12 months

112 per 10001

153 per 1000
(93 to 253)

RR 1.37
(0.83 to 2.27)

410
(5 studies)

⊕⊕⊝⊝
low2,3,4

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Baseline risk calculated as average across all control groups.
2 The Risk of Bias has been downgraded as all of the studies included under this outcome contained some unclear risks.
3 There were no differences across two subgroups for Bupropion use (1) without additional NRT; 2) with NRT across both control and intervention). Taking NRT did not change the overall effect.
4 Number of events is fewer than 300, and the confidence intervals encompass both negative and positive outcomes.

Figuras y tablas -
Summary of findings 2. Bupropion versus control for smokers with current depression. Abstinence at six months or longer follow‐up
Summary of findings 3. Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or longer follow‐up

Psychosocial mood management versus control for smokers with past depression. Abstinence at 6 months or longer follow‐up.

Patient or population: patients with smokers with past depression
Intervention: Psychosocial mood management

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Psychosocial mood management

Smoking cessation
Biochemical validation (majority) and self report
Follow‐up: 6‐12 months

142 per 10001

201 per 1000
(161 to 252)

RR 1.41
(1.13 to 1.77)

1496
(13 studies1)

⊕⊕⊝⊝
low2,3

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Baseline control risk calculated as average across included studies.
2 The Risk of Bias has been downgraded as most of the studies included under this outcome contained unclear or high risks, especially where allocation concealment, blinding or incomplete data were concerned.
3 Total number of events fewer than 300.

Figuras y tablas -
Summary of findings 3. Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or longer follow‐up
Summary of findings 4. Bupropion versus control for smokers with past depression. Abstinence at six months or longer follow‐up

Bupropion for smokers with past depression

Patient or population: patients with smokers with past depression
Intervention: Bupropion

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Bupropion

Bupropion versus placebo
Biochemical validation (majority) and self report
Follow‐up: 6‐12 months

123 per 10001

251 per 1000
(161 to 391)

RR 2.04
(1.31 to 3.18)2

404
(4 studies)

⊕⊕⊝⊝
low3,4

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Baseline control risk calculated as average across included studies.
2 There were no differences across two subgroups for Bupropion use (1) without additional NRT; 2) with NRT across both control and intervention). Taking NRT did not change the overall effect.
3 The risk of bias has been downgraded as all the studies included under this outcome contained unclear or high risks, mainly where blinding or incomplete outcome data were concerned.
4 Total number of events fewer than 300.

Figuras y tablas -
Summary of findings 4. Bupropion versus control for smokers with past depression. Abstinence at six months or longer follow‐up
Comparison 1. Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Psychosocial mood management versus control for smokers with current depression Show forest plot

11

1844

Risk Ratio (M‐H, Fixed, 95% CI)

1.47 [1.13, 1.92]

2 Psychosocial mood management versus control for smokers with current depression (without Carmody 2008 and Vickers 2009) Show forest plot

9

1658

Risk Ratio (M‐H, Fixed, 95% CI)

1.42 [1.07, 1.88]

3 Length of follow‐up Show forest plot

11

1844

Risk Ratio (M‐H, Fixed, 95% CI)

1.47 [1.13, 1.92]

3.1 abstinence 6m follow‐up

5

1292

Risk Ratio (M‐H, Fixed, 95% CI)

1.45 [0.99, 2.11]

3.2 abstinence 12m follow‐up

6

552

Risk Ratio (M‐H, Fixed, 95% CI)

1.50 [1.03, 2.18]

4 Current depression measurement Show forest plot

11

1844

Risk Ratio (M‐H, Fixed, 95% CI)

1.47 [1.13, 1.92]

4.1 current major depression

5

257

Risk Ratio (M‐H, Fixed, 95% CI)

1.71 [0.90, 3.26]

4.2 multi item depressive symptoms

5

536

Risk Ratio (M‐H, Fixed, 95% CI)

1.56 [1.03, 2.36]

4.3 one item depressive symptoms

1

1051

Risk Ratio (M‐H, Fixed, 95% CI)

1.31 [0.86, 1.98]

5 Depression group in study Show forest plot

11

1844

Risk Ratio (M‐H, Fixed, 95% CI)

1.47 [1.13, 1.92]

5.1 depression inclusion criteria

2

128

Risk Ratio (M‐H, Fixed, 95% CI)

2.26 [0.34, 15.08]

5.2 depression subgroup pre stated

5

242

Risk Ratio (M‐H, Fixed, 95% CI)

1.18 [0.64, 2.20]

5.3 depression subgroup posthoc

4

1474

Risk Ratio (M‐H, Fixed, 95% CI)

1.52 [1.13, 2.06]

6 Published or unpublished data Show forest plot

11

1844

Risk Ratio (M‐H, Fixed, 95% CI)

1.47 [1.13, 1.92]

6.1 published data

3

181

Risk Ratio (M‐H, Fixed, 95% CI)

2.25 [0.68, 7.46]

6.2 unpublished data

8

1663

Risk Ratio (M‐H, Fixed, 95% CI)

1.43 [1.09, 1.88]

7 Antidepressants use participants exclusion criteria Show forest plot

11

1844

Risk Ratio (M‐H, Fixed, 95% CI)

1.47 [1.13, 1.92]

7.1 antidepressants use is an exclusion criteria

3

350

Risk Ratio (M‐H, Fixed, 95% CI)

1.42 [0.88, 2.29]

7.2 antidepressants use is not an exclusion criteria

8

1494

Risk Ratio (M‐H, Fixed, 95% CI)

1.49 [1.08, 2.05]

8 Format intervention Show forest plot

11

1844

Risk Ratio (M‐H, Fixed, 95% CI)

1.47 [1.13, 1.92]

8.1 group

1

45

Risk Ratio (M‐H, Fixed, 95% CI)

0.42 [0.09, 1.85]

8.2 group plus self help

1

68

Risk Ratio (M‐H, Fixed, 95% CI)

4.72 [0.24, 94.85]

8.3 individual

2

120

Risk Ratio (M‐H, Fixed, 95% CI)

2.0 [0.54, 7.36]

8.4 individual plus telephone

1

126

Risk Ratio (M‐H, Fixed, 95% CI)

2.19 [0.90, 5.33]

8.5 telephone

1

1051

Risk Ratio (M‐H, Fixed, 95% CI)

1.31 [0.86, 1.98]

8.6 telephone plus self help

1

237

Risk Ratio (M‐H, Fixed, 95% CI)

1.62 [0.96, 2.76]

8.7 self help

4

197

Risk Ratio (M‐H, Fixed, 95% CI)

1.56 [0.77, 3.18]

9 Level of behavioural support Show forest plot

11

1844

Risk Ratio (M‐H, Fixed, 95% CI)

1.47 [1.13, 1.92]

9.1 multi session behavioural support

7

1647

Risk Ratio (M‐H, Fixed, 95% CI)

1.46 [1.09, 1.94]

9.2 no behavioural support

4

197

Risk Ratio (M‐H, Fixed, 95% CI)

1.56 [0.77, 3.18]

10 Additional pharmacotherapy Show forest plot

9

1562

Risk Ratio (M‐H, Fixed, 95% CI)

1.52 [1.11, 2.09]

10.1 pharmacotherapy

3

254

Risk Ratio (M‐H, Fixed, 95% CI)

2.20 [0.98, 4.94]

10.2 no pharmacotherapy

6

1308

Risk Ratio (M‐H, Fixed, 95% CI)

1.41 [1.00, 2.00]

Figuras y tablas -
Comparison 1. Psychosocial mood management versus control for smokers with current depression. Abstinence at six months or greater follow‐up
Comparison 2. Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Psychosocial mood management versus control for smokers with past depression Show forest plot

13

1496

Risk Ratio (M‐H, Fixed, 95% CI)

1.41 [1.13, 1.77]

2 Psychosocial mood management versus control for smokers with past depression (without Carmody 2008) Show forest plot

12

1394

Risk Ratio (M‐H, Fixed, 95% CI)

1.38 [1.09, 1.74]

3 Length of follow‐up Show forest plot

13

1496

Risk Ratio (M‐H, Fixed, 95% CI)

1.41 [1.13, 1.77]

3.1 abstinence 6m follow‐up

2

247

Risk Ratio (M‐H, Fixed, 95% CI)

2.29 [1.13, 4.64]

3.2 abstinence 12m follow‐up

11

1249

Risk Ratio (M‐H, Fixed, 95% CI)

1.32 [1.04, 1.68]

4 Past depression measurement Show forest plot

13

1496

Risk Ratio (M‐H, Fixed, 95% CI)

1.41 [1.13, 1.77]

4.1 past major depression

12

1394

Risk Ratio (M‐H, Fixed, 95% CI)

1.38 [1.09, 1.74]

4.2 single item depressive symptoms

1

102

Risk Ratio (M‐H, Fixed, 95% CI)

2.01 [0.86, 4.68]

5 Depression group in study Show forest plot

13

1496

Risk Ratio (M‐H, Fixed, 95% CI)

1.41 [1.13, 1.77]

5.1 depression inclusion criteria

3

693

Risk Ratio (M‐H, Fixed, 95% CI)

1.45 [1.04, 2.02]

5.2 depression subgroup pre stated

7

547

Risk Ratio (M‐H, Fixed, 95% CI)

1.33 [0.91, 1.93]

5.3 depression subgroup post hoc

3

256

Risk Ratio (M‐H, Fixed, 95% CI)

1.49 [0.86, 2.60]

6 Published or unpublished data Show forest plot

13

1496

Risk Ratio (M‐H, Fixed, 95% CI)

1.41 [1.13, 1.77]

6.1 published data

7

901

Risk Ratio (M‐H, Fixed, 95% CI)

1.61 [1.21, 2.14]

6.2 unpublished data

6

595

Risk Ratio (M‐H, Fixed, 95% CI)

1.12 [0.76, 1.63]

7 Antidepressants use participants exclusion criteria Show forest plot

13

1496

Risk Ratio (M‐H, Fixed, 95% CI)

1.41 [1.13, 1.77]

7.1 antidepressants use is an exclusion criteria

6

910

Risk Ratio (M‐H, Fixed, 95% CI)

1.39 [1.04, 1.86]

7.2 antidepressants use is not an exclusion criteria

7

586

Risk Ratio (M‐H, Fixed, 95% CI)

1.45 [1.01, 2.09]

8 Format intervention Show forest plot

13

1496

Risk Ratio (M‐H, Fixed, 95% CI)

1.41 [1.13, 1.77]

8.1 group

5

292

Risk Ratio (M‐H, Fixed, 95% CI)

1.44 [0.87, 2.36]

8.2 group plus self help

1

179

Risk Ratio (M‐H, Fixed, 95% CI)

0.70 [0.32, 1.52]

8.3 individual

1

194

Risk Ratio (M‐H, Fixed, 95% CI)

1.56 [0.67, 3.65]

8.4 individual plus telephone

1

102

Risk Ratio (M‐H, Fixed, 95% CI)

2.01 [0.86, 4.68]

8.5 telephone plus self help

1

485

Risk Ratio (M‐H, Fixed, 95% CI)

1.70 [1.16, 2.49]

8.6 self help

4

244

Risk Ratio (M‐H, Fixed, 95% CI)

1.16 [0.70, 1.93]

9 Level of behavioural support Show forest plot

13

1496

Risk Ratio (M‐H, Fixed, 95% CI)

1.41 [1.13, 1.77]

9.1 multi session behavioural support

9

1252

Risk Ratio (M‐H, Fixed, 95% CI)

1.48 [1.15, 1.91]

9.2 no behavioural support

4

244

Risk Ratio (M‐H, Fixed, 95% CI)

1.16 [0.70, 1.93]

10 Additional pharmacotherapy Show forest plot

9

794

Risk Ratio (M‐H, Fixed, 95% CI)

1.30 [0.95, 1.79]

10.1 pharmacotherapy

2

148

Risk Ratio (M‐H, Fixed, 95% CI)

1.99 [1.01, 3.92]

10.2 no pharmacotherapy

7

646

Risk Ratio (M‐H, Fixed, 95% CI)

1.14 [0.80, 1.65]

Figuras y tablas -
Comparison 2. Psychosocial mood management versus control for smokers with past depression. Abstinence at six months or greater follow‐up
Comparison 3. Bupropion versus placebo for current depression. Abstinence at six months or greater follow‐up

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Bupropion versus placebo Show forest plot

5

410

Risk Ratio (M‐H, Fixed, 95% CI)

1.37 [0.83, 2.27]

1.1 Bupropion alone versus placebo

4

355

Risk Ratio (M‐H, Fixed, 95% CI)

1.32 [0.78, 2.24]

1.2 Bupropion and NRT versus placebo and NRT

1

55

Risk Ratio (M‐H, Fixed, 95% CI)

1.93 [0.38, 9.68]

Figuras y tablas -
Comparison 3. Bupropion versus placebo for current depression. Abstinence at six months or greater follow‐up
Comparison 4. Fluoxetine versus placebo for current depression. Abstinence at six months or greater follow‐up

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Fluoxetine versus placebo Show forest plot

2

64

Risk Ratio (M‐H, Fixed, 95% CI)

1.02 [0.14, 7.32]

Figuras y tablas -
Comparison 4. Fluoxetine versus placebo for current depression. Abstinence at six months or greater follow‐up
Comparison 5. Paroxetine versus placebo for current depression. Abstinence at six months or greater follow‐up

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Paroxetine versus placebo Show forest plot

1

43

Risk Ratio (M‐H, Fixed, 95% CI)

1.09 [0.34, 3.51]

Figuras y tablas -
Comparison 5. Paroxetine versus placebo for current depression. Abstinence at six months or greater follow‐up
Comparison 6. Bupropion versus placebo for past depression. Abstinence at six months or greater follow‐up

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Bupropion versus placebo Show forest plot

4

404

Risk Ratio (M‐H, Fixed, 95% CI)

2.04 [1.31, 3.18]

1.1 Bupropion alone versus placebo

4

317

Risk Ratio (M‐H, Fixed, 95% CI)

1.57 [0.96, 2.58]

1.2 Bupropion and NRT versus placebo and NRT

1

87

Risk Ratio (M‐H, Fixed, 95% CI)

5.46 [1.71, 17.40]

Figuras y tablas -
Comparison 6. Bupropion versus placebo for past depression. Abstinence at six months or greater follow‐up
Comparison 7. Fluoxetine versus placebo for past depression. Abstinence at six months or greater follow‐up

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Fluoxetine versus placebo Show forest plot

2

147

Risk Ratio (M‐H, Fixed, 95% CI)

1.18 [0.47, 2.93]

Figuras y tablas -
Comparison 7. Fluoxetine versus placebo for past depression. Abstinence at six months or greater follow‐up
Comparison 8. Nortriptyline versus placebo for past depression. Abstinence at six months or greater follow‐up

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Nortriptyline versus placebo Show forest plot

1

65

Risk Ratio (M‐H, Fixed, 95% CI)

1.03 [0.41, 2.61]

Figuras y tablas -
Comparison 8. Nortriptyline versus placebo for past depression. Abstinence at six months or greater follow‐up
Comparison 9. Paroxetine versus placebo for past depression. Abstinence at six months or greater follow‐up

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Paroxetine versus placebo Show forest plot

1

60

Risk Ratio (M‐H, Fixed, 95% CI)

2.03 [0.86, 4.74]

Figuras y tablas -
Comparison 9. Paroxetine versus placebo for past depression. Abstinence at six months or greater follow‐up
Comparison 10. Selegiline versus placebo for past depression. Abstinence at six months or greater follow‐up

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Selegiline versus placebo Show forest plot

1

26

Risk Ratio (M‐H, Fixed, 95% CI)

3.75 [0.20, 71.12]

Figuras y tablas -
Comparison 10. Selegiline versus placebo for past depression. Abstinence at six months or greater follow‐up
Comparison 11. Sertraline versus placebo for past depression. Abstinence at six months or greater follow‐up

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Sertraline versus placebo Show forest plot

1

134

Risk Ratio (M‐H, Fixed, 95% CI)

0.71 [0.30, 1.64]

Figuras y tablas -
Comparison 11. Sertraline versus placebo for past depression. Abstinence at six months or greater follow‐up
Comparison 12. Psychosocial intervention for current depression. Abstinence at six months or greater follow‐up

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Telephone counselling versus self help Show forest plot

2

5421

Risk Ratio (M‐H, Fixed, 95% CI)

1.17 [0.98, 1.39]

Figuras y tablas -
Comparison 12. Psychosocial intervention for current depression. Abstinence at six months or greater follow‐up
Comparison 13. NRT versus placebo for past depression. Abstinence at six months or greater follow‐up

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 NRT versus placebo Show forest plot

3

432

Risk Ratio (M‐H, Fixed, 95% CI)

1.17 [0.85, 1.60]

Figuras y tablas -
Comparison 13. NRT versus placebo for past depression. Abstinence at six months or greater follow‐up