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Web-based cessation programs are now common for intervening with smokers. However, it remains unclear how acceptable or effective these interventions are among people with affective disorders and symptoms (ADS; eg, depression and anxiety). Research examining this is extremely limited, with mixed results on cessation rates. Additional large studies are needed to more fully understand whether Web-based interventions are similarly used and equally effective among people with and without affective disorder symptomology. If not, more targeted Web-based interventions may be required.
The goal of the research was to compare Web-based treatment acceptability (defined by satisfaction and use) and 12-month cessation outcomes between smokers with and without ADS.
Participants (N=2512) were adult smokers enrolled in a randomized, comparative effectiveness trial of two Web-based smoking interventions designed for the general population of smokers. At baseline, participants reported demographic and smoking characteristics and completed measures assessing ADS. Participants were then classified into subgroups based on their self-reported ADS—either into a no ADS group or into six nonmutually exclusive subgroups: depression, posttraumatic stress disorder (PTSD), panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), and more than one ADS. Surveys at 12 months postrandomization included subjective ratings of treatment acceptability and self-reported smoking cessation. Treatment use (ie, number of log-ins and total duration of exposure) was assessed via automated records.
Relative to the no ADS group, all six ADS subgroups reported significantly greater satisfaction with their assigned Web treatment program, but they spent less time logged in than those with no ADS. For number of log-ins, a treatment arm by ADS group interaction was observed across all ADS subgroups except GAD, suggesting that relative to the no ADS group, they logged in less to one website but not the other. At the 12-month follow-up, abstinence rates in the no ADS group (153/520, 29.42%) were significantly higher than for participants who screened positive for depression (306/1267, 24.15%;
Despite reporting higher levels of treatment satisfaction, most smokers with ADS used their assigned intervention less often and had lower quit rates than smokers with no ADS at treatment onset. The results support the need for developing more targeted interventions for smokers with ADS.
Clinical Trials.gov NCT01812278; https://clinicaltrials.gov/ct2/show/NCT01812278 (Archived by WebCite at http://www.webcitation.org/78L9cNdG4)
With lifetime prevalence rates ranging from 16.6% to 28.8%, affective disorders such as depression and anxiety are among the most common mental health conditions in the United States [
One way to increase rates of cessation among smokers with ADS is to make treatment more accessible. This can be accomplished with interventions that are low-burden, low-cost, and high-reach, including Web-based interventions. Indeed, each year an estimated 12 million smokers look online for help to quit smoking [
Based on research with other (non-Web) treatment modalities, one might expect that standard Web-based interventions would be less effective for smokers with ADS relative to those who do not have this symptomology [
To best guide these targeted treatment development efforts, it is important to understand how smokers with different ADS respond differentially to Web-based cessation programs relative to smokers without ADS. Thus, the primary goal of this study was to compare treatment acceptability, defined both by self-reported satisfaction and treatment use, and 12-month abstinence rates among smokers with and without symptoms of one or more common affective disorders (depression, social anxiety disorder [SAD], generalized anxiety disorder [GAD], panic disorder [PD], and PTSD). All participants were recruited as part of a prior comparative effectiveness trial of two online interventions, each targeting the general population of smokers and testing two different Web-based interventions [
A comprehensive description of study methods can be found in the main outcomes paper [
At baseline, participants reported demographic characteristics including age, gender, race and ethnicity, marital status, education, employment status, and sexual orientation. Level of nicotine dependence was assessed using the Fagerström Test for Nicotine Dependence (FTND) [
To assess for elevated levels depression and anxiety, participants completed validated self-report screening instruments for five common affective disorders. Symptoms of depression were assessed with the Center for Epidemiologic Studies Depression scale using the recommended score of ≥16 to indicate elevated symptoms [
Smokers who screened positive for one or more affective disorders were classified into six nonmutually exclusive subgroups based on their baseline affective disorder symptomology: depression, PTSD, PD, GAD, SAD, and more than one affective disorder. Thus, these participants could be classified into more than one ADS subgroup. Participants who did not screen positive for any affective disorder listed above were categorized as not having elevated symptoms of any affective disorder (No AD).
As a subjective measure of treatment acceptability, participants answered three treatment satisfaction questions at the 3-month follow-up survey (eg, How useful did you find your assigned website?). Response options ranged from 1 (not at all) to 5 (very much), with a score ≥2 (ie, somewhat or more) indicating participant satisfaction. Additionally, website engagement over the 12-month period was calculated from data automatically logged by the secured server as indices of two objective measures of treatment acceptability—number of log-ins (primary use outcome) and total minutes spent on the website (secondary use outcome). We qualified user activity occurring more than 15 minutes after the last instance of activity as a new log-in.
Consistent with primary cessation outcomes reported in the parent trial, the primary cessation outcome for this study was self-reported 30-day point prevalence abstinence (PPA) (no smoking, not even a puff in the last 30 days) at 12 months postrandomization analyzed using a complete case methodology. The secondary cessation outcome also used 30-day PPA but with missing values imputed as smoking. Biochemical confirmation was not used in accordance with recommendations for assessing smoking status in large, population-based cessation trials in which there is no face-to-face contact and the demand characteristics for false reporting are minimal [
For descriptive purposes, baseline characteristic variables of participants with ADS (each diagnostic group considered separately) were examined and compared against the no AD group using chi-square tests for categorical variables and
Of the 2512 participants who provided sufficient data on the screening measures to establish whether the screen was positive or negative, the majority (1938/2512, 77.15%) screened positive for at least one affective disorder at baseline. Of those, the majority screened positive for depression (1470/1938, 75.85%), followed by PTSD (1383/1938, 71.36%), PD (1145/1938, 59.08%), GAD (903/1938, 46.59%), and SAD (797/1938, 41.25%). Additionally, as can be seen in
The baseline characteristics of all groups can be found in
As can be seen in
With regard to objective website use data, our hypotheses were partially supported. Relative to the no ADS group, the GAD group logged in to their assigned website significantly fewer times (
Frequency and proportion of participants screening positive for multiple affective disorders.
ADS subgroups | Depression (n=1470), |
PTSDa (n=1383), |
PDb (n=1145), |
GADc (n=903), |
SADd (n=797), |
Depression | — | 1152/1378 (83.59) | 854/1143 (74.72) | 836/900 (92.89) | 697/795 (87.67) |
PTSD | 1152/1450 (79.45) | — | 836/1144 (73.08) | 796/900 (88.44) | 664/796 (82.42) |
PD | 854/1343 (63.59) | 836/1285 (65.05) | — | 597/847 (70.48) | 479/733 (65.35) |
GAD | 836/1364 (61.29) | 796/1375 (57.89) | 597/1139 (52.14) | — | 506/796 (63.57) |
SAD | 697/1468 (47.48) | 664/1382 (48.05) | 479/1145 (41.83) | 506/902 (56.10) | — |
aPTSD: posttraumatic stress disorder.
bPD: panic disorder.
cGAD: generalized anxiety disorder.
dSAD: social anxiety disorder.
Baseline characteristics by affective disorder symptomology group.
Characteristics | Comparison group (no ADSa; n=574) | Affective disorder symptomology subgroup | ||||||
Depression |
PTSDb |
PDc |
GADd |
SADe |
2+ ADSf |
|||
Age in years, mean (SD) | 49.1 (13.0) | 44.5 (13.5)g | 43.5 (13.2)g | 43.9 (13.1)g | 42.3 (13.4)g | 43.3 (13.4)g | 43.9 (13.3)g | |
Female, n (%) | 441 (76.8) | 1181 (80.34) | 1096 (79.25) | 916 (80.00) | 734 (81.28)i | 653 (81.93)i | 1226 (80.18) | |
Caucasian, n (%) | 413 (71.9) | 1051 (71.49) | 962 (69.56) | 813 (71.00) | 633 (70.09) | 559 (70.14) | 1079 (70.57) | |
Hispanic, n (%) | 43 (7.5) | 134 (9.12) | 137 (9.91) | 107 (9.34) | 96 (10.63) | 80 (10.04) | 148 (9.68) | |
Married, n (%) | 232 (40.4) | 494 (33.61)h | 473 (34.20)i | 423 (36.94) | 315 (34.88)i | 255 (31.99)h | 533 (34.86)i | |
≤ HSj education, n (%) | 121 (21.1) | 454 (30.88)g | 415 (30.00)g | 330 (28.82)g | 286 (31.67)g | 266 (33.38)g | 466 (30.48)g | |
LGBk, n (%) | 40 (6.9) | 168 (11.43)h | 159 (11.49)h | 139 (12.14)h | 115 (12.74)g | 93 (11.67)h | 175 (11.45)h | |
FTNDl, mean (SD) | 5.4 (2.3) | 5.8 (2.1)g | 5.8 (2.2)g | 5.8 (2.2)g | 5.9 (2.1)g | 5.9 (2.1)g | 5.8 (2.2)g | |
>20 cpdm, n (%) | 174 (30.3) | 520 (35.37)i | 468 (33.84) | 388 (33.89) | 307 (33.99) | 268 (33.62) | 518 (33.88) | |
Past month e-cigarette use, n (%) | 179 (31.2) | 532 (36.19)i | 506 (36.59)i | 413 (36.07) | 323 (35.77) | 287 (36.01) | 553 (36.17)i | |
CQSSn, mean (SD) | 4.2 (0.7) | 3.9 (0.8)g | 3.9 (0.8)g | 4.0 (0.8)g | 4.0 (0.8)g | 3.9 (0.8)g | 3.9 (0.8)g | |
AIS-sensationso, mean (SD) | 3.1 (0.5) | 2.9 (0.5)g | 2.8 (0.4)g | 2.8 (0.4)g | 2.8 (0.4)g | 2.8 (0.4)g | 2.8 (0.4)g |
aADS: affective disorders and symptoms.
bPTSD: posttraumatic stress disorder.
cPD: panic disorder.
dGAD: generalized anxiety disorder.
eSAD: social anxiety disorder.
f2+ ADS: screened positive for 2 or more affective disorders.
g
h
i
jHS: high school.
kLGB: identify as lesbian, gay, or bisexual.
lFTND: Fagerström Test for Nicotine Dependence.
mcpd: cigarettes per day.
nCQSS: Commitment to Quitting Smoking Scale.
oAIS-sensations: Avoidance and Inflexibility Scale–sensations subscale.
Treatment acceptability (subjective and objective indices) by affective disorders and symptoms group.
Outcome variable | Comparison group (no ADSa) | Affective disorder symptomology subgroup | |||||||
Depression | PTSDb | PDb | GADd | SADe | 2+ ADSf | ||||
Satisfied with website | 359/473 |
938/1123 |
910/1090 |
734/891 |
598/699 |
540/640 |
991/1184 |
||
Website useful for quitting | 334/483 |
835/1162 |
829/1126 |
664/918 |
527/714 |
487/654 |
892/1221 |
||
Would recommend website to friend | 369/409 |
957/1021 |
920/986 |
738/793 |
604/638 |
537/575 |
1008/1079 |
||
Number of log-ins, mean (SD) | 7.9 (19.9) | –j | – | – | 5.8 (15.4)i | – | – | ||
Mean (SD) | 9.3 (21.7) | 8.6 (31.2) | 8.6 (31.5) | 8.4 (26.0) | — | 9.6 (40.6) | 8.5 (30.7) | ||
n | 270 | 733 | 690 | 561 | — | 389 | 759 | ||
Mean (SD) | 6.7 (18.1) | 4.6 (6.5)i | 4.5 (6.2)i | 4.5 (6.0)i | —l | 4.5 (5.4)i | 4.5 (6.3)i | ||
n | 304 | 737 | 693 | 584 | — | 408 | 770 | ||
Total minutes | 35.4 (107.5) | 29.2 (84.1)i | 29.3 (86.4)i | 26.9 (47.2)i | 26.3 (70.3)i | 31.4 (108.8)i | 28.6 (82.7)i |
aADS: affective disorders and symptoms.
bPTSD: posttraumatic stress disorder.
cPD: panic disorder.
dGAD: generalized anxiety disorder.
eSAD: social anxiety disorder.
f2+ ADS: screened positive for 2 or more affective disorders.
g
h
i
jIndicates significant treatment by subgroup interaction; results for these groups are separated by treatment arm in subsequent rows.
kACT: acceptance and commitment therapy.
lIndicates no significant treatment by subgroup interaction.
Cessation rates for each ADS group are shown in
Logistic regressions comparing 12-month cessation outcomes by affective disorders and symptoms group.
Characteristic | 30-day PPAa, n/N (%) | Models controlling for trial stratification variablesb and treatment arm | ||
ORc (95% CI) | ||||
No ADSd | 153/520 (29.42) | reference group | reference group | |
Depression | 306/1267 (24.15) | 0.78 (0.62-0.98) | .03 | |
PTSDe | 294/1215 (24.19) | 0.78 (0.62-0.98) | .03 | |
229/1003 (22.83) | 0.73 (0.57-0.92) | .009 | ||
GADg | 195/792 (24.62) | 0.80 (0.62-1.03) | .08 | |
SADh | 176/696 (25.29) | 0.82 (0.63-1.06) | .13 | |
2+ ADSi | 323/1332 (24.25) | 0.78 (0.62-0.98) | .03 | |
No ADS | 153/574 (26.55) | reference group | reference group | |
Depression | 306/1470 (20.82) | 0.74 (0.59-0.93) | .009 | |
PTSD | 294/1383 (21.26) | 0.76 (0.60-0.95) | .02 | |
PD | 229/1145 (20.00) | 0.70 (0.56-0.89) | .004 | |
GAD | 195/903 (21.59) | 0.77 (0.60-0.99) | .04 | |
SAD | 176/797 (22.08) | 0.79 (0.61-1.01) | .06 | |
2+ ADS | 323/1529 (21.12) | 0.75 (0.60-0.94) | .01 |
aPPA: point prevalence abstinence; no smoking, not even a puff in the last 30 days.
bTreatment stratification variables were gender, high school or less education, and smoking >20 cigarettes per day.
cOR: odds ratio.
dADS: affective disorders and symptoms.
ePTSD: posttraumatic stress disorder.
fPD: panic disorder.
gGAD: generalized anxiety disorder.
hSAD: social anxiety disorder.
i2+ ADS: screened positive for 2 or more affective disorders.
To develop a better understanding of the factors contributing to lower quit rates among the symptom subgroups who were less likely to quit, post hoc analyses examined (1) whether each ADS group uniquely predicts abstinence after including baseline variables that differed between groups and were associated with cessation in the models and (2) whether website use (ie, log-ins, total time spent on website) mediated the relationship between ADS subgroup and abstinence.
As shown in
Post hoc logistic regression analyses including additional covariates.
Characteristic | Models controlling for trial potential confounding variables | |||
ORa (95% CI) | Additional covariates | |||
No ADSb | reference group | reference group | ||
Depression | 0.90 (0.71-1.13) | .36 | FTNDc, CQSSd | |
PTSDe | 0.90 (0.71-1.14) | .39 | FTND, CQSS | |
0.81 (0.63-1.03) | .09 | FTND, CQSS | ||
2+ ADSg | 0.87 (0.69-1.10) | .26 | FTND, CQSS | |
No ADS | reference group | |||
Depression | 0.84 (0.67-1.06) | .15 | FTND, CQSS | |
PTSD | 0.87 (0.69-1.10) | .24 | FTND, CQSS | |
PD | 0.78 (0.61-0.99) | .04 | FTND, CQSS | |
2+ ADS | 0.86 (0.67-1.11) | .24 | CQSS |
aOR: odds ratio.
bADS: affective disorders and symptoms.
cFTND: Fagerström Test for Nicotine Dependence.
dCQSS: Commitment to Quitting Smoking Scale.
ePTSD: posttraumatic stress disorder.
fPD: panic disorder.
g2+ ADS: screened positive for 2 or more affective disorders.
To inform future treatment development efforts for smokers with ADS, we conducted the first study comparing treatment acceptability and long-term smoking cessation outcomes between smokers who screened positive for five common affective disorders (depression, PTSD, PD, GAD, SAD, as well as those who screened positive for ≥2 diagnostic categories). All ADS subgroups differed from the no ADS group (those who did not screen positive for any affective disorder) on most demographic and smoking characteristics assessed at baseline, similar to other reports [
All ADS subgroups had higher subjective acceptability ratings of their assigned website compared with the no ADS group. It may be that, relative to smokers without affective disorder symptomology, smokers with ADS see greater potential for Web-based smoking interventions or find the Web-based format particularly helpful and convenient, leading to greater subjective acceptability among those groups. Although unanticipated, this finding is important and demonstrates that smokers who screen positive for affective disorders are open to this treatment modality and find them helpful. However, the higher subjective ratings did not translate into greater use of the websites as one might expect. Although most ADS subgroups logged in significantly less to the Smokefree.gov website (with no differential log-in rates for the ACT-based website) relative to the no ADS group, all ADS subgroups spent significantly less time on both websites overall, which is on par with our hypotheses. The differential log-in rates for the websites across groups may mean that smokers with ADS engage more with Web-based cessation programs (ie, find them more acceptable) when they are grounded in ACT, presented in a stepwise fashion, or when they have features that prompt tracking.
Reasons for the discrepancy in the findings between the subjective and objective indices of acceptability are unclear. On the one hand, it may be that the cognitive and affective symptoms experienced by smokers with ADS impede them from using the websites as much as individuals without ADS. Alternatively, given that the websites in the parent trial were designed for the general population of smokers, it may also be that smokers with ADS found them less personally relevant, which could have contributed to them having lower levels of engagement [
The quit rates at 12-month follow-up for all symptom subgroups were promising (20% to 25%). However, in the primary analyses most symptom subgroups (those screening positive for depression, PTSD, PD, or ≥2 affective disorders) had significantly lower quit rates (23% to 24%) relative to the no ADS group (29%). Thus, there is some evidence of the possibility of differential outcomes being disorder-specific. However, all subgroups had descriptively lower quit rates than the no ADS group, suggesting that there is room to improve quit rates for all symptom subgroups and doing so would likely be significant at the population level considering the large proportion of smokers who screen positive for ADS.
Results from post hoc analyses suggest that the lower cessation rates among most groups may be influenced in part by their having greater levels of nicotine dependence and lower commitment to resist smoking in difficult situations at baseline. While greater levels of nicotine dependence among individuals with ADS is a robust finding in the literature [
There are numerous strengths to this study including a large, geographically diverse sample of adult smokers living in the United States, the use of validated self-report instruments to assess mental health conditions, and assessing long-term cessation outcomes at 12-months with a high rate of outcome data retention. Despite these strengths, the limitations of this study should be considered when interpreting the results. The primary limitation is the exploratory nature of the study as secondary analyses embedded in a larger clinical trial [
This is the first study to compare treatment acceptability and long-term quit rates in response to Web-based smoking interventions between smokers who do versus do not screen positive for five common affective disorders. Findings suggest that while Web-based interventions are appealing to these groups, most individuals with ADS used their assigned website less and were less likely to quit smoking than their counterparts in response to the two interventions, each designed for the general population of smokers. Overall, these results support the need for developing targeted interventions for smokers with affective disorders and elevated affective symptomology.
acceptance and commitment therapy
affective disorder
affective disorders and symptoms
Avoidance and Inflexibility Scale
Commitment to Quitting Smoking Scale
Fagerström Test for Nicotine Dependence
generalized anxiety disorder
lesbian, gay, or bisexual
panic disorder
point prevalence abstinence
posttraumatic stress disorder
randomized controlled trial
social anxiety disorder
The authors would like to acknowledge funding by the US National Cancer Institute (R01 CA166646; R01CA192849), and the US National Institute on Drug Abuse (R01 DA038411; F32 DA041100). Funders had no role in the trial conduct or interpretation of results.
In July 2016, JBB was a consultant to Glaxo Smith Kline, the makers of a nicotine replacement therapy. He now serves on the Scientific Advisory Board of Chrono Therapeutics, the makers of a nicotine replacement therapy device. JLH has received research support from Pfizer, the makers of a smoking cessation medication. Other authors have no declarations.