Cognitive coping skills and depression vulnerability among cigarette smokers
Introduction
Depressed people are overrepresented among current smokers, especially smokers high in nicotine dependence (e.g., Breslau, Kilbey, & Andreski, 1991). Moreover, they have a harder time achieving and maintaining abstinence than do nondepressed smokers (Glassman, 1993). This difficulty in quitting has been observed even with low, subclinical levels of depressive symptoms (Niaura et al., 2001) or a history of depression in the absence of current depression (Kenford et al., 2002), which is the focus of the research reported in this article.
A history of depression may serve as a marker of current depression vulnerability (Coyne, Pepper, & Flynn, 1999), and depression-vulnerable smokers are especially likely to use smoking as a means of managing negative affect (Lerman et al., 1996). Therefore, smoking cessation would seem to deprive depression-vulnerable smokers of one of their most dependably available and effective mood-regulating coping skills, which could account for the difficulty that they experience in trying to quit. Consistent with this conjecture are findings indicating that smoking cessation selectively increases depressive symptoms (Niaura et al., 1999) and negative mood (Hall et al., 1996) among smokers with a history of major depression, and that increases in negative mood upon quitting smoking predict relapse Covey et al., 1998, Kenford et al., 2002.
Treatments for depression may therefore be useful in helping depression-prone smokers achieve abstinence. One plausible treatment for this purpose is cognitive behavior therapy (CBT; Beck, Rush, Shaw, & Emery, 1979). Extensive research supports the efficacy of CBT, which is classified as a well-established depression treatment by the Task Force on Psychological Interventions (Chambless et al., 1998). The hypothesis that CBT techniques could be adapted from the treatment of depression to the treatment of depression-vulnerable smokers has been tested in a series of studies in which the CBT packages draw from aspects of Beck's cognitive therapy (Beck et al., 1979) as well as from Lewinsohn's behavior therapy for depression (e.g., Zeiss, Lewinsohn, & Munoz, 1979).
Results from such studies are mixed and inconclusive (Niaura & Abrams, 2002). Hall, Munoz, and Reus (1994) compared two treatment conditions. In one, a five-session cognitive-behavioral “mood management” group treatment, based on the CBT of depression, was added to a standard health-education-based program for smokers; in the other, the health education program alone was included. Treatment condition interacted significantly with depression history in predicting 1-year follow-up results. The mood-management treatment was effective only for depression-history-positive smokers. The same result was obtained by Hall et al. (1998). However, a third clinical trial by the same research group equated the two conditions for therapy contact time and failed to replicate this significant interaction (Hall et al., 1996). One study using a similar protocol with Hall's found that CBT significantly enhanced the efficacy of a behavioral treatment based on nicotine fading and self-monitoring in the treatment of depression-history-positive smokers, even with therapy contact time controlled (Patten, Martin, Myers, Calfas, & Williams, 1998). However, this result does not resolve the mixed findings from the studies by Hall et al. because (a) all participants had a history of alcohol dependence, and it is not known whether the results would generalize to other smokers, (b) the sample was small (N=29 total), which decreases the precision of treatment effect estimates, and (c) all participants were positive for a history of depression, thus, there is no way to determine whether the beneficial impact of CBT mood-management training was specific to this group.
There is a range of possible explanations of these variable results in clinical trials of CBT for depression-history-positive smokers. For one, the primary premise of the incorporation of CBT principles into smoking cessation interventions for depression-vulnerable smokers may be mistaken. In particular, the design of these treatment programs presumes that depression-vulnerable smokers are deficient in the skills taught in the CBT, such that learning the skills would be novel for them and will bolster their ability to manage negative affect during early maintenance and therefore avoid relapse. Although it is not certain what mediates the impact of CBT on depression (Solomon & Haaga, 2004), one viable hypothesis is that a key mediator is learning new skills useful in regulating and delimiting episodes of sadness and negative thinking (Barber & DeRubeis, 1989). This hypothesis is consistent with evidence that (a) CBT is equally effective as an antidepressant medication, in the short term, in relieving depressive symptoms, but the impact of CBT may be more durable (DeRubeis & Crits-Christoph, 1998); (b) depressed people rated at posttreatment as highly skilled in responding to their own negative automatic thoughts were especially likely to maintain improvement in their depressive symptoms through 6-month follow-up (Neimeyer & Feixas, 1990); and (c) depressed patients appear to be deficient in a normal metacognitive monitoring process of “double checking” dysfunctional thoughts (Sheppard & Teasdale, 2000), which may be corrected in the CBT, as they learn to distance themselves from automatically accepting the validity of such thoughts as they occur (Teasdale et al., 2000).
To understand the variable results of efforts to adapt CBT for depression, specifically to target depression-history-positive smokers, then, it would be helpful to know whether such smokers are indeed deficient in the skills being taught in the CBT.
Rabois and Haaga (1997) tested the interrelations of smoking status, depression history, and cognitive coping skills. A positive depression history was inferred from ratings on a self-report inventory of lifetime depression, and cognitive coping skills were indexed by the Ways of Responding test (WOR; Barber & DeRubeis, 1992). Participants with a history of depression, whether smokers or not, scored significantly higher on the “negative” scale of the WOR than did their never-depressed counterparts. Thus, smokers with a history of depression were more often rated as responding to negative automatic thoughts, with cognitions considered negative and dysfunctional from the standpoint of CBT (e.g., catastrophizing, overgeneralizing implications of negative situations). At a more molar level of analysis of cognitive coping, however, history of depression did not significantly relate to coping skill. Smokers scored lower than nonsmokers did in the overall quality of response to negative automatic thoughts on the WOR, and the trend was for depression-history-positive participants to score lower but not significantly so (P<.13).
The current study was designed to replicate and extend, in several ways, the research by Rabois and Haaga (1997). First, we recruited larger samples of depression-history-positive and history-negative smokers. The nonsignificant difference in the molar ratings of quality on the WOR was inconclusive, given that there were only 41 smokers (18 with positive history of depression) in the study of Rabois and Haaga. Second, we measured depression history on the basis of a structured diagnostic interview rather than a self-rating symptom measure.
Third, we added a continuous-variable, self-rating measure of current depression vulnerability. A history of depression may be an imprecise indicator of vulnerability (Just, Abramson, & Alloy, 2001). Some never-depressed persons are actually high in vulnerability but have not experienced a depressive episode as yet because no sufficiently major stressor has occurred to activate this vulnerability. As such, some history-negative-but-vulnerable smokers would be, in effect, false negatives if vulnerability is identified solely on the basis of prior experience of major depression. Conversely, whatever method (self-help or formal therapy) enabled the recovered-depressed person to recover in the first place may also have decreased their vulnerability to future episodes. If so, there may be false positive cases as well in a depression-history design—smokers with a history of major depression but who are now no more vulnerable to subsequent depressive episodes than an average history-negative smoker. These considerations imply that clearer, more robust findings may emerge if current depression vulnerability, rather than history of depression, is measured. Brandon et al. (1997) obtained results consistent with this possibility. An adaptation of CBT principles, “negative affect reduction counseling,” proved specifically effective for smokers high in depression vulnerability as measured by the self-rating depression proneness inventory (DPI; Alloy, Hartlage, Metalsky, & Abramson, 1987). In a subsequent study, the DPI was positively correlated with being a current smoker, with having ever smoked, and with reporting negative mood reduction as a motive to smoke (Brody, 2001).
Finally, we evaluated whether the association of depression proneness and cognitive coping skills among smokers would be the same for African-Americans as for Caucasians. The research establishing depression as a correlate of cigarette smoking has not focused specifically on African-Americans. Although the overall prevalence of cigarette smoking is equal for African-Americans and Caucasians (CDC, 2001), African-Americans appear to start smoking later (U.S. Department of Health and Human Services, 1998) and are less likely to become nicotine dependent, given that they smoke (Breslau, Johnson, Hiripi, & Kessler, 2001). It is possible that the psychosocial correlates of smoking vary by ethnicity as well (Klonoff & Landrine, 1999).
In sum, we studied whether depression vulnerability among currently nondepressed smokers is associated with a deficiency in cognitive coping skills taught in the CBT for depression. In so doing, we addressed measurement issues by indexing depression vulnerability both as a history of major depression and by the potentially more sensitive indicator of self-rated depression proneness, and we compared African-American and Caucasian subsamples with respect to the validity of the main hypothesis.
Section snippets
Participants
Participants were 134 adult (age at least 18 years) cigarette smokers (at least 10 cigarettes/day), ranging in age from 18 to 70 years (M=41.5, S.D.=12.6). There were 67 women (31 African-American, 31 Caucasian, and 5 of other races or unknown) and 67 men (42 African-American, 23 Caucasian, and 2 of other races or unknown). The participants were recruited via newspaper advertisements for a “psychology research seeking cigarette smokers (at least 10 cigarettes/day) who are not currently
Convergent validity of depression vulnerability indicators
There was a positive association of SCID-derived diagnoses of past major depression with self-rated current depression proneness (DPI). Those diagnosed with past major depression (n=65, M=30.63, S.D.=8.96) scored significantly higher on the DPI than did those with no history of major depression [n=68, M=21.67, S.D.=8.14; t(131)=6.05, P<.001, effect size d=1.05; Cohen, 1988]. As argued in the Introduction, we do not view these measures as interchangeable, but we would certainly expect a positive
Discussion
Among smokers not currently experiencing an MDE, those with a history of major depression showed less functional cognitive coping skills from the standpoint of CBT. This result bolsters a key premise of efforts to use adaptations of CBT for depression to help depression-vulnerable smokers cope better with negative affect and thereby be more likely to achieve smoking cessation. Our results replicate and extend those of Rabois and Haaga (1997) in this regard.
We began this research with the aim of
Acknowledgements
The research reported in this article was funded by the National Cancer Institute (1R15CA77732-01). Some of these data were presented at the 35th annual convention of the Association for Advancement of Behavior Therapy (AABT), Philadelphia, November 2001, and at the 36th annual convention of AABT, Reno, NV, November 2002. We are grateful to Daniel Brown, Alicia Fields, Kelly Godfrey, April Hendrickson, Charrise Hipol, Siobhan Sharkey, and Andrea Stoudt for assistance in conducting this research.
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