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Anne N. Thorndike, MD, MPH; Susan Regan, PhD; Kathleen McKool, RN, MSN; Richard C. Pasternak, MD; Susan Swartz, MD; Nancy Torres-Finnerty, MD; Nancy A. Rigotti, MD

Arch Intern Med. 2008;168(2):186-191.

Background  Although smoking cessation is essential for prevention of secondary cardiovascular disease (CVD), many smokers do not stop smoking after hospitalization. Mild depressive symptoms are common during hospitalization for CVD. We hypothesized that depressive symptoms measured during hospitalization for acute CVD would predict return to smoking after discharge from the hospital.

Methods  This was a planned secondary analysis of data from a placebo-controlled, double-blind, randomized trial of bupropion hydrochloride therapy in 245 smokers hospitalized for acute CVD. All subjects received smoking counseling in the hospital and for 12 weeks after discharge. Depressive symptoms were measured during hospitalization with the Beck Depression Inventory (BDI), and smoking cessation was biochemically validated at 2-week, 12-week, and 1-year follow-up. The effect of depressive symptoms on smoking cessation was assessed using multiple logistic regression and survival analyses.

Results  Twenty-two percent of smokers had moderate to severe depressive symptoms (BDI 16) during hospitalization. These smokers were more likely to resume smoking by 4 weeks after discharge (P = .007; incidence rate ratio, 2.40; 95% confidence interval, 1.48-3.78) than were smokers with lower BDI scores. Smokers with low BDI scores were more likely to remain abstinent than were those with high BDI scores at 3-month follow-up (37% vs 15%; adjusted odds ratio, 3.02; 95% confidence interval, 1.28-7.09) and 1-year follow-up (27% vs 10%; adjusted odds ratio, 3.77; 95% confidence interval, 1.31-10.82). We estimate that 27% of the effect of the BDI score on smoking cessation was mediated by nicotine withdrawal symptoms.

Conclusions  Moderate to severe depressive symptoms during hospitalization for acute CVD are independently associated with rapid relapse to smoking after discharge and lower rates of smoking cessation at long-term follow-up. The relationship was mediated in part by the stronger nicotine withdrawal symptoms experienced by smokers with higher depressive symptoms.

Trial Registration  clinicaltrials.gov Identifier: NCT00181818

Author Affiliations: Tobacco Research and Treatment Center, General Medical Division, and Cardiology Division, Massachusetts General Hospital and Harvard Medical School (Drs Thorndike, Regan, Pasternak, and Rigotti and Ms McKool) and Boston Medical Center (Dr Torres-Finnerty), Boston, Massachusetts; and Maine Medical Center, Portland (Dr Swartz). Dr Pasternak is now with Merck & Co, Inc, Whitehouse Station, New Jersey. Dr Torres-Finnerty is now with the Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston.

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