Behavioral activation and smoking cessation outcomes: The role of depressive symptoms

Journal Pre-proofs Behavioral activation and smoking cessation outcomes: the role of depressive symptoms Carmela Martínez-Vispo, Ana López-Durán, Carmen Senra, Rubén RodríguezCano, Elena Fernández del Río, Elisardo Becoña PII: DOI: Reference:

S0306-4603(19)30764-6 https://doi.org/10.1016/j.addbeh.2019.106183 AB 106183

To appear in:

Addictive Behaviors Addictive Behaviors

Received Date: Revised Date: Accepted Date:

20 June 2019 13 September 2019 14 October 2019

Please cite this article as: C. Martínez-Vispo, A. López-Durán, C. Senra, R. Rodríguez-Cano, E. Fernández del Río, E. Becoña, Behavioral activation and smoking cessation outcomes: the role of depressive symptoms, Addictive Behaviors Addictive Behaviors (2019), doi: https://doi.org/10.1016/j.addbeh.2019.106183

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© 2019 Published by Elsevier Ltd.

Behavioral activation and smoking cessation outcomes: the role of depressive symptoms Carmela Martínez-Vispo, PhD1*, Ana López-Durán, PhD 1, 2, Carmen Senra, PhD2, Rubén Rodríguez-Cano, PhD1**, Elena Fernández del Río, PhD 3, & Elisardo Becoña, PhD 1, 2 1Smoking

Cessation and Addictive Disorders Unit, Faculty of Psychology, University of Santiago de Compostela, Galicia, Spain

2Department

of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Santiago de Compostela, Galicia, Spain

3Department

of Psychology and Sociology, University of Zaragoza, Zaragoza, Spain

*Corresponding author: Carmela Martínez Vispo, PhD Smoking and Addictive Disorders Unit Department of Clinical Psychology and Psychobiology Faculty of Psychology, University of Santiago de Compostela 15782 Santiago de Compostela, Spain Tel.: 0034881813939 E-mail: [email protected] **Rubén

Rodriguez Cano is now working in the Department of Behavioral Science, The

University of Texas MD Anderson Cancer Center (Houston, TX, USA)

1

Abstract Introduction: Depressive symptoms are related to smoking cessation outcomes. We examined the effects of behavioral activation (BA), as part of a cognitive behavioral intervention to quit smoking, in terms of abstinence rates according to depressive symptom level. We also analyzed whether BA could differentially benefit participants with higher versus lower anhedonia. Methods: The sample was composed of 183 smokers (Mage= 45.3; 62.8% female) who participated in a randomized clinical trial assessing the effects of a BA intervention compared to a standard intervention. Smoking outcomes were biochemically confirmed point prevalence abstinence, and abstinence days after treatment during one year followup. The intensity of depressive symptomatology and anhedonic symptoms were assessed using the Beck Depression Inventory-II. Results: No differences in abstinence rates were found in relation to depressive symptom level. The BA condition (vs. standard condition) predicted greater abstinence rates (OR = 1.91) in participants with lower scores on depressive symptoms, whereas in participants with higher scores, it did not (OR = 1.17). Moreover, the BA condition predicted greater abstinence rates in participants with lower scores on anhedonia. When examining days of abstinence during the one-year follow-up period, a significant interaction was found between depressive symptoms and treatment condition, favoring the BA condition. Conclusion: BA implemented as part of a cognitive behavioral intervention to quit smoking improves long-term abstinence rates, especially among those with fewer depressive symptoms. Keywords Depressive symptomatology, anhedonia, smoking cessation, behavioral activation

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1. Introduction Depressive symptomatology has been shown to impact negatively on smoking cessation treatment outcomes. Previous studies indicate that greater depressive symptoms are associated with difficulties to quit smoking and with a greater likelihood of relapse (Cooper, Borland, McKee, Yong, & Dugué, 2016; Nieva, Comín, Valero, & Bruguera, 2017). In addition, research has shown that even minimum levels of depressive symptomatology at pretreatment in non-clinically depressed samples are related to poorer abstinence outcomes (Leventhal, Ramsey, Brown, LaChance, & Kahler, 2008; Niaura et al., 2001). A growing body of research shows that subclinical depressive symptomatology has an impact on quality of life and health (Rodríguez, Nuevo, Chatterji, & AyusoMateos, 2012). Moreover, such subclinical manifestations are likely to become fullblown depressive syndromes (Cuijpers, de Graaf, & van Dorsselaer, 2004; Rowe & Rapaport, 2006). Therefore, analyzing the full spectrum of depressive psychopathology may be an appropriate way to examine the impact of depressive symptoms on smoking outcomes. In addition, the depressive syndrome encompasses a heterogeneous group of symptoms (affective, cognitive, behavioral, and physiological) which, due to their particular nature, may differentially hinder the effect of smoking cessation interventions (Leventhal, Waters, Kahler, Ray, & Sussman, 2009). For example, some typical manifestations of depressive states (i.e., dysphoria, withdrawal, irritability) have been found to influence smoking motivation through negative reinforcement (Piper et al., 2004). According to this approach, smokers use tobacco as a strategy to alleviate and/or avoid negative affect-related states, which increases the value of cigarette use. In addition, studies have shown that negative affect is associated with cessation failure and smoking relapse (Brodbeck, Bachmann, Brown, & Znoj, 2014), as well as with the withdrawal syndrome (Baker, Piper, McCarthy, Majeskie, & Fiore, 2004). Another feature that specifically characterizes depression is anhedonia, generally associated with low positive affect, and defined as decreased interest or pleasure in activities that were formerly enjoyable or as the inability to feel pleasure (American Psychiatric Association, 1980). Previous research has stated that anhedonia is not only a defining characteristic of depression, but also a variable linked to other psychopathologies such as substance use (Hatzigiakoumis, Martinotti, Giannantonio, & Janiri, 2011). Regarding smoking behavior, anhedonia has been shown to be associated 3

with shorter abstinence interval after quitting (Cook et al., 2010), poorer smoking cessation outcomes (Leventhal, Piper, Japuntich, Baker, & Cook, 2014), and also it influences the relationship between urgency and nicotine dependence, strengthening it (Roys, Weed, Carrigan, & MacKillop, 2016). Previous literature such as the aforementioned is consistent with the idea that smoking cessation interventions that specifically target different dimensions of depressive symptomatology could lead to an improvement of abstinence rates. One effective intervention option that addresses depressive symptoms, and particularly anhedonia, is Behavioral Activation (BA; Kanter & Puspitasari, 2012). This intervention approach was initially developed as a component of Cognitive Behavioral Therapy (CBT) for treatment of depression, but BA itself has been shown to be as efficacious as CBT and antidepressant medication (Ekers et al., 2014). It focuses on behavior, providing the individual with the opportunity to engage in positively reinforcing experiences and activities (Dimidjian, Barrera, Martell, Muñoz, & Lewinsohn, 2011; Kanter et al., 2010). Thus, BA applied in the context of smoking cessation treatment provides diverse resources of rewarding activities/stimuli, alternatives to cigarettes, as a strategy that targets not only depressive symptoms but also the rewarding value of cigarettes. Previous studies integrating BA in smoking cessation interventions have obtained positive results in terms of abstinence rates (Macpherson et al., 2010), and in the mean number of abstinence days after treatment (Busch et al., 2017). Nevertheless, to our knowledge, no studies have examined whether BA may improve smoking-related outcomes according to the intensity and heterogeneity of depressive symptoms. To determine whether participants with a greater level of depressive symptomatology would benefit from receiving a BA intervention for smoking cessation (Standard Cognitive Behavioral Smoking Cessation Treatment with Behavioral Activation: SCBSCT-BA) compared to a standard treatment condition (Standard Cognitive Behavioral Smoking Cessation Treatment: SCBSCT), we conducted a secondary analysis of the data of Martínez-Vispo et al. (2019). In addition to the intensity of the depressive symptoms, we also examined the particular effect of anhedonic and non-anhedonic depressive symptoms. Therefore, the specific aims of the present study are: (1) to examine abstinence rates according to depressive symptom level; (2) to examine the main effects of SCBSCT-BA (vs. SCBSCT), depressive symptomatology, and their interaction on abstinence rates; (3) to examine whether 4

SCBSCT-BA (vs. SCBSCT) could improve abstinence rates of participants according to depressive symptom level, and also according to anhedonic and non-anhedonic depressive symptom level; and (4) to examine the main effects and interaction between treatment condition and anhedonia in the prediction of self-reported abstinence days after treatment. 2. Materials and method 2.1. Participants The initial sample was composed of 219 smokers participating in a smoking cessation randomized clinical trial (RCT), of whom 110 were randomized to the SCBSCT-BA condition and 109 to the SCBSCT. For the purpose of this study, we selected those participants who attended at least the first intervention session and reported smoking status at the end of the treatment (n = 183). The complete description of the parent study procedures, the study protocol and the main RCT results have been published (see Becoña et al., 2017; Martínez-Vispo et al., 2019). The study was approved by the Bioethics Committee of the University of Santiago de Compostela, and participants provided informed consent. 2.2. Procedure Participants were randomly assigned to one of the intervention conditions. Before beginning intervention sessions, two baseline assessment sessions were carried out. 2.2.1. Measures A face-to-face interview was conducted, and participants completed the following self-reported questionnaires about smoking and depression-related variables. Smoking Habit Questionnaire (Becoña, 1994). It consists of 56 items collecting sociodemographic data (sex, age, marital status, educational level) and tobacco use (i.e., cigarettes per day; years smoking, or use of other tobacco products). Beck Depression Inventory II (BDI-II, Beck, Steer, & Brown, 1996; Spanish version by Sanz & Vazquez, 2011) This is a 21-item self-report scale measuring current depressive symptoms, whose scores are interpreted as 0-13 (minimal), 14-19 (mild), 2028 (moderate) and 29-63 (severe). The Spanish version has a Cronbach alpha of .90. We used some of the items of this instrument to assess anhedonia (Joiner, Brown, & Metalsky, 2003), namely: Item #4 (loss of enjoyment/satisfaction), Item #12 (loss of interest in people), and Item #21 (loss/no interest in sex). The Cronbach's alpha for this 5

measure in this sample was .72. Additionally, a total score excluding the three anhedonia-related items was used in order to examine whether non-anhedonic depressive symptoms were related to study outcomes. The Cronbach's alpha for this measure was .88. The correlation between the anhedonia and non-anhedonic symptoms subscales was .66. In order to examine the effect of depressive symptomatology, we dichotomized the BDI-II scores using two procedures: (1) BDI-II scores in the range 0-13 were classified as “minimal” and those equal to or higher than 14 as “higher than minimal”; and (2) splitting the sample into participants with “lower” versus “greater” depressive symptomatology, using BDI-II z-scores. 2.2.2. Smoking cessation conditions A complete description of the intervention components is available in Becoña et al. (2017). Both conditions consisted of eight weekly group sessions of 60 minutes. The standard condition consisted of a cognitive-behavioral intervention (SCBSCT) to quit smoking (Becoña, 2007), including components such as smoking self-report, information about tobacco, nicotine fading, stimulus control, activities to prevent withdrawal syndrome, physiological feedback through CO in expired air, and relapseprevention strategies. The treatment condition including BA (SCBSCT-BA) incorporated the aforementioned components as well as information about the relationship between behavior and mood, identification of behaviors that worsen mood, identification of avoidance patterns and rumination, self-report of daily activities, and activity scheduling to increase engagement in non-smoking-related rewarding activities. 2.2.2. Abstinence outcomes The primary outcome was self-reported and biochemically confirmed 24-hours abstinence at the end of treatment (Session 8), and 7-day point prevalence abstinence at the 3-, 6-, and 12-month follow-ups (West, Hajek, Stead, & Stapleton, 2005). The Micro+ Smokerlyzer (Bedfont Scientific Ltd, Maidstone, Kent, UK) was used to assess carbon monoxide (CO) in expired air at baseline, at the end of treatment, and at the 3-, 6-, and 12-month follow-ups to corroborate self-reported abstinence objectively (CO reading of < 5 parts per million) (Perkins, Karelitz, & Jao, 2013). We also collected data about self-reported abstinence days after treatment using Time Line Follow Back (Brown et al., 1998). Therefore, we examined two types of abstinence outcomes: (1) a binary outcome (abstinence vs. smoking), and (2) a continuous outcome (number of abstinence days 6

during the 12-month follow-up). This approach sought to provide a broad vision of smoking abstinence maintenance, as it is a dynamic process (Kirchner, Shiffman, & Wileyto, 2012). 2.3.

Analytic strategy Firstly, differences between participants with minimal and with higher than

minimal scores in depressive symptoms (BDI-II < 14 or BDI-II ≥ 14, respectively) were examined regarding demographics, smoking-related and depression-related variables, and abstinence status at the end of treatment, and at the 3-, 6-, and 12-month follow-ups, using Chi-square tests for categorical variables (corrected by Bonferroni test for multiple comparisons), and Student’s t-test for continuous variables. The primary smoking outcome analysis examined smoking abstinence with the generalized estimating equations (GEE), using SPSS 24. The model for this outcome analysis was a 2 (Treatment groups) × 4 (Time points: end of treatment, 3-, 6-, and 12month follow-ups) repeated measures design that was fit using an autoregressive working correlation structure (including participants with missing data). Abstinence outcomes were analyzed using odds ratios comparing SCBSCT-BA with SCBSCT conditions. In the model, baseline BDI-II scores and the interaction between depressive symptoms and treatment condition were also included. The GEE analysis was adjusted by means of the following covariates: sex, age, marital status, education, and past depression treatment. GEE analyses were also conducted to examine main effects of treatment condition separately for individuals deemed greater/lower in: (1) depressive symptoms based on mean-split BDI-II z-scores; and (2) separately in the two specific depression dimensions based on mean-split z-scores: anhedonia and non-anhedonic depressive symptoms. Finally, a univariate General Linear Model (GLM) was conducted to examine main effects and interactions between treatment condition and specific depressive symptoms (i.e., anhedonia and non-anhedonic symptoms) in predicting self-reported abstinence days during the one-year period of follow-up. Analyses were adjusted by sex, age, marital status, education, and past depression treatment. 3. Results Of the total sample, 62.8% were female (n = 115), and the mean age was 45.37 (SD = 10.88). Regarding tobacco consumption, the mean of cigarettes smoked per day 7

was 18.77 (SD = 6.84). In relation to depressive symptoms, the mean score of the BDIII was 10.20 (SD = 8.69). According to treatment condition, of the participants randomized to the SCBSCT, 65.5% were female (n = 57), with a mean age of 45.45 (SD = 10.83) and smoking an average of 19.20 (SD = 7.50) cigarettes per day. Of the participants randomized to the SCBSCT-BA condition, 60.4% were female (n = 58), with a mean age of 45.29 (SD = 10.98) and smoking an average of 18.38 (SD = 6.19) cigarettes per day. Regarding depression-related variables, the mean score of depressive symptomatology (BDI-II total) was 10.48 (SD = 9.38) for SCBSCT and 9.95 (SD = 8.05) for SCBSCT-BA. No differences in demographic, tobacco, and depression-related variables were found at baseline according to treatment condition. Analyses examining differences in demographics, smoking-related variables, and abstinence at the end of treatment and at the 3-, 6-, and 12-month follow-ups between participants with minimal depressive symptomatology (BDI-II < 14) and those with higher than minimal (BDI-II ≥ 14) are reported in Table 1. 3.1. Effect of treatment condition and depressive symptoms on smoking cessation outcomes The adjusted GEE analysis showed significantly greater abstinence ORs for participants of the SCBSCT-BA (Table 2). There was a significant effect for time (p = .001), whereas the Time × Intervention Condition interaction was nonsignificant (p = .503). Baseline BDI-II scores (≥ 14) were nonsignificant predictors of smoking status (p =.665). The Interaction between treatment condition and depressive symptomatology was nonsignificant (p = .433). 3.2. Effect of treatment condition on smoking cessation outcomes as a function of depressive symptom level When examining the effects of treatment condition after splitting the sample by depressive symptoms (mean BDI-II z-scores); the SCBSCT-BA intervention yielded significantly greater abstinence ORs for participants with lower depressive symptomatology (Table 3). The SCBSCT-BA condition (vs. SCBSCT) did not obtain significantly greater abstinence ORs for participants with greater depressive symptoms.

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3.3. Effect of treatment condition on smoking cessation outcomes as a function of anhedonia and non-anhedonic symptom level When analyzing the effects of treatment condition after splitting the sample by anhedonia and non-anhedonic symptoms (mean z-scores); the SCBSCT-BA intervention yielded significant greater abstinence ORs for participants with lower scores in both variables (Table 4). 3.4. Effect of treatment condition, anhedonia, and non-anhedonic symptom interaction on abstinence days during the one-year follow-up period The GLM model results showed that the SCBSCT-BA condition (vs. SCBSCT) predicted a significantly higher number of abstinence days after treatment (Table 5). The interaction between treatment condition and anhedonia (Figure 1), and the interaction between treatment condition and non-anhedonic symptoms were both significant (Figure 2). The effect size was greater for Treatment Condition × Anhedonia interaction than for Treatment Condition × Non-Anhedonic Symptoms interaction (ηp2= .023 vs. ηp2= .015, respectively). 4. Discussion The present study was designed to examine whether participants who completed the treatment sessions benefit differentially depending on the treatment they received (SCBSCT-BA vs. SCBSCT) as a function of depressive symptom level. In addition, we also sought to examine whether treatment differentially predicted smoking outcomes in participants as a function of anhedonia level. In a preliminary step, we found that when analyzing the whole sample, participants with a higher than minimal level of depressive symptomatology obtained similar abstinence rates compared with participants with minimal depressive symptoms. Although previous literature has indicated that depressive symptomatology is related to poorer smoking cessation outcomes and a higher likelihood of relapse (Berlin & Covey, 2006; Cooper et al., 2016), our findings are in line with studies showing that depressed smokers can achieve abstinence in comparable rates with non-depressed smokers following a similar intervention to quit smoking (John, Meyer, Rumpf, & Hapke, 2004; Ziedonis et al., 2008). When examining the entire sample, the predictive analysis of treatment condition effects showed that the SCBSCT-BA condition (vs. SCBSCT) obtained 9

significantly higher abstinence rates, but neither depressive symptomatology nor the interaction between treatment and depressive symptoms achieved significant effects in the prediction of abstinence. Despite the fact that depression has been found to hinder smoking cessation interventions (Stepankova et al., 2017), other variables, such as selfefficacy, readiness to quit, or craving severity, may have an impact on this result (Cinciripini et al., 2003; Minnix, Blalock, Marani, Prokhorov, & Cinciripini, 2011). When analyzing treatment effects according to depressive symptom level (lower and higher separately), our results showed that the SCBSCT-BA condition yielded significantly greater abstinence ORs for participants with lower depressive symptomatology. These findings are consistent with the idea that a BA intervention may increase well-being and also positive mood among non-depressed individuals (Mazzucchelli, Kane, & Rees, 2010), which may facilitate smoking abstinence. In fact, preliminary evidence has shown that increasing positive affect could benefit abstinence achievement (Castro et al., 2014). In addition, as BA increases individuals’ opportunities to engage in new rewarding activities, such activities may function as competitors/substitutes of smoking behavior, contributing to abstinence achievement and relapse prevention (Audrain-McGovern et al., 2009; Schnoll et al., 2016). In fact, previous studies have underscored the relevance of alternative and complementary reinforcers concerning smoking behavior (Bickel, Johnson, Koffarnus, MacKillop, & Murphy, 2014; Khoddam & Leventhal, 2016). Another possible and complementary explanation is that participants receiving the BA condition may have learned that engagement in non-smoking alternative reinforcing/rewarding activities can be an effective strategy to cope not only with craving or high-risk smoking situations, but also as a self-regulation skill that serves to deal with negative emotional states in general (Roos & Witkiewitz, 2017). The results of SCBSCT-BA effects (vs. SCBSCT) in participants with higher depressive symptomatology showed that the BA condition did not obtain significantly greater abstinence OR. This result was unexpected, as BA has shown preliminary efficacy as part of a smoking cessation treatment in smokers with depressive symptomatology (Macpherson et al., 2010). In addition, due to the fact that BA has shown its efficacy in depression treatment (Ekers et al., 2014), and that depression is related to lower abstinence rates (Stepankova et al., 2017), we expected BA to improve abstinence rates in participants with greater depressive symptoms. A plausible explanation of this result is that the sample size of the participants with greater 10

depressive symptoms has not enough power to detect statistically significant differences between treatment conditions. Additionally, compliance and engagement in BA tasks might be lower in the group of participants with greater depressive symptomatology, which could limit the effects of BA (Hopko, Magidson, & Lejuez, 2011). Furthermore, other factors, such as the belief that smoking reduces negative affect (Weinberger, George, & McKee, 2011), the dispositional hedonic capacity (Audrain-McGovern et al., 2012) or reward responsiveness (Powell, Dawkins, & Davis, 2002) of smokers with greater depressive symptoms could preclude benefits from BA strategies. Results suggest that participants with greater depressive symptoms may benefit differentially in terms of length of abstinence (i.e., total number of abstinence days during the 12 months after treatment) based on the type of treatment they receive. Concretely, participants with a higher level of anhedonia who were randomized to the SCBSCT-BA condition maintained abstinence for a greater number of days than those in the SCBSCT condition. This effect was nonsignificant in participants with a higher level of non-anhedonic depressive symptoms. This differential pattern could be driven by the fact that the benefit of the SCBSCT-BA condition may be specific for anhedoniarelated symptomatology. In fact, BA theoretical conceptualization considers depression as a function of reduced rewarding activities and stimuli in daily life (Jacobson, Martell, & Dimidjian, 2001). Thus, BA could be considered to target anhedonia specifically, and additionally, it provides the chance to contact with rewarding stimuli and engage in alternative activities to cigarettes (McKay, 2017). Lastly, our findings showed that the BA condition (vs. the standard one) did not predict greater abstinence rates in participants with higher anhedonia scores, although participants receiving BA were abstinent for more days after treatment. A possible reason for this apparently contradictory phenomenon could be related to the differences in the smoking outcomes used (binary vs. continuous outcomes). Concretely, it is plausible that participants with greater anhedonic symptoms who had been classified as smokers (vs. abstainers) during the follow-ups could have had longer abstinence periods or last more days before relapse in the BA condition than participants of the standard condition. Therefore, the BA condition could have a positive effect in terms of length of abstinence during the one-year period of follow-up in this group of participants. This is a relevant finding, as longer quit attempts have been related to increased success in subsequent quit attempts (Gilpin, Pierce, Farkas, & Farkas, 1997; Hyland et al., 2006). More research is needed to confirm the observed patterns of results. 11

This study has some limitations that should be mentioned. We examined the effect of depressive symptoms in a non-clinical sample using a self-reported instrument to assess depressive symptomatology. In addition, we used three items from the BDI-II to examine anhedonia. Although the use of such assessment had shown to be reliable (Joiner et al., 2003) and had been used in previous literature (Crits-Christoph et al., 2018; Leventhal, Chasson, Tapia, Miller, & Pettit, 2006), it would be appropriate to examine this variable with a specific instrument. Another limitation of this study is related to the sample size. Further research is needed to examine the effects of BA in smokers as a function of depressive symptom level in larger samples. Finally, the use of a nonclinical sample composed of Caucasians prevents generalization of the findings to clinical samples from other ethnic backgrounds. 5. Conclusions The integration of BA components in smoking cessation interventions is a promising option to increase abstinence rates for non-clinical smokers seeking treatment. Our findings revealed that participants can achieve and maintain abstinence in a similar way, regardless of the level of depressive symptoms, although those with lower intensity appear to benefit the most from receiving the BA condition. In addition, participants with a higher level of anhedonia who received BA maintained abstinence for significantly more days than those in the standard condition.

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Table 1 Sociodemographics, depression, and smoking-related variables as a function of depressive symptomatology level.

Age Sex (female) Marital status (married/living with a partner) Education (High) Baseline CO Cigarettes per day Years smoking BDI-II BDI-II Anhedonia symptoms BDI-II Non-anhedonic symptoms Past depression treatment (yes) Treatment condition

Smoking status End of Treatment Abstainer Smoker 3-month follow-up Abstainer Smoker Missing 6-month follow-up Abstainer Smoker Missing 12-month follow-up Abstainer Smoker Missing

BDI-II < 14 (N =127) M (SD) / % (n) 45.9 (10.2) 63.8 (81)

BDI-II ≥ 14 (N =56) M (SD) / % (n) 43.9 (12.1) 60.7 (34)

52.8 (67)

53.6 (30)

45.7 (58) 18.7 (8.4) 18.7 (6.4) 26.6 (10.8) 5.6 (3.6) 1.0 (1.2) 4.6 (3.0) 38.6 (49) SCBSCT (N = 87) BDI-II < 14 BDI-II ≥ 14 (n = 59) (n = 28) % (n) % (n)

61.0 (36) 39.0 (23)

67.9 (19) 32.1 (9)

27.1 (16) 55.9 (33) 16.9 (10)

32.1 (9) 42.9 (12) 25.0 (7)

22.0 (13) 50.8 (30) 27.1 (16)

25.0 (7) 42.9 (12) 32.1 (9)

22.0 (13) 39.0 (23) 39.0 (23)

25.0 (7) 39.3 (11) 35.7 (10)

χ2/t 1.09 0.15 0.01

30.4 (17) 3.76 18.2 (8.4) 0.39 18.8 (7.7) -0.10 25.0 (12.1) 0.88 20.5 (7.8) -13.68 *** 3.3 (2.1) -7.69*** 17.1 (6.6) -13.49*** 46.4 (26) 0.98 SCBSCT-BA (N = 96) BDI-II < 14 BDI-II ≥ 14 χ2a (n = 68) (n = 28) % (n) % (n) 0.186 77.9 (53) 78.6 (22) 22.1 (15) 21.4 (6) 1.292 41.2 (28) 50.0 (14) 48.5 (33) 42.9 (12) 10.3 (7) 7.1 (2) 0.076 33.8 (23) 35.7 (10) 48.5 (33) 53.6 (15) 17.6 (12) 10.7 (3) 0.006 33.8 (23) 32.1 (9) 45.6 (31) 46.4 (13) 20.6 (14) 21.4 (6)

Note. BDI-II = Beck Depression Inventory Second Edition; SCBSCT-BA = Standard Cognitive Behavioral Smoking Cessation Treatment with Behavioral Activation; SCBSCT = Standard Cognitive Behavioral Smoking Cessation Treatment. aBonferroni´s correction for multiple comparisons. *p < .05. **p < .01. ***p < .001.

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Table 2 Predictors of biochemically-confirmed abstinence during the 12-month follow-up period through GEE analysis Abstinence OR

95% CI

Treatment conditiona (SCBSCT-BA)

1.69*

1.04-2.75

Time

0.74***

0.66-0.83

Treatment condition × Time

0.94

0.80-1.11

Depressive symptoms (BDI-II ≥14)

1.26

0.73-2.17

Treatment condition × Depressive symptoms (BDI-II ≥14)

0.75

0.36-1.55

aReference

group for treatment effects was SCBSCT. by sex, age, marital status, education, and past depression treatment. Note. BDI-II = Beck Depression Inventory Second Edition; SCBSCT-BA = Standard Cognitive Behavioral Smoking Cessation Treatment with Behavioral Activation; SCBSCT = Standard Cognitive Behavioral Smoking Cessation Treatment. *p < .05. **p < .01. ***p < .001. bAdjusted

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Table 3 GEE analysis of treatment condition effect on smoking cessation outcomes as a function of depressive symptom level Abstinence ORa Sample split by depressive symptomsb

Lower (n = 112)

95% CI

Greater

95% CI

(n = 71)

Treatment conditionc (SCBSCT-BA)

1.94*

1.11-3.38 1.03

0.49-2.15

Time

0.77**

0.66-0.89 0.70***

0.58-0.86

Treatment condition × Time

0.89

0.73-1.10 1.01

0.77-1.34

Note. SCBSCT-BA = Standard Cognitive Behavioral Smoking Cessation Treatment with Behavioral Activation aAdjusted by sex, age, marital status, education, and past depression treatment. bSample split based on z-score means. cReference group for treatment effects was SCBSCT. *p < .05. **p < .01. ***p < .001.

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Table 4 GEE analysis of treatment condition effect on smoking cessation outcomes as a function of anhedonia and non-anhedonic depressive symptom level Abstinence ORa Sample split by anhedoniab Treatment conditionc (SCBSCT-BA) Time Treatment condition × Time

Treatment condition × Time

95% CI

Lower

Greater

(n = 94)

(n = 89)

1.01-3.36

1.23

0.64-2.34

0.78***

0.67-0.91

0.69***

0.56-0.83

0.83

0.65-1.05

1.08

0.85-1.37

depressive symptomsb Time

ORa

1.79*

Sample split by non-anhedonic Treatment conditionc (SCBSCT-BA)

95% CI

Lower

Greater

(n = 109)

(n = 74)

1.94*

1.11-3.42

1.05

0.50-2.18

0.76***

0.65-0.88

0.71***

0.59-0.86

0.91

0.74-1.12

0.99

0.75-1.30

Note. SCBSCT-BA = Standard Cognitive Behavioral Smoking Cessation Treatment with Behavioral Activation aAdjusted by sex, age, marital status, education, and past depression treatment. bSample split based on z-score means. cReference group for treatment effects was SCBSCT. *p < .05. **p < .01. ***p < .001.

22

Table 5 Treatment condition, anhedonia, and non-anhedonic depressive symptoms as predictors of self-reported abstinent days after treatment (12-month follow-up). Self-reported abstinent days post interventiona F

ηp2

Treatment condition b (SCBSCT-BA)

12.55

0.017*

Anhedonia

2.51

0.003

Non-anhedonic depressive symptoms

0.78

0.001

Treatment condition × Anhedonia

16.78

0.023*

11.29

0.015*

Treatment condition × Non-anhedonic depressive symptoms

Note. SCBSCT-BA = Standard Cognitive Behavioral Smoking Cessation Treatment with Behavioral Activation aAnalyses were conducted using univariate general linear modeling and were adjusted by sex, age, marital status, education, and past depression treatment bReference group for treatment effects was SCBSCT. *p < .05.

23

Figure 1. Self-reported abstinence days after treatment by anhedonia and treatment condition

Note. SCBSCT-BA = Standard Cognitive Behavioral Smoking Cessation Treatment with Behavioral Activation; SCBSCT = Standard Cognitive Behavioral Smoking Cessation Treatment.

24

Figure 2. Self-reported abstinence days after treatment by non-anhedonic depression symptoms and treatment condition

Note. SCBSCT-BA = Standard Cognitive Behavioral Smoking Cessation Treatment with Behavioral Activation; SCBSCT = Standard Cognitive Behavioral Smoking Cessation Treatment.

Highlights -

No significant differences in abstinence rates were found regarding depressive symptoms level

-

BA obtained greater abstinence rates in participants with lower depressive symptoms

-

Smokers with greater anhedonia receiving BA were abstinent more days after treatment

Conflicts of interest All authors declare that they have no conflicts of interest. The authors alone are responsible for the content and writing of the article. Acknowledgments This research was supported by the Spanish Ministry of Economy and Competitiveness (Project

reference:

PSI2015-66755-R)

and

by

FEDER

(European

Regional

Development Fund; pluri-annual plan 2014-2020). 25

Role of funding sources/sponsors The funding sources had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

26