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Smoking Behavior Postmyocardial Infarction Among ENRICHD Trial Participants: Cognitive Behavior Therapy Intervention for Depression and Low Perceived Social Support Compared With Care as Usual

From the Department of Psychiatry and Behavioral Sciences (M.T.), Stanford University School of Medicine, Stanford, California; Section of Cardiovascular Medicine Yale University School of Medicine, and Division of General Medicine (M.B.), Columbia University School of Medicine, New York, New York; Mayo Clinic and Mayo Medical School (A.J.), Rochester Minnesota; and Department of Psychiatry and Behavioral Sciences (C.B.T.), Stanford University School of Medicine, Stanford, California.

Address correspondence and reprint requests to Mickey Trockel, MD, PhD, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723. E-mail: trockel{at}stanford.edu

Introduction: Patients with cardiovascular disease who stop smoking lower their risk of subsequent morbidity and mortality. However, patients who have suffered a myocardial infarction (MI) are more likely to be depressed than the general population, which may make smoking cessation more difficult. Poor social support may also make smoking cessation more difficult for some patients. This study examines the effect of cognitive behavior therapy (CBT) for depression, low perceived social support or both on smoking behavior in post-MI patients.

Methods: Participants were 1233 patients with a history of smoking enrolled in the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) trial who provided 7-day point-prevalence smoking behavior information at baseline and at two or more follow-up assessments. The ENRICHD trial enrolled post-MI patients with depression, low perceived social support or both. Participants were randomly assigned to either CBT intervention or usual care. We used mixed effects models to accommodate data from multiple smoking point-prevalence measures for each individual participant.

Results: CBT did not significantly reduce post-MI smoking across all intervention patients with a history of smoking. However, CBT did reduce post-MI smoking among the subgroup of depressed patients with adequate perceived social support (OR, 0.68; 95% CI, 0.47–0.98).

Conclusion: CBT for depression without more specific attention to smoking cessation may have little overall value as a strategy for helping post-MI patients refrain from smoking. However, use of CBT to treat depression may have the gratuitous benefit of reducing smoking among some post-MI patients.

Key Words: cognitive behavioral therapy • smoking • depression • cardiovascular disease • myocardial infarction • social support

Abbreviations: ENRICHD = Enhancing Recovery in Coronary Heart Disease Patients; MI = myocardial infarction; CBT = cognitive behavioral therapy; LPSS = low perceived social support; MDD = major depressive disorder; BDI = Beck Depression Inventory; OR = odds ratio.