***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Tobacco Dependence among smokers with psychiatric disorders has been under-addressed by the mental health , addictions , and tobacco control communities . This study examined depressed smokers ' readiness to quit and the applicability of the Stages of Change framework to a psychiatric sample . Currently depressed smokers ( N=322 ) were recruited from four outpatient psychiatric clinics . Participants averaged 16 cigarettes per day ( S.D.=10 ) and 24 years ( S.D.=13 ) of smoking . The majority ( 79 % ) reported intention to quit smoking with 24 % ready to take action in the next 30 days . Individuals in the preparation stage reported more prior quit attempts , a greater commitment to abstinence , increased recognition of the cons of smoking , and greater use of the processes of change . Precontemplators were least likely to identify a goal related to their smoking behavior . Depressive symptom severity and history of recurrent depressive episodes were unrelated to readiness to quit . This study is one of the first to examine the smoking behaviors of currently depressed psychiatric out patients . The level and longevity of their tobacco use underscore the need for cessation interventions . The consistency in hypothesized patterns among theoretical constructs of the Stages of Change model supports the transfer of stage-tailored interventions to this clinical population BACKGROUND R and omized efficacy clinical trials conducted in research setting s may not accurately reflect the benefits of tobacco dependence treatments when used in real-world clinical setting s. Effectiveness trials ( eg , in primary care setting s ) are needed to estimate the benefits of cessation treatments in real-world use . METHODS A total of 1346 primary care patients attending routine appointments were recruited by medical assistants in 12 primary care clinics . Patients were r and omly assigned to 5 active pharmacotherapies : 3 monotherapies ( nicotine patch , nicotine lozenge , and bupropion hydrochloride sustained release [ SR ] ) and 2 combination therapies ( patch + lozenge and bupropion SR + lozenge ) . Patients were referred to a telephone quit line for cessation counseling . Primary outcomes included 7-day point prevalence abstinence at 1 week , 8 weeks , and 6 months after quitting and number of days to relapse . RESULTS Among 7128 eligible smokers ( > or = 10 cigarettes per day ) attending routine primary care appointments , 1346 ( 18.9 % ) were enrolled in the study .  Six-month abstinence rates for the 5 active pharmacotherapies were the following : bupropion SR , 16.8 % ; lozenge , 19.9 % ; patch , 17.7 % ; patch + lozenge , 26.9 % ; and bupropion SR + lozenge , 29.9 % . Bupropion SR + lozenge was superior to all of the monotherapies ( odds ratio , 0.46 - 0.56 ) ; patch + lozenge was superior to patch and bupropion monotherapies ( odds ratio , 0.56 and 0.54 , respectively ) . CONCLUSIONS One in 5 smokers attending a routine primary care appointment was willing to make a serious quit attempt that included evidence -based counseling and medication . In this comparative effectiveness study of 5 tobacco dependence treatments , combination pharmacotherapy significantly increased abstinence compared with monotherapies . Provision of free cessation medications plus quit line counseling arranged in the primary care setting holds promise for assisting large numbers of smokers to quit . Trial Registration clinical trials.gov Identifier : NCT00296647 BACKGROUND People with psychiatric disorders are more likely to smoke and smoke more heavily than the general population , and they suffer disproportionally from smoking-related illnesses . However , little is known about how quitting versus continuing to smoke affects mental health and the likelihood of developing a psychiatric diagnosis . This study used data from a large prospect i ve clinical trial to examine the relations of smoking cessation success with psychiatric diagnoses 1 and 3 years after the target quit day . METHODS This study enrolled 1504 smokers ( 83.9 % white ; 58.2 % female ) in a cessation trial that involved the completion of the Composite International Diagnostic Interview to assess psychiatric diagnoses and biochemical confirmation of point-prevalence abstinence at Baseline and Years 1 and 3 . RESULTS Regression analyses showed that , after controlling for pre-quit ( past-year ) diagnoses , participants who were smoking at the Year 3 follow-up were more likely to have developed and maintained a substance use or major depressive disorder by that time than were individuals who were abstinent at Year 3 . CONCLUSIONS Quitting smoking does not appear to negatively influence mental health in the long-term and may be protective with respect to depression and substance use diagnoses ; this should encourage smokers to make quit attempts and encourage clinicians to provide cessation treatment It was hypothesized that smoking 's calming effects are cognitively mediated and depend on the presence of a benign distractor , smoking narrows the focus of attention , thereby reducing anxiety by facilitating distraction from stressful cognitions ( cf . C. M. Steele & R. A. Josephs 's [ 1988 ] attention-allocation model of alcohol reinforcement ) . This notion was tested by examining the effect of  smoking ( vs. not smoking )  on anxiety with and without a concurrent distraction in 82 smokers ; distraction effects were also assessed in 42 nonsmokers . As predicted , smoking reduced anxiety only when paired with a distractor . Further , these findings could not be explained by direct nicotine effects or nicotine withdrawal . Several measures of attention allocation failed to confirm the hypothesized cognitive mechanisms , however . Implication s of the findings are discussed The effects of exposure to two classes of smoking-relevant cues ( environmental ; negative affect ) on desire to smoke and smoking topography were evaluated . Sixty chronic smokers were r and omly assigned to one of six groups in a two-way ANOVA design in which the salience of environmental cues and presence of negative affective cues were manipulated . This was followed by a 20-minute interval during which ad libitum smoking was videotaped in an unobtrusive manner . Results indicated that the experimental manipulations differentially influenced ratings of desire and topographical components of smoking behavior . Implication s are raised regarding the role of cue reactivity in the maintenance of smoking behavior This study is a r and omized , double-blind , placebo-controlled clinical trial examining the effects of an intensive cognitive-behavioral mood management treatment ( CBTD ) and of bupropion , both singularly and in combination , on  smoking cessation in adult smokers . As an extension of our previous work , we planned to examine the synergistic effects of CBTD and bupropion on smoking cessation outcomes in general and among smokers with depression vulnerability factors . Participants were 524 smokers ( 47.5 % female , M ( age ) = 44.27 years ) who were r and omized to one of four 12-week treatments : ( a ) st and ard , cognitive-behavioral smoking cessation treatment ( ST ) plus bupropion ( BUP ) , ( b ) ST plus placebo ( PLAC ) , ( c ) st and ard cessation treatment combined with cognitive-behavioral treatment for depression ( CBTD ) plus BUP , and ( d ) CBTD plus PLAC . Follow-up assessment s were conducted 2 , 6 , and 12 months after treatment , and self-reported abstinence was verified biochemically . Consistent with previous studies , bupropion , in comparison with placebo , result ed in better smoking outcomes in both intensive group treatments . Adding CBTD to st and ard intensive group treatment did not result in improved smoking cessation outcomes . In addition , neither CBTD nor bupropion , either alone or in combination , was differentially effective for smokers with single-past-episode major depressive disorder ( MDD ) , recurrent MDD , or elevated depressive symptoms . However , findings with regard to recurrent MDD and elevated depressive symptoms should be interpreted with caution given the low rate of recurrent MDD and the low level of depressive symptoms in our sample . An a priori test of treatment effects in smokers with these depression vulnerability factors is warranted in future clinical trials BACKGROUND Nosological boundaries for depressive disorders as well as the prevalence and impact of ' subsyndromal ' depression remain unclear . AIMS To examine the impact of subsyndromal depressive disorders on health status and to assess if depressive disorders lie on a continuum of severity . METHOD The sample was composed of r and omly selected respondents from the general population in 68 countries from across the world participating in the World Health Organization 's World Health Survey . RESULTS The pattern of risk factors for depressive disorders was consistent across all types of depression ( subsyndromal , brief depressive episode and depressive episode ) : odds ratios for females ranged between 1.49 and 1.80 , and for the unemployed from 1.19 to 1.25 . All types of depression produced a significant decrement in health status compared with no depression after controlling for demographic variables , income and country . CONCLUSIONS Subthreshold depressive disorders occur commonly all across the world and are associated with the same risk factors everywhere . They produce significant decrements in health and do not qualitatively differ from full-blown episodes of depression as currently defined , and lie on a continuum with more severe forms of depressive episodes but are distinct from normal mood changes IMPORTANCE Reward-related disturbances after withdrawal from nicotine are hypothesized to contribute to relapse to tobacco smoking but mechanisms underlying and linking such processes remain largely unknown . OBJECTIVE To determine whether withdrawal from nicotine affects reward responsiveness ( ie , the propensity to modulate behavior as a function of prior reinforcement experience ) across species using translational behavioral assessment s in humans and rats . DESIGN , SETTING , PARTICIPANTS Experimental studies used analogous reward responsiveness tasks in both humans and rats to examine whether reward responsiveness varied in ( 1 ) an ad libitum smoking condition compared with a 24-hour acute nicotine abstinence condition in 31 human smokers with ( n = 17 ) or without ( n = 14 ) a history of depression ; ( 2 ) rats  24 hours after withdrawal from chronic nicotine ( n = 19 ) or saline ( n = 20 ) ; and ( 3 ) rats  following acute nicotine exposure after withdrawal from either chronic nicotine or saline administration . MAIN OUTCOMES AND MEASURES Performance on a reward responsiveness task under nicotine and nonnicotine conditions . RESULTS In both human smokers and nicotine-treated rats , reward responsiveness was significantly reduced after 24-hour withdrawal from nicotine ( P < .05 ) . In humans , withdrawal-induced deficits in reward responsiveness were greater in those with a history of depression . In rats previously exposed to chronic nicotine , acute nicotine reexposure long after withdrawal potentiated reward responsiveness ( P < .05 ) . CONCLUSIONS AND RELEVANCE These findings across species converge in suggesting that organisms have diminished ability to modulate behavior as a function of reward during withdrawal of nicotine . This blunting may contribute to relapse to tobacco smoking , particularly in depression-vulnerable individuals , to reinstate responsiveness to natural rewards and to experience potentiated nicotine-induced reward responsiveness . Moreover , demonstration of behavioral homology across humans and rodents provides a strong translational framework for the investigation and development of clinical treatments targeting reward responsiveness deficits during early withdrawal of nicotine Two notions strongly held by many smokers are that negative mood increases smoking behavior and that this increase is due to the ability of smoking to alleviate negative affect . This study used a modified mood induction procedure to examine both the impact of smoking on induced mood , as well as the effect of induced mood on actual smoking behavior .  Forty-eight smokers were r and omly assigned to a  smoking or a  water-drinking comparison group . Each participant attended 3 sessions during which 1 of 3 mood states ( positive , negative , or neutral ) was induced . Contrary to expectation , smoking did not attenuate negative affect . However , negative mood induction subsequently quickened latency to smoke and increased number of puffs consumed ad lib INTRODUCTION A growing literature suggests that anhedonia-an affective dimension related to the inability to experience pleasure-is associated with poor smoking cessation outcomes . Despite these findings , research of the motivational mechanisms linking anhedonia and smoking has been limited . Accordingly , the present study examined ( a ) relationships between anhedonia and motivationally relevant smoking characteristics and ( b ) whether anhedonia moderated the effects of tobacco deprivation on appetitive and aversive aspects of smoking urges . METHODS Smokers ( N = 212 ; > or=5 cigarettes/day ) first attended a baseline session during which measures of anhedonia and smoking characteristics were completed . Prior to a subsequent experimental session , a portion of participants were r and omized to one of two groups : ( a ) 12-hr tobacco deprivation before the session ( n = 51 ) and ( b ) ad libitum smoking ( n = 69 ) . RESULTS Smokers with higher levels of anhedonia reported a greater number of past failed quit attempts and a higher proportion of quit attempts that ended in rapid relapse within 24 hr , rs > .20 , ps < .05 . Anhedonia did not consistently correlate with smoking heaviness , chronicity , and dependence motives . Anhedonia significantly moderated the influence of tobacco deprivation on appetitive smoking urges , such that deprivation 
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RESULTS Our review identified three primary mechanisms that underlie persistent smoking among depressed smokers : low positive affect , high negative affect and cognitive impairment .
We propose a novel application of incentive learning theory which posits that depressed smokers experience greater increases in the expected value of smoking in the face of these three motivational states , which promotes goal -directed choice of smoking behavior over alternative actions .
The incentive learning theory accounts for current evidence on how depression primes smoking behavior and provides a unique framework for conceptualizing psychological mechanisms of smoking maintenance among depressed smokers .
Treatment should focus upon correcting adverse internal states and beliefs about the high value of smoking in those states to improve cessation outcomes for depressed smokers