Exercise Interventions for Depressed Smokers: The Promise of Community Settings and Robots

Christi A. Patten1*, James A. Levine2, Pamela S. Sinicrope1, Ioannis T. Pavlidis3

1Department of Psychology and Psychiatry, Mayo Clinic, Rochester, Minnesota, USA

2Foundation Ipsen, Paris, France; and Case Western Reserve University, Ohio, USA

3Department of Computer Science, University of Houston, Houston, Texas, USA

Smokers have an increased risk of depressive symptoms and depressive disorders. Smokers reporting higher levels of depressive symptoms prior to cessation treatment have greater difficulty quitting smoking. However, few interventions have targeted depressed smokers, a tobacco use disparity group. There is preliminary evidence to support the use of supervised, vigorous intensity exercise interventions to help smokers with depression quit. This Mini-Review addresses the potential role of exercise interventions for this population. We cover: (1) tobacco cessation treatments that have targeted depressed smokers, (2) efficacy of supervised exercise interventions for depression and smoking cessation, (3) results from a pilot study of supervised, vigorous intensity exercise for depressed women delivered in a community setting, and (4) future directions including technologies to scale up delivery of exercise interventions and exercise maintenance strategies. Future studies are needed that broaden the characteristics of participants in trials to include racially diverse men and women with a range of depressive symptoms. Positioning exercise delivery within community settings enhances the possible reach of interventions to a more diverse population of smokers. Delivery of exercise coaching through robotic and other digital technologies could also increase intervention scalability and open new avenues to explore methods and strategies to promote exercise adherence/maintenance.

In 2016, cigarette smoking prevalence among U.S. adults was 15.5%, with higher prevalence among men (17.5%) than women (13.5%)1. Cigarette smoking disparities persist as a function of sociodemographic characteristics: race, education, income, and insurance status1,2. Adults with severe psychological distress (anxiety and depressive symptoms) also report a higher smoking prevalence (35.8%) compared with adults without such distress (14.7%)1; these differences are accentuated among individuals with low income status and education levels3. Cigarette smoking reduces life expectancy by 10-15 years among individuals with depression and other serious mental illnesses4.

Smokers have increased risk of depressive disorders and depressive symptoms5. In smoking cessation treatment samples, 34-50% report elevated depressive symptoms6,7. With few exceptions, elevated depressive symptoms and major depressive disorder (MDD) diagnosis prior to treatment predict reduced likelihood of quitting smoking8. Thus, designing effective smoking cessation interventions for currently depressed smokers, a tobacco-use disparity group, is a public health priority9.

This Mini-Review addresses the potential role of exercise interventions among depressed smokers. We cover: (1) treatments for depressed smokers, (2) supervised exercise interventions for depression and smoking cessation, (3) results from a pilot study of supervised, vigorous intensity exercise for depressed women delivered in a community setting, and (4) future directions.

Aside from exercise intervention studies described below10-12, only four treatment studies have targeted smokers with current depressive symptoms13-16. These studies included fluoxetine14, varenicline13, and computerized motivational feedback combined with nicotine replacement therapy (NRT)15. A preliminary study of mildly depressed smokers indicated behavioral activation therapy increased smoking abstinence compared with standard cessation treatment16, but was less effective for women and those with more severe depression. Cognitive-behavioral therapy (CBT) is effective for treating depression and has been studied extensively in smokers with a past history of MDD, and was only found to be effective for those with recurrent episodes17,18. Interestingly, mindfulness approaches to deescalate stress and negative emotions are effective for smoking cessation19, but lack evaluation among depressed smokers, as well as combining cognitive approaches with exercise.

Exercise is an effective treatment for depression, with effects comparable to CBT or pharmacotherapy20. Most studies of exercise for depression used supervised, facility-based exercise21. Chalder et al22 found that providing advice and encouragement to increase physical activity (no supervised exercise) was ineffective for promoting exercise adherence or reducing depressive symptoms. Similarly, in a randomized trial of men and women outpatients with MDD (1/3 smokers), our research team found that providing exercise counseling to encourage fitness center attendance (no supervised exercise) was not effective for promoting physical activity23.

Among smokers, acute exercise reduces cigarette cravings and negative affect24,25. The most recent Cochrane review of 20 randomized trials among smokers without depression concluded there was little evidence that exercise was effective as a smoking cessation intervention26. However, the review suggested these interventions were limited by inadequate control groups, insufficient exercise intensity, and a lack of support provided to ensure exercise adherence.

One of the few trials to show a long-term effect on smoking abstinence targeted women using 12 weeks of thrice weekly (i.e., 36 sessions) supervised, research-facility-based, vigorous intensity exercise27. When this treatment was streamlined to only four supervised exercise sessions (versus 36), it was not effective for smoking cessation and there was poor adherence to home exercise28. Moreover, two studies encouraging home-based exercise counseling among depressed female smokers, including one study by our research lab, revealed that such methods were not effective for promoting exercise adherence or smoking cessation compared with a health education contact control group, presumably due to the lack of supervision and support10,12.

Though not directly targeting depressed smokers, Abrantes et al29 piloted a 12-week supervised exercise intervention of moderate intensity (1 session/week), with CBT components to reinforce home-based exercise. No statistically significant differences were detected on smoking abstinence for the intervention versus health education control but higher levels of moderate-to-vigorous exercise were associated with lower depression severity during treatment.

Smits and colleagues30 observed that a supervised exercise protocol similar to Marcus et al27 was effective for smoking cessation among adults with high symptoms of anxiety sensitivity, a cognitive factor that may amplify the subjective experience of exertion (effort) during exercise, resulting in lower adherence with physical activity31. Therefore, rigorously designed studies suggest that a supervised exercise program could benefit smokers with psychological distress, including depressed smokers, by providing reinforcement, guidance, and support for exercise, thus improving adherence26.

Our research team explored if the same effective intervention tested among women smokers27 could also be efficacious for female smokers with depression11. In addition to the positive results obtained for women smokers27, vigorous exercise was used because of potential benefits of greater intensity exercise32,33 and increased cardiorespiratory fitness34 on depressive symptoms. Unlike the Marcus study27, the intervention was delivered in a community YMCA setting, instead of a research facility, enhancing its dissemination potential.

To adapt the intervention to depressed smokers, we incorporated language in the coaching manual from our team’s prior study of consumer preferences for exercise interventions conducted among 464 depressed men and women35. Advice and feedback from a community sample of 12 depressed women smokers also informed adaptations to the treatment protocol. For the pilot trial11, 30 adult women smokers with moderate-severe depressive symptoms were randomly assigned to 12 weeks of thrice weekly, in-person sessions of supervised, vigorous intensity, YMCA-based exercise (EX; n=15), or to a HE contact control condition (n=15). Participants received behavioral smoking cessation counseling and NRT. Treatment adherence was high for both groups (72% EX, 66% HE, p=0.55). All EX participants engaged in some vigorous exercise at every session, and at the final session attended, participants averaged 25 minutes (SD=6, range 123-30) of vigorous exercise (of 30 minutes recommended by week 12), suggesting the exercise protocol is feasible. The biochemically verified smoking abstinence rate was higher for EX than HE at week 12 (11/15 [73%] vs. 5/15 [33%], p=0.028), but not at week 26 (27% vs. 40%, p=0.439), even after adjusting analyses for depression score and antidepressant medication use (week 12, p=0.035; week 26, p=0.48. Cardiorespiratory fitness levels at week 12 increased significantly (p=0.002) more from baseline among EX than HE participants.

From this pilot study11 we concluded that supervised, vigorous intensity exercise is feasible, and our data suggest exercise enhances short-term smoking cessation among depressed female smokers. The lack of treatment condition differences at 6 months suggests the need to incorporate exercise maintenance strategies.

Our pilot study11 was limited by sample characteristics: women only, 90% White, with moderate-severe depressive symptoms. Exercise interventions for smoking cessation need to be adapted for suitability to a racially diverse sample of men and women with a range of depressive symptoms. Within smoking cessation intervention trials generally, a recent literature review on sex differences found that of 126 trials conducted, only two observed that women were significantly more likely to quit smoking than men, compared to 59 that found women were significantly less likely to quit smoking than men. The remaining 65 studies reported no sex differences36.

As these limitations exemplify, a major challenge is to discover innovative and cost-effective strategies to bolster long-term exercise adherence among diverse populations, including those living in rural and impoverished communities, while considering that supervised exercise is associated with better outcomes in studies of both depression37 and smoking cessation (see also Ussher et al26 for review)38,39. Because at least a third of all smokers in the U.S. have elevated symptoms of depression, identification of highly scalable solutions for cessation is a public health imperative.

Our research team is exploring a novel application of technology for delivering exercise coaching, without losing necessary supervision, using a robotic interface. Coaching is done in real time via an iPad tablet placed atop a mobile robotic wheel base, controlled remotely using an iOS device or computer. The current intervention prototype interacts in real time and thus bridges the gap between human and embodied support40,41. The robotic interface can move around the participant, not only to examine how the participant performs an exercise, but also to facially interact with him/her. A robotic-assisted coach could thus achieve similar functions as an in-person coach including: supervision, interaction, instruction and correction of exercise form, accountability, support, and reinforcement. The technology is different than web assisted video- or skype phone-conferencing because the robotic interface accompanies and moves with and around the participant during exercise while the participant remains hands-free.

We gathered preliminary data on acceptability of the robotic interface among 100 adult men and women recruited from two local community settings serving populations with low-income status, the YMCA and Rochester Public Library42. Participants watched a brief demonstration of the robot-delivered exercise coaching and then completed a survey. Respondents were 40% female, 41% racial minority, 56% unemployed, 38% current smoker, 58% had a history of depression, and 66% were sedentary. The mean Technology Acceptance Scale score was 34.0 (SD=5.5, range 16-40) of a possible score of 40, indicating very good overall receptivity to the robot. Racial minorities and unemployed participants reported greater technology acceptance than White (p=0.015) and employed (p<0.001) respondents; suggesting the potential utility of this technology for diverse populations. No associations were detected between TAS score and smoking status, sedentariness, depression history, sex, or age. Qualitative feedback indicated the robot was perceived as a novel, motivating way to prompt exercise, increase accessibility of interventions, and was the “wave of the future.” We concluded that robotic technology has potential applicability for exercise coaching in diverse populations, including depressed smokers, but that formative research is needed to assess consumer uptake and feasibility.

Additional options to increase intervention scalability include digital health coaching delivered through the web or mobile phones (e.g., texting, applications) as substantial research has documented the efficacy of such treatment delivery platforms for smoking cessation and physical activity43. In depression treatment, support provided by a virtual coach (i.e., embodied conversational agent) can facilitate participant engagement and self-disclosure due to its greater perceived anonymity and non-judgmental nature44. One drawback is that these technologies emulate, but do not include, the support and empathy of a live coach45. For example, a recent study utilizing a fully automated robot for motivational interviewing to increase physical activity found that while participants appreciated the novelty and non-judgmental nature of the technology, their experience was limited by the lack of individualized responses or social interactions with the robot46. As internet and Wi-Fi access improves in the future47, robotic-assisted and other digital technologies could have applications for several health behavior change interventions.

Maintenance of physical activity or of any health behavior change is a challenge for community settings48,49. One option is holding booster sessions, though little evidence provides efficacy for maintenance of physical activity or smoking cessation50. For physical activity maintenance, the literature suggests strategies to enhance social translucence (accountability) and social support for exercise48,49. Thus, future work might consider embedding the intervention within existing community settings, such as a YMCA or community health center. For example, YMCA desk staff or fitness center attendants could check-in individuals for their exercise program and document and verbally reinforce their attendance to provide accountability and social support. YMCAs also implement substantially reduced membership fees based on income and award points for facilities use, which could be useful for both initiating and extending memberships. Technology options discussed above could also be evaluated for providing social support.

This Mini-Review highlights the importance of focusing on depressed smokers as a tobacco-use disparity group. We identify several directions for research, most notably, broadening the characteristics of participants in trials to include racially diverse men and women with a range of depressive symptoms. Positioning exercise delivery within community settings enhances the possible reach of interventions to a more diverse population of smokers. In addition, delivery of exercise coaching through digital technologies could increase intervention scalability and open new avenues to explore methods and strategies to promote exercise adherence/maintenance and smoking cessation.

  1. Jamal A, Phillips E, Gentzke AS, et al. Current cigarette smoking among adults - United States, 2016. MMWR Morb Mortal Wkly Rep. 2018; 67(2): 53-59.
  2. Levinson AH. Where the U.S. tobacco epidemic still rages: most remaining smokers have lower socioeconomic status. J Health Care Poor Underserved. 2017; 28(1): 100-107.
  3. Weinberger AH, Gbedemah M, Martinez AM, et al. Trends in depression prevalence in the USA from 2005 to 2015: widening disparities in vulnerable groups. Psychol Med. 2018; 48(8): 1308-1315.
  4. Sharma R, Gartner CE, Hall WD. The challenge of reducing smoking in people with serious mental illness. Lancet Respir Med. 2016; 4(10): 835-844.
  5. Pratt LA, Brody DJ. Depression and smoking in the U.S. household population aged 20 and over, 2005-2008. NCHS Data Brief. 2010; (34): 1-8.
  6. Hebert KK, Cummins SE, Hernandez S, et al. Current major depression among smokers using a state quitline. Am J Prev Med. 2011; 40(1): 47-53.
  7. Wewers ME, Ferketich AK, Harness J, et al. Effectiveness of a nurse-managed, lay-led tobacco cessation intervention among Ohio Appalachian women. Cancer Epidemiol Biomarkers Prev. 2009; 18(12): 3451-3458.
  8. Weinberger AH, Mazure CM, Morlett A, et al. Two decades of smoking cessation treatment research on smokers with depression: 1990-2010. Nicotine Tob Res. 2013; 15(6): 1014-1031.
  9. Passey M, Bonevski B. The importance of tobacco research focusing on marginalized groups. Addiction. 2014; 109(7): 1049-1051.
  10. Bernard P, Ninot G, Cyprien F, et al. Exercise and counseling for smoking cessation in smokers with depressive symptoms: a randomized controlled pilot trial. J Dual Diagn. 2015; 11(3-4): 205-216.
  11. Patten CA, Bronars CA, Vickers Douglas KS, et al. Supervised, vigorous intensity exercise intervention for depressed female smokers: a pilot study. Nicotine Tob Res. 2017; 19(1): 77-86.
  12. Vickers KS, Patten CA, Lewis BA, et al. Feasibility of an exercise counseling intervention for depressed women smokers. Nicotine Tob Res. 2009; 11(8): 985-995.
  13. Anthenelli RM, Morris C, Ramey TS, et al. Effects of varenicline on smoking cessation in adults with stably treated current or past major depression: a randomized trial. Ann Intern Med. 2013; 159(6): 390-400.
  14. Brown RA, Abrantes AM, Strong DR, et al. Efficacy of sequential use of fluoxetine for smoking cessation in elevated depressive symptom smokers. Nicotine Tob Res. 2014; 16(2): 197-207.
  15. Hall SM, Tsoh JY, Prochaska JJ, et al. Treatment for cigarette smoking among depressed mental health outpatients: a randomized clinical trial. Am J Public Health. 2006; 96(10): 1808-1814.
  16. MacPherson L, Tull MT, Matusiewicz AK, et al. Randomized controlled trial of behavioral activation smoking cessation treatment for smokers with elevated depressive symptoms. J Consult Clin Psychol. 2010; 78(1): 55-61.
  17. Brown RA, Kahler CW, Niaura R, et al. Cognitive-behavioral treatment for depression in smoking cessation. J Consult Clin Psychol. 2001; 69(3): 471-480.
  18. Haas AL, Munoz RF, Humfleet GL, et al. Influences of mood, depression history, and treatment modality on outcomes in smoking cessation. J Consult Clin Psychol. 2004; 72(4): 563-570.
  19. Garland EL, Froeliger B, Howard MO. Mindfulness training targets neurocognitive mechanisms of addiction at the attention-appraisal-emotion interface. Front Psychiatry. 2014; 4: 173.
  20. Blumenthal JA, Babyak MA, Doraiswamy PM, et al. Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosom Med. 2007; 69(7): 587-596.
  21. Schuch FB, Vancampfort D, Richards J, et al. Exercise as a treatment for depression: a meta-analysis adjusting for publication bias. J Psychiatr Res. 2016; 77: 42-51.
  22. Chalder M, Wiles NJ, Campbell J, et al. Facilitated physical activity as a treatment for depressed adults: randomised controlled trial. BMJ. 2012; 344: e2758.
  23. Patten CA, Vickers KS, Lewis BA, et al. Feasibility trial of an unsupervised, facility-based exercise programme for depressed outpatients. Psychol Health Med. 2019; 24(3): 320-332.
  24. Abrantes AM, Farris SG, Minami H, et al. Acute effects of aerobic exercise on affect and smoking craving in the weeks before and after a cessation attempt. Nicotine Tob Res. 2018; 20(5): 575-582.
  25. Haasova M, Warren FC, Ussher M, et al. The acute effects of physical activity on cigarette cravings: systematic review and meta-analysis with individual participant data. Addiction. 2013; 108(1): 26-37.
  26. Ussher MH, Taylor AH, Faulkner GE. Exercise interventions for smoking cessation. Cochrane Database Syst Rev. 2014; (8): CD002295.
  27. Marcus BH, Albrecht AE, King TK, et al. The efficacy of exercise as an aid for smoking cessation in women: a randomized controlled trial. Arch Intern Med. 1999; 159(11): 1229-1234.
  28. Whiteley JA, Williams DM, Dunsiger S, et al. YMCA commit to quit: randomized trial outcomes. Am J Prev Med. 2012; 43(3): 256-262.
  29. Abrantes AM, Bloom EL, Strong DR, et al. A preliminary randomized controlled trial of a behavioral exercise intervention for smoking cessation. Nicotine Tob Res. 2014; 16(8): 1094-1103.
  30. Smits JA, Zvolensky MJ, Davis ML, et al. The efficacy of vigorous-intensity exercise as an aid to smoking cessation in adults with high anxiety sensitivity: a randomized controlled trial. Psychosom Med. 2016; 78(3): 354-364.
  31. Farris SG, Uebelacker LA, Brown RA, et al. Anxiety sensitivity predicts increased perceived exertion during a 1-mile walk test among treatment-seeking smokers. J Behav Med. 2017; 40(6): 886-893.
  32. Dunn AL, Trivedi MH, Kampert JB, et al. Exercise treatment for depression: efficacy and dose response. Am J Prev Med. 2005; 28(1): 1-8.
  33. Perraton LG, Kumar S, Machotka Z. Exercise parameters in the treatment of clinical depression: a systematic review of randomized controlled trials. J Eval Clin Pract. 2010; 16(3): 597-604.
  34. Galper DI, Trivedi MH, Barlow CE, et al. Inverse association between physical inactivity and mental health in men and women. Med Sci Sports Exerc. 2006; 38(1): 173-178.
  35. McPherson K, Bronars C, Patten C, et al. Understanding word preference for description of exercise interventions as a means for enhancing recruitment and acceptability of exercise treatment among adults treated for depression. Mental Health and Physical Activity. 2014; 7(2): 73-77.
  36. Smith PH, Bessette AJ, Weinberger AH, et al. Sex/gender differences in smoking cessation: a review. Prev Med. 2016; 92: 135-140.
  37. Stanton R, Reaburn P. Exercise and the treatment of depression: a review of the exercise program variables. J Sci Med Sport. 2014; 17(2): 177-182.
  38. Bize R, Willi C, Chiolero A, et al. Participation in a population-based physical activity programme as an aid for smoking cessation: a randomised trial. Tob Control. 2010; 19(6): 488-494.
  39. Maddison R, Roberts V, McRobbie H, et al. Exercise counseling to enhance smoking cessation outcomes: The Fit2Quit randomized controlled trial. Ann Behav Med. 2014; 48(2): 194-204.
  40. Michie S, Yardley L, West R, et al. Developing and evaluating digital interventions to promote behavior change in health and health care: recommendations resulting from an international workshop. J Med Internet Res. 2017; 19(6): e232.
  41. Riek LD. Wizard of Oz studies in HRI: a systematic review and new reporting guidelines. Journal of Human-Robot Interaction. 2012; 1(1): 119-136.
  42. Patten C, Levine J, Pavlidis I, et al. Survey of potential receptivity to robotic-assisted exercise coaching in a diverse sample of smokers and nonsmokers. PLoS One. 2018; 13(5): e0197090.
  43. Afshin A, Babalola D, McLean M, et al. Information technology and lifestyle: a systematic evaluation of internet and mobile interventions for improving diet, physical activity, obesity, tobacco, and alcohol use. J Am Heart Assoc. 2016; 5(9): e003058.
  44. Provoost S, Lau HM, Ruwaard J, et al. Embodied conversational agents in clinical psychology: a scoping review. J Med Internet Res. 2017; 19(5): e151.
  45. Santarossa S, Kane D, Senn CY, et al. Exploring the role of in-person components for online health behavior change interventions: can a digital person-to-person component suffice. J Med Internet Res. 2018; 20(4): e144.
  46. Galvao Gomes da Silva J, Kavanagh DJ, Belpaeme T, et al. Experiences of a motivational interview delivered by a robot: qualitative study. J Med Internet Res. 2018; 20(5): e116.
  47. Anderson M, Perrin A. 13% of Americans don't use the internet. Who are they? Accessed 11 February 2018. Available at: http://www.pewresearch.org/fact-tank/2016/09/07/some-americans-dont-use-the-internet-who-are-they/.
  48. Hillsdon MM, Brunner EJ, Guralnik JM, et al. Prospective study of physical activity and physical function in early old age. Am J Prev Med. 2005; 28(3): 245-250.
  49. Middleton KR, Anton SD, Perri MG. Long-term adherence to health behavior change. Am J Lifestyle Med. 2013; 7(6): 395-404.
  50. Goyder E, Hind D, Breckon J, et al. A randomised controlled trial and cost-effectiveness evaluation of 'booster' interventions to sustain increases in physical activity in middle-aged adults in deprived urban neighbourhoods. Health Technol Assess. 2014; 18(13): 1-210.

Article Info

Article Notes

  • Published on: December 18, 2018


  • Exercise

  • Depression
  • Intervention
  • Treatment
  • Smoking
  • Tobacco
  • Maintenance
  • Robotics
  • Technology


Dr. Christi Patten, PhD
Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA; Telephone No: 1-507-261-0718
Email: patten.christi@mayo.edu.