Smoking withdrawal dynamics: I. Abstinence distress in lapsers and abstainers.

Smoking withdrawal reports from a clinical trial (n=893) were submitted to hierarchical linear modeling as a cross-method replication of a heterogeneity approach to withdrawal measurement and to clarify the influence of postcessation smoking on symptom reports. Five individual difference parameters tapping distinct facets of withdrawal were derived: intercepts (mean severity), linear slope (direction and rate of change), quadratic trend (curvature), volatility (scatter) and, among lapses, a cigarette coefficient (smoking-related deflections of symptoms). All parameters were highly variable across persons. Lapsers had more aversive symptom patterns than abstainers, and symptoms tended to be higher than otherwise predicted on lapse days. These results reinforce the conclusion that withdrawal symptoms are highly variable and argue against discarding withdrawal data from participants who lapse. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Does reducing withdrawal severity mediate nicotine patch efficacy? A randomized clinical trial.

Nicotine replacement therapy (NRT) repeatedly has been shown to improve smoking treatment outcome. The major mechanism posited for this improvement in outcome is that NRT reduces nicotine craving and withdrawal. The authors tested this hypothesized mechanism of action using real-time data on craving and withdrawal, collected by ecological momentary assessments administered on a palm-top computer. Smokers (N = 324) were randomized to receive either active high-dose (35 mg) 24-hr patches or placebo. Increases in positive affect and decreases in craving, negative affect, and attention disturbance severity were related to lower risk of lapsing. Although NRT treatment did significantly decrease withdrawal and craving severity, these reductions only partially accounted for NRT's impact on time to first lapse: The results from a mediation analysis showed that the hazard ratio for NRT, when controlling for withdrawal and craving severity, was only a third to a half lower than the uncontrolled hazard ratio for NRT alone. This suggests that other mechanisms for the effectiveness of NRT need to be examined. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Smoking Withdrawal Dynamics: III. Correlates of Withdrawal Heterogeneity.

Five parameters of postcessation smoking withdrawal variability derived from clinical data (T. M. Piasecki, D. E. Jorenby, S. S. Smith, M. C. Fiore, & T. B. Baker, 2003a, 2003b) were predicted from baseline measures and pharmacotherapy assignment. Smokers who were more dependent, older, and high in negative affect reported more severe withdrawal. Women, heavier smokers, and those with a history of depression reported more variable symptoms. Smokers treated with nicotine patch, bupropion, or both reported less severe withdrawal than did those given placebo, but medication did not affect the slope of symptoms over time, day-to-day variability of symptoms, or the size of acute changes in symptoms associated with lapses to smoking. Prior research has shown that these symptom facets predict later relapse: thus, current pharmacotherapies may aid cessation by diminishing withdrawal severity, but they do not affect all clinically important aspects of withdrawal. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Acute nicotine reinforcement, but not chronic tolerance, predicts withdrawal and relapse after quitting smoking.

Little research has examined the association of tobacco dependence with nicotine tolerance or reinforcement in a clinical sample. Smokers preparing to quit smoking participated in laboratory sessions to assess nicotine tolerance on subjective, cardiovascular, and performance measures and to assess nicotine reinforcement using a choice procedure. Participants were then provided with individual counseling (but no medication), made a quit attempt, and were followed for 1 year to determine clinical outcome, as determined by postquit withdrawal and days to relapse. Nicotine tolerance was unrelated to either withdrawal or relapse. However, acute nicotine reinforcement was significantly related to both greater withdrawal and faster relapse. Results challenge the common assumption that nicotine tolerance is closely related to dependence but suggest that nicotine reinforcement may have theoretical and clinical significance for dependence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Brain injury and morphine withdrawal.

"A review of the literature indicates lack of agreement as to the presence or absence of opiate withdrawal symptoms following surgically imposed brain damage. The controversy is resolved when recourse is made to the temporal factor, i.e., the time at which withdrawal is carried out relative to the time an operation is performed. It is suggested that the withdrawal phenomenon is as complex as addiction itself, and that both are related to many peculiar effects that accrue to cerebral tissue destruction." 26 references. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Immediate Antecedents of Cigarette Smoking: An Analysis of Unrestricted Smoking Patterns.

Theory suggests that cigarette smoking is under stimulus control and that affect is a key trigger for smoking. A previous study (S. Shiftman et al., 2002) showed little relationship between affect and smoking, but this relationship could have been suppressed by the impact of smoking restrictions. The study evaluated these associations in a 1988 sample that was subject to few smoking restrictions. Smokers (N = 28) not seeking treatment used palmtop computers to record context and affect prior to smoking (n = 2,217 observations) and also at random times when not smoking (n = 2,380). Comparisons showed little relationship between smoking and affect. Smoking was associated with particular activities and locations. Urge to smoke was the strongest predictor of smoking. The results replicated the findings of S. Shiffman et al. (2002). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Nicotine withdrawal in smokers with current depressive disorders undergoing intensive smoking cessation treatment.

The authors investigated withdrawal in smokers with current threshold and subthreshold depressive disorders (N = 21) who were participating in a pilot study of intensive counseling interventions for smoking cessation. The majority of participants (67%) were taking antidepressants when they entered the trial. Withdrawal symptoms were compared in prolonged abstainers versus nonabstainers across a 12-week treatment period and at the 3-month follow-up assessment visit. Prolonged abstinence was associated with an increase in positive affect and a decrease in depressive symptoms and craving over time. Nonabstinence was associated with little overall change in these variables from treatment onset to the 3-month follow-up. At the 3-month follow-up, 44% of prolonged abstainers were in complete remission of their baseline depressive disorders, compared with 0% remission among nonabstainers. Findings suggest that within the context of an intensive smoking cessation intervention, some smokers with current depressive disorders may experience significant improvement in affective and craving symptoms. Findings also suggest that abstinence may be associated with improvement in affect. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Negative Affect and Smoking Lapses: A Prospective Analysis.

Relapse is a central problem in smoking treatment. Data collected at the time of relapse episodes indicate that stress and negative affect (NA) promote relapse, but retrospective data are potentially biased. The authors performed a prospective analysis of stress and NA prior to initial lapses in smokers (N = 215). Day-to-day changes in stress (daily negative and positive events and Perceived Stress Scale scores) and NA (multiple momentary affect ratings) did not predict lapse risk on the following day. However, within the lapse day itself, NA was already significantly increasing hours before lapses, but only for episodes attributed to stress or bad mood. Thus, rapid increases in NA, but not slow-changing shifts in stress and NA, were associated with relapse. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Tobacco withdrawal and negative affect: An analysis of initial emotional response intensity and voluntary emotion regulation.

This report used emotion-modulated startle to refine theoretically critical claims about negative affect during tobacco withdrawal. Forty-eight dependent smokers (assigned to either a 24-hr nicotine withdrawal condition or a continued smoking condition) and 48 nonsmokers participated in this study. Participants viewed a series of neutral and unpleasant photographic images and were instructed to enhance, suppress, or maintain their emotional response during specific trials. Participants' startle response was measured before and after this regulation instruction to index 2 components of emotional response: initial negative emotional response intensity and emotion regulation. Compared with the nonwithdrawn groups (continuing smokers and nonsmokers), withdrawal significantly increased self-reported negative affect. However, startle response indicated that emotional response intensity and emotion regulation success were not affected by withdrawal. These results are important because they constrain interpretation of the predominantly self-report literature on the affective consequences of tobacco withdrawal. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Smoking.

The task force on cigarette smoking research in health psychology addressed three questions: What are the major current research directions of health psychologists on this topic? What are the major future research directions that health psychologists should address on this topic? What barriers to smoking research exist for health psychologists? Discussion of current research focused on five areas: prevention, cessation, relapse, basic science research, and public policy. Smoking prevention research centers on school-based interventions in longitudinal trials targeting adolescent substance abuse--including cigarette smoking--and focusing on the processes influenced by the intervention that, in turn, prevent smoking. Research also is being conducted outside the school setting to test community-wide public information campaigns and to reach adolescents in other social groups. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Smoking withdrawal dynamics in unaided quitters.

Considerable research shows that withdrawal severity is inconsistently related to smoking cessation outcomes. This may result from measurement problems or failure to scrutinize important dimensions of the withdrawal experience. Two recent studies demonstrated that withdrawal elevation and variations in the time course of withdrawal were related to relapse in smokers treated with the nicotine patch (T. M. Piasecki, M. C. Fiore, & T. B. Baker, 1998). This article reports a conceptual replication and extension of those findings in unaided quitters. Evidence for temporal heterogeneity was found across different types of withdrawal symptoms. Patterns or slopes of affect and urge reports over time predicted smoking status at follow-up, as did mean elevation in withdrawal symptoms. These results suggest that affect and urge withdrawal symptoms make independent contributions to relapse and that relapse is related to both symptom severity and trajectory. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Dynamic Self-Efficacy and Outcome Expectancies: Prediction of Smoking Lapse and Relapse.

According to social learning models of drug relapse, decreases in abstinence self-efficacy (ASE) and increases in positive smoking outcome expectancies (POEs) should foreshadow lapses and relapse. In this study, the authors examined this hypothesis by using ecological momentary assessment data from 305 smokers who achieved initial abstinence from smoking and monitored their smoking and their ASE and POEs by using palmtop computers. Daily ASE and POEs predicted the occurrence of a 1st lapse on the following day. Following a lapse, variations in daily ASE predicted the onset of relapse, even after controlling for concurrent smoking. ASE and POEs generally neither mediated nor moderated each other's effects. These data emphasize the role of dynamic factors in the relapse process. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Characterizing nicotine withdrawal in pregnant cigarette smokers.

Maternal smoking is a leading preventable cause of poor pregnancy outcomes and infant morbidity and mortality. Whereas pregnancy has been thought of as a "window of opportunity" when women are more motivated to change health behaviors such as smoking, only 20% of pregnant women quit smoking upon learning they are pregnant and remain abstinent at the end of the pregnancy. Greater understanding of possible obstacles to smoking during pregnancy, such as nicotine withdrawal, is needed. The symptoms of nicotine withdrawal have been well characterized in nonpregnant smokers, but there has been only 1 report conducted during pregnancy, and that was a retrospective study. The aim of the present study was to characterize nicotine withdrawal and craving in pregnant cigarette smokers. These data were collected as part of prospective clinical trials assessing the efficacy of voucher-based incentives to promote abstinence from cigarette smoking during pregnancy and postpartum. The authors examined results from the Minnesota Nicotine Withdrawal Scale (J. R. Hughes & D. K. Hatsukami, 1998) in 27 abstainers (reported no or very low levels of smoking, which was confirmed biochemically) and 21 smokers (smoked at >80% of their baseline smoking level) during the first 5 days of a cessation attempt. Abstainers reported more impatience, anger, and difficulty concentrating than did smokers. The results also suggest that pregnant smokers generally may have elevated baseline levels of withdrawal, which need to be considered in the design and analysis of future studies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

High-dose transdermal nicotine and naltrexone: Effects on nicotine withdrawal, urges, smoking, and effects of smoking.

Although treatment with transdermal nicotine replacement (TNR) has improved smoking abstinence rates, higher doses of TNR could improve effects on urge to smoke, nicotine withdrawal, and reinforcement from smoking, and naltrexone might further reduce reinforcement and urges. A laboratory investigation with 134 smokers using a 3 × 2 parallel-group design evaluated the effects of TNR (42-mg, 21-mg, or 0-mg patch) as crossed with a single dose of naltrexone (50 mg) versus placebo on urge to smoke, withdrawal, and responses to an opportunity to smoke (intake, subjective effects) after 10 hr of deprivation. Urge and withdrawal were assessed both prior to and after cigarette cue exposure. Only 42 mg TNR, not 21 mg, prevented urge to smoke, heart rate change, and cue-elicited increase in withdrawal. Both 21 and 42 mg TNR blocked cue-elicited drop in heart rate and arterial pressure. Naltrexone reduced cue-elicited withdrawal symptoms but not urges to smoke or deprivation-induced withdrawal prior to cue exposure. Neither medication significantly affected carbon monoxide intake or subjective effects of smoking except that 42 mg TNR resulted in lower subjective physiological activation. No interaction effects were found, and no results differed by gender. Results suggest that starting smokers with 42 mg TNR may increase comfort during initial abstinence, but limited support is seen for naltrexone during smoking abstinence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Gender differences in acute tobacco withdrawal: Effects on subjective, cognitive, and physiological measures.

Gender differences in tobacco withdrawal are of considerable clinical importance, but research findings on this topic have been mixed. Methodological variation in samples sizes, experimental design, and measures across studies may explain the inconsistent results. The current study examined whether male (n = 101) and female (n = 102) smokers (≥15 cigarettes/day) differed in abstinence-induced changes on a battery of self-report measures (withdrawal, affect, craving), cognitive performance tasks (attention, psychomotor performance), and physiological responses (heart rate, blood pressure, brain electroencephalogram). Participants attended 2 counterbalanced laboratory sessions, 1 following 12 hr of abstinence and the other following ad libitum smoking. Results showed that women reported greater abstinence-induced increases in negative affect, withdrawal-related distress, and urge to smoke to relieve withdrawal distress. In contrast, both genders reported similar abstinence-induced changes in positive affect and urge to smoke for pleasure. Men and women exhibited generally similar abstinence-induced changes in physiological and cognitive performance measures. In addition, gender did not moderate the association between withdrawal symptoms and baseline measures of smoking behavior and dependence. Abstinence-induced changes in withdrawal distress mediated the effect of gender on latency until the 1st cigarette of the day at trend levels ( p     

Effect of Bupropion on Depression Symptoms in a Smoking Cessation Clinical Trial.

Bupropion is an antidepressant shown to be efficacious for smoking cessation. This study examined the short- and long-term effects of bupropion (300 mg/day for 10 weeks) versus placebo on depression symptoms among 497 smokers attempting to quit in a randomized trial of bupropion plus behavioral counseling. Depression symptoms were assessed via the Center for Epidemiological Studies Depression Scale (L. Radloff, 1977) at baseline, end of treatment, and at 6-month follow-up. Baseline nicotine dependence level was assessed with the Fagerstrom Test for Nicotine Dependence (T. F. Heatherton, L. T. Kozlowski, R. C. Frecker, & K. O. Fagerstr?m, 1991). A regression model of depression symptoms demonstrated a significant interaction between nicotine dependence and treatment for the treatment phase and during follow-up. Depression symptoms did not mediate the effects of bupropion on abstinence at either time point. Highly nicotine-dependent smokers who receive bupropion are more likely to experience a decrease in depressive symptoms during active treatment but are also more likely to experience a rebound in depressive symptoms when bupropion is discontinued. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Smoking patterns and dependence: Contrasting chippers and heavy smokers.

The authors used ecological momentary assessment to contrast smoking patterns among chippers (CHs; n = 26)--smokers who smoke despite an apparent absence of tobacco dependence--with those seen in heavy smokers (HSs; n = 28). Smoking and nonsmoking settings (activity, mood, etc.) were assessed by means of electronic diary. CHs were not social smokers; like HSs, they smoked half their cigarettes while alone. When smoking, CHs' urge levels equaled those of HSs; between cigarettes, CHs had few urges, whereas HSs reported moderate urges. CHs' smoking was particularly associated with indulgent activities: relaxation, socializing, eating, and drinking alcohol. Outside of these indulgent settings, CHs' (but not HSs') smoking was associated with negative affect. In idiographic analyses, CHs' smoking was under much stronger stimulus control than was that of HSs. The authors propose that the disappearance of stimulus control over use is a characteristic of dependence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The time course and significance of cannabis withdrawal.

Withdrawal symptoms following cessation of heavy cannabis (marijuana) use have been reported, yet their time course and clinical importance have not been established. A 50-day outpatient study assessed 18 marijuana users during a 5-day smoking-as-usual phase followed by a 45-day abstinence phase. Parallel assessment of 12 ex-users was obtained. A withdrawal pattern was observed for aggression, anger, anxiety, decreased appetite, decreased body weight, irritability, restlessness, shakiness, sleep problems, and stomach pain. Onset typically occurred between Days 1-3, peak effects between Days 2-6, and most effects lasted 4-14 days. The magnitude and time course of these effects appeared comparable to tobacco and other withdrawal syndromes. These effects likely contribute to the development of dependence and difficulty stopping use. Criteria for cannabis withdrawal are proposed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Measurement of the effects of abstinence from tobacco: A qualitative review.

This article reviews terms, methodologies, and scales used to describe the effects of abstinence from tobacco in humans. The review suggests operational definitions for withdrawal, offset, novel, and indefinite abstinence effects. The review recommends the use of prospective studies that use smokers trying to quit, multiple data points preabstinence and very soon after abstinence, comparison groups, at least 16 hrs of abstinence, objective measures, measures of clinical significance, and data analytic techniques that allow use of all participants' data. The 8 most commonly used tobacco withdrawal measures differ in coverage, brevity, and use of single vs. multiple items to describe each symptom. Of the measures, 6 consistently increase with abstinence, but no single measure appears superior. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effect of high-dose nicotine patch on the characteristics of lapse episodes.

Objective: Nicotine patch improves treatment outcomes, but lapses are still common. To understand the process of relapse on patch, we investigated differences in the antecedents (withdrawal, setting, triggers) of lapse episodes experienced on high-dose (35 mg) nicotine patches versus placebo. Design: Participants were smokers who lapsed during a randomized, double-blind trial of active patches (n = 100) versus placebo (n = 85). Participants used electronic diaries to monitor their smoking, affect, and activities in real time for 5 weeks during their cessation attempt. Results: We analyzed 490 lapse episodes (active: 266; placebo: 224). Lapses on nicotine patch were characterized by significantly lower positive affect and higher negative affect than placebo lapses. Participants treated with high-dose patch were also significantly more likely to lapse in situations involving little or no craving. Situational antecedents of lapses on patch resembled those on placebo. Conclusion: The results suggest that treatment with patch may set a higher threshold for affective stimuli to provoke lapses, but does not change the proximal cues that trigger lapses. This suggests that behavioral relapse-prevention strategies developed for unmedicated smokers should also apply to those treated with nicotine patch. (PsycINFO Database Record (c) 2010 APA, all rights reserved)