Self-reported abstinence effects in the first month after smoking cessation

Abstract

The present study evaluated self-reported subjective complaints (29 single items and 11 scales) at precessation, on quit day, and on Days 1, 2, 3, 7, 14, 21, and 28 after cessation in 46 healthy quitters who remained abstinent for the first month after cessation (biochemically confirmed). Also tested on the same schedule were 29 nonsmokers matched for age and gender. Specific criteria were set for transient and offset effects based on the direction, magnitude, and time course of changes in symptoms after cessation. Results indicated that single-item anger, anxiety, depression, difficulty concentrating, irritability, restlessness, dizziness, and nausea, and the Shiffman–Jarvik Stimulation/Sedation Subscale, the Perceived Stress scale, and the POMS anger, confusion, and tension subscales met the criteria for transient effects, and that single-item desire to smoke, cough, and headache, and the Shiffman–Jarvik Psychological Subscale met the criteria for offset effects. These findings help to clarify which subjective complaints after smoking cessation are transient effects and which are offset effects, a distinction with important implications for understanding nicotine dependence and for designing pharmacological and nonpharmacological interventions for smoking cessation.

Introduction

In the 1940s, it was recognized that abrupt smoking cessation produced signs of withdrawal (Finnegan, Larson, & Haag, 1945). Since then, a considerable number of studies have attempted to determine the specific withdrawal signs associated with smoking cessation. The research literature includes many retrospective studies, which have asked ex-smokers to describe changes that occurred after smoking cessation. Cessation effects reported with this methodology, however, may be unreliable because of the ex-smoker's inability to recall them accurately (USDHHS, 1988). Some studies using a prospective approach have measured for only a few days after cessation or failed to obtain baseline measures. Other prospective studies neglected to incorporate a group of nonsmokers or continuing smokers who were assessed on a similar schedule to serve as a basis for determining the “normal” (i.e., noncessation) fluctuations in self-reported subjective complaints over time.

Because of the wide variety of methodologies used in studies of the effects of smoking cessation, a consensus is difficult to reach on the specific signs of nicotine withdrawal. For example, the list provided in the Surgeon General's Report (USDHHS, 1988) differs somewhat from the criteria for diagnosing nicotine withdrawal set by the American Psychiatric Association in its most recent Diagnostic and Statistical Manual, the DSM-IV (American Psychiatric Association, 1994). The DSM-IV gives criteria for nicotine withdrawal of “daily use of nicotine for at least several weeks and an abrupt cessation of nicotine use or reduction in the amount of nicotine used, followed within 24 h by at least four of the following signs.” The DSM-IV signs are dysphoria or depressed mood; insomnia; irritability, frustration, or anger; anxiety; difficulty concentrating; restlessness; decreased heart rate; and increased appetite or weight gain. The Surgeon General's Report (USDHHS, 1988), which listed the most frequent cessation effects reported by the prospective studies to date, excluded frustration and added tension, drowsiness, fatigue, and desire to smoke. The most comprehensive review of nicotine abstinence effects to date suggested that impatience should be added to the list and fatigue should be removed (Hughes, Higgins, & Hatsukami, 1990).

In addition to the lack of consensus on the specific signs of nicotine abstinence, subjective complaints are usually mistakenly referred to as “withdrawal symptoms” when it is not clear how many of these cessation effects actually meet the definition of a withdrawal symptom (Hughes et al., 1990). The more correct terms are transient and/or offset effects. Transient effects are demonstrated when “the postcessation data points indicate a biphasic, finite time course” (Hughes et al., 1990, p. 320). In contrast, offset effects are “uniphasic changes in a direction opposite to the agonist effects of nicotine followed by a stabilization. This effect is due to the ‘offset’ of drug effects, and this pattern occurs when cessation of tobacco allows the variable being measured to return to a tonic level” (Hughes et al., 1990, p. 320). Transient and offset effects are mutually exclusive. Because the time course has been described for only a few cessation effects, Hughes et al. (1990) suggested that substantiated changes after smoking cessation be referred to generically as “abstinence effects” until further description and classification is possible.

The current study was undertaken so that changes in symptomatology associated with cessation could be determined prospectively. Then, using the definitions of Hughes et al. (1990), we sought to classify the various subjective complaints as either transient or offset effects. The methodology prospectively measured the self-reported emotional, cognitive, and physical changes that occurred after smoking cessation in quitters who remained abstinent for 1 month and compared these changes to the normal degree of variation observed in a group of nonsmokers. The direction, magnitude, and time course of the changes were used to classify them into the two types of abstinence effects.