Relapse Back to Smoking: The Core Role of the Tobacco Withdrawal Syndrome

WITHTHOMAS PIASECKI

MICHAEL FIORE

SMOKING IS BAD ABOUT 24% OF ADULT AMERICANS

SMOKE A LEADING PREVENTABLE CAUSE

OF MORTALITY & MORBIDITY ACCOUNTS FOR 430,000+

DEATHS/YEAR IN THE US ALONE ON AVERAGE SMOKERS LOSE 14

YEARS OF LIFE

RELAPSE: GORDIAN KNOT SMOKERS ARE MOTIVATED TO

QUIT ABOUT HALF OF SMOKERS TRY TO

QUIT EACH YEAR ONLY ABOUT 5% ARE SUCCESSFUL MOST WHO BECOME ABSTINENT,

EVENTUALLY RELAPSE

WHAT CAUSES OR LEADS UP TO RELAPSE BACK TO SMOKING?

TRADITIONAL ACCOUNT WITHDRAWAL SYMPTOMS

ABSTINENCE FROM TOBACCO CAUSES STRONG INCREASES IN WITHDRAWAL SYMPTOMS

DEPRESSION, ANXIETY, IRRITABILITY, URGES, INABILITY TO CONCENTRATE

THE SMOKER IS MOTIVATED TO USE TOBACCO TO MEDICATE THESE SYMPTOMS

BUT, ACCORDING TO SOME RESEARCH …

HOWEVER, MUCH RESEARCH OVER THE PAST 20 YEARS CASTS DOUBT ON A WITHDRAWAL ACCOUNT

“IT IS CONCLUDED THAT THE RESEARCH TO DATE DOES NOT APPEAR TO STRONGLY IMPLICATE NICOTINE WITHDRAWAL IN ADVERSELY AFFECTING SMOKING CESSATION OR MAINTENANCE OF ABSTINENCE.” (PATTON & MARTIN, 1996)

BUT, SMOKERS TELL US…1. “IT HAS BEEN 2 MONTHS SINCE I QUIT AND THE

URGES ARE WORSE THAN EVER”

2. “QUITTING SMOKING HAS CHANGED MY PERSONALITY…I AM ALWAYS CRABBY AND HAVE BEEN EVER SINCE I QUIT.”

3. “MY WITHDRAWAL WENT AWAY AFTER 3 WEEKS, AND NOW IT IS BACK.”

FOR YEARS WE TOLD THE SMOKER THAT THESE REPORTS CANNOT BE CORRECT SINCE WITHDRAWAL GOES AWAY IN TWO-THREE WEEKS!

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Withdrawal Heterogeneity: SMOKERS ARE RIGHT!

• In -- acute drug removal.

• At the level of the individual, idiosyncracies may be observed

• Which day do you pick for measuring withdrawal?

IMPOSING SIMPLE MEASUREMENT MODELS ON A COMPLEX PHENOMENON

SIMPLISTIC MEASUREMENT IS AT HEART OF SCIENCE’S FAILURE

WITHDRAWAL HAS BEEN ASSUMED TO BE A STEREOTYPIC PHYSIOLOGIC REACTION TO ABSTINENCE THAT PRODUCES A PROTOTYPIC SYMPTOM WAVEFORM ACROSS TIME

MEASUREMENT STRATEGY 55 DAYS OF DAILY POST-

CESSATION WITHDRAWAL RATINGS SUBMITTED TO DYNAMIC CLUSTER ANALYSES

CLUSTERED DISTINCT GROUPS OF INDIVIDUALS WHOSE PATTERNS OF SYMPTOMS WERE SIMILAR OVER TIME

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Cluster I (N=71)Cluster II ( N=31)Cluster III (N=122)

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From: Piasecki, Fiore & Baker, 1998; Study 2

RESULTS ATYPICAL PATTERN ASSOCIATED

WITH 2-4 TIMES HIGHER RISK OF RELAPSE NO OTHER VARIABLE PREDICTS

RELAPSE AS WELL WOMEN & PREVIOUSLY DEPRESSED

MORE LIKELY TO HAVE SUSTAINED OR WORSENING WITHDRAWAL

ADDITIONAL MEASUREMENT MODEL

PROFILES CAN ALSO BE CAPTURED BY 3 COMPONENTS YIELDED BY GROWTH CURVE MODELING elevation over time shape/trajectory volatility/scatter

WRINGING INFORMATION FROM PROFILES

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PARTICIPANT 1001 RAW SYMPTOM REPORTSMOKING-COVARIED PREDICTED FUNCTION SMOKING RECORD

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GROWTH PARAMETERS

INTERCEPT:

LINEAR SLOPE:

QUADRATIC:

VOLATILITY:

CIGARETTE:

6.54

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PARTICIPANT 1004 RAW SYMPTOM REPORTSMOKING-COVARIED PREDICTED FUNCTIONSMOKING RECORD

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GROWTH PARAMETERS

INTERCEPT:

LINEAR SLOPE:

QUADRATIC:

VOLATILITY:

CIGARETTE:

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PARTICIPANT 1003 RAW SYMPTOM REPORTSMOKING-COVARIED PREDICTED FUNCTIONSMOKING RECORD

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GROWTH PARAMETERS

INTERCEPT:

LINEAR SLOPE:

QUADRATIC:

VOLATILITY:

CIGARETTE:

5.98

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PARTICIPANT 1010 RAW SYMPTOM REPORTSMOKING-COVARIED PREDICTED FUNCTIONSMOKING RECORD

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GROWTH PARAMETERS

INTERCEPT:

LINEAR SLOPE:

QUADRATIC:

VOLATILITY:

CIGARETTE:

7.92

Individual Projected WD Curves

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Time from Quit Date (weeks)

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WHAT DOES GROWTH CURVE MODELING TELLS US? WITHDRAWAL DRAMATICALLY INCREASES ALL 3

DIMENSIONS OF WITHDRAWAL SYMPTOMS, E.G., 2-3 TIMES THE EMOTIONAL VOLATILITY VS.

PRE-CESSATION (WOMEN & PREVIOUSLY DEPRESSED)

ALL 3 DIMENSIONS ARE HIGHLY PREDICTIVE OF RELAPSE

SMOKERS SHOULD NOT BE TOLD THAT WITHDRAWAL WILL GET BETTER IN 2 WEEKS!

IMPLICATIONS & GOALS WE ARE TRACKING WITHDRAWAL &

INTERVENING BEFORE RELAPSE: JUST IN TIME TREATMENT

IDENTIFYING SPECIFIC GENES THAT ASSOCIATED WITH WITHDRAWAL DIMENSIONS

DEVELOPING INTERVENTIONS DESIGNED TO ADDRESS ALL 3 COMPONENTS OF WITHDRAWAL