Judith L. Marks

Who gets what symptom? Effects of psychiatric cofactors and nicotine dependence on patterns of smoking withdrawal symptomatology

The present study used logistic regression techniques to examine the extent to which depression, anxiety, disordered eating, and nicotine dependence increased risk of experiencing craving and the eight DSM-IV withdrawal symptoms (depressed mood, insomnia, irritability, anxiety, difficulty concentrating, restlessness, decreased heart rate, increased appetite) during smoking abstinence, assessed retrospectively. Data were provided by a racially diverse sample of 365 male and female smokers recruited to participate in laboratory studies. Results indicate that variables known to be associated with smoking are risk factors for distinct and only somewhat overlapping patterns of symptomatology. Smokers scoring high on measures of anxiety, depression, or disordered eating were at increased risk primarily of experiencing withdrawal symptomatology pathognomonic to their particular disorder, whereas smokers scoring high on nicotine dependence appeared to be at increased risk of experiencing a syndromal pattern of withdrawal, encompassing craving and insomnia as well as cognitive/affective symptoms. Our results support the possibility that some individuals use smoking as a form of self-medication and suggest that elucidation of patterns of withdrawal symptomatology may contribute to improved specification of smoking phenotypes as well as facilitate treatment-matching.

Smoking patterns and abstinence effects in smokers with no ADHD, childhood ADHD, and adult ADHD symptomatology

Cigarette smokers are known to be overrepresented among adults with Attention Deficit Hyperactivity Disorder (ADHD). To date, however, no attempt has been made to determine the extent to which a lifetime diagnosis of ADHD may be associated with smoking even in the absence of current symptomatology. We hypothesized that nicotine dependence and abstinence effects-especially effects relevant to ADHD symptomatology-would be more pronounced in adult ADHD smokers in comparison with those who reported childhood ADHD symptoms only. Results indicated that, in contrast to controls without ADHD symptomatology, both adult and childhood ADHD groups were significantly more likely to experience a number of nicotine withdrawal symptoms, including irritability and difficulty concentrating; in no instance did the ADHD groups differ from one another in this regard. Thus, studying people with childhood symptoms of ADHD, even in the absence of an adult diagnosis, may shed light on the known association between smoking and ADHD.

A multidimensional model for characterizing tobacco dependence.

The standard tool for assessing tobacco dependence is the Fagerström Tolerance Questionnaire (FTQ) or its more recent variant, the Fagerström Test for Nicotine Dependence (FTND). Although both of these scales reportedly assess physiological dependence on nicotine, they might not tap some facets of dependence, particularly psychosocial factors. To determine whether tobacco dependence exhibits multidimensional properties, we examined two existing, independent data sets, one from SRI International (n=443) and another from the University of Michigan (n=445). Based on our knowledge from existing literature, standard psychometric statistical analyses, and results from exploratory factor analysis using SRIs data set, we identified two competing models for dependence representing a hybrid of the FTQ/FTND and the Smoking Motives Questionnaire. We then examined these models using confirmatory factor analysis with data from the University of Michigan. We characterized the final model by five first-order factors, each consisting of two to four items, and one higher-order factor. The first-order factors were termed stimulation, automaticity, sedation, psychosocial motives, and morning smoking; the higher-order factor, tobacco dependence, underlay each of the first-order factors. The ranges of interitem correlations and Cronbachs alpha estimates of internal consistency for the first-order factors were .34 - .68 and .64 - .81, respectively. Results of these analyses support the hypothesis that tobacco dependence is multidimensional.

Association of parental smoking history with nicotine dependence, smoking rate, and psychological cofactors in adult smokers

Family history is a powerful predictor of variation in risk of common diseases and conditions because it can represent the influence of both shared genes and shared environments. To investigate the relationship of parental smoking history with nicotine dependence and smoking rate, as well as with known psychological cofactors for smoking (depression, anxiety, alcoholism, disordered eating), we studied smoking adults who provided smoking history for both parents. We found that having two ever-smoking parents, in comparison to zero or one, was associated with higher nicotine dependence scores, cigarettes per day, and levels of anxiety in participant, with a trend for depression. Participants whose mothers smoked during pregnancy had significantly higher scores on nicotine dependence, smoking rate, and disordered eating than participants with either ever-smoking mothers who did not smoke during pregnancy or never-smoking mothers. These findings suggest that family history of smoking may be a key determinant of interindividual variation in smoking behavior, nicotine dependence, and psychological cofactors among smokers.

Development and validation of a self-rating scale for positive- and negative-reinforcement smoking: The Michigan Nicotine Reinforcement Questionnaire

Positive- and negative-reinforcement consequences of smoking were assessed using a self-report inventory. Data from 429 current smokers (348 women, 81 men) were subjected to an exploratory factor analysis, with concurrent validation of resulting scales in 288 current smokers (235 women, 53 men), controlling for sex and age. The solution with three factors--positive reinforcement, negative reinforcement, and smoking patterns--provided the clearest and most interpretable factor solution. The Michigan Nicotine Reinforcement Questionnaire (M-NRQ), which yields positive- and negative-reinforcement scales, was developed based on these results. Positive-reinforcement smoking was associated with higher scores on novelty seeking, reward dependence, alcohol dependence, and pleasurable sensations upon early smoking experimentation, and with lower scores on displeasurable sensations and nausea upon early smoking experimentation. Negative-reinforcement smoking was associated with higher scores for nicotine dependence, depression, anxiety, and harm avoidance. The M-NRQ has potential as a diagnostic tool for individualizing behavioral intervention and pharmacotherapy and also may be useful in identifying new phenotypes for genetic research on smoking.

Effects of menstrual phase on nicotine, alcohol, and caffeine intake in smokers.

To determine whether cigarette smoking and other drug use are affected by menstrual phase, daily diaries rating menstrual symptomatology, smoking, and alcohol and caffeine intake in female smokers were examined. Women with premenstrual symptomatology were excluded. Menstrual symptomatology peaked during menses and was accounted for primarily by symptoms indicative of physical discomfort. Smoking did not differ as a function of menstrual phase, nor did there emerge any systematic intrasubject correlation between symptomatology and smoking. Alcohol and caffeine intake also failed to show phase-related differences. It was concluded that substance intake is highly stable across the menstrual cycle in female smokers.

Effects of menstrual phase and smoking abstinence in smokers with and without a history of major depressive disorder

Although considerable progress has been made towards understanding the role of menstrual cycle phase in smoking, little is known about the possible effects of menstrual phase upon nicotine intake, withdrawal symptomatology, and craving in women with psychiatric cofactors. Fourteen women with and without a history of Major Depressive Disorder (MDD) were studied during five biologically-confirmed phases over the course of one menstrual cycle: smoking logs, salivary cotinine, and ratings of craving and withdrawal were collected daily. During a second cycle, subjects remained abstinent for 3 consecutive days during the postmenses and premenstrual phases. Although a significant omnibus F-test emerged for cigarettes per day across phases during ad libitum smoking, only trends were observed post hoc and supported midcycle rather than premenstrual elevations. There were no significant phase differences for cotinine. Withdrawal symptomatology was markedly elevated during smoking abstinence and in women with a history of depression. but showed no evidence of phase effects. Thus, the hypothesis that depressed individuals would be differentially affected by phase and abstinence was not strongly supported by our results, though overall elevations emphasize the need for special attention to withdrawal severity in this population. Craving was significantly elevated during smoking abstinence and was significantly higher during postmenses, consistent with the midcycle elevation in smoking rate, but showed no group differences. Our findings overall lend little support for the need to control for menstrual phase under conditions of ad libitum smoking. The strong association of self-reported menstrually related dysphoria during abstinence with both craving and withdrawal symptoms, however, is consistent with an exacerbation of smoking abstinence effects in women with severe menstrual symptomatology.

Effects of menstrual phase on reactivity to nicotine.

The possible impact of menstrual phase upon reactivity to nicotine was investigated in 12 healthy women smokers. Controlled doses of nicotine were administered via an intranasal aerosol delivery device to overnight-deprived women smokers in four hormonally verified menstrual phases. Physiological, biochemical, and subjective measures were collected. Cycle-related symptomatology differed significantly across phase, with lowest values during the mid-follicular phase. No significant differences were found for baseline variables, including withdrawal measures. Nicotine increment was stable across phase, confirming reliability of the dosing method. No significant menstrual phase differences were found for physiological, subjective, or biochemical responses to nicotine. Pending investigations conducted over longer intervals, in a wider variety of subjects; findings suggest that for this type of study, complex strategies to control for menstrual-cycle phase effects may be unnecessary.

Why Women Smoke

Although tobacco use by both men and women has been documented throughout history,’1, 2, 3two technological developments in the 19th century radically and irreversibly changed societal patterns of nicotine use. First, the introduction of flue-curing yielded a product with a lower pH and milder smoke that could be readily inhaled through the lungs, producing a rapid rise of nicotine in plasma that appears to contribute to the reinforcing and addictive properties of nicotine by partially overcoming tolerance,4 and delivering nicotine via a process that maximizes exposure to carcinogens. Second, the invention by a Virginian named James Bonsack of a cigaret-rolling machine, which could turn out as many cigarets as could 40 workers rolling manually,5 made that product widely and cheaply available. With these innovations, tobacco use was fairly quickly transformed from a somewhat distasteful and unhealthful habit, alternately lauded and reviled, to what is arguably the most critical public health problem we face today. Certainly.

Prolonged nicotine patch use in quitters with past abstinence-induced depressed mood

To test the efficacy of sustained nicotine patch use among at-risk smokers, 55 smokers with a history of abstinence-induced depressed mood were randomly assigned to either Nicotine Maintenance or Standard Treatment following preliminary high-dose patch treatment. The Nicotine Maintenance group received 21 mg transdermal nicotine for 8 additional weeks; the Standard Treatment group followed a tapered dosing regimen. Significant differences favoring the Nicotine Maintenance group were found in self-reported craving but not withdrawal. No difference was observed in continuous abstinence or in relapse rates. When dropouts who did not relapse during patch use were classified as successful, however, the Nicotine Maintenance group had significantly lower relapse rates. Rate of lapse in the Nicotine Maintenance group during post-trial tapering did not differ significantly from that in the Standard Treatment group during tapering in the trial, suggesting that the benefits of sustained dosing may persist only as long as dosing continues.