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Increase in anger symptoms after smoking cessation predicts relapse

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Abstract

Smokers tend to increase their cigarette consumption during angry states. We sought to determine whether increases in post-quit anger symptoms predict relapse among smokers who had received 8-weeks of smoking cessation treatment (21 mg nicotine patch + smoking cessation counseling). The 15-item state anger assessment [from Spielberger, C., 1999. STAXI-2: the state trait anger expression inventory professional manual, Odessa, FL] was administered at pre-treatment (2 weeks before the target quit date; TQD) and 1 week after the TQD. Abstinence at 8-weeks post-quit was biochemically verified using carbon monoxide. Smokers who reported increases in pre- to post-quit state anger levels (n = 117) were significantly more likely to relapse by 8-weeks after treatment as compared to smokers whose anger did not change or decreased after quitting (n = 130) (OR = 1.06; CI = 1.01–1.10; p = 0.01). Furthermore, smokers with increased post-quit anger relapsed almost twice as quickly than those who did not have an increase in post-quit anger symptoms (HR = 1.98; CI: 1.32–2.96; p = 0.001). These data suggest that anger may be an important withdrawal symptom that influences liability to relapse. Future studies are needed to evaluate treatment strategies that effectively help smokers reduce and manage post-quit anger.

Introduction

Support for anger as a nicotine abstinence induced withdrawal symptom (Hughes, 2007) comes from data showing that anger symptoms increase post cessation (Gilbert et al., 2002, Ward et al., 2001) and that nicotine reduces feelings of anger (Jamner et al., 1999). Specifically, in a study conducted by Gilbert et al. (2002), self-reported anger was compared in 96 female smokers, half of whom were abstinent while the other half continued to smoke over a 31-day period. Results showed that mean state anger scores for the women who quit were significantly higher as compared to the women who continued to smoke (Gilbert et al., 2002). Similarly, Ward et al. (2001) compared self-reports of state anger from a group of 46 smokers who had been quit for a month, with 29 current smokers who had been matched for age and gender. Results showed that compared to the matched smokers, those quitting smoking had significantly higher mean state anger scores in the first 28-days of being quit (Ward et al., 2001). Finally, in a within-subject human laboratory study, 30 smokers and 30 nonsmokers kept an “anger-diary” over two, 24-h periods. An active nicotine patch was worn in one monitoring period, a placebo patch in the other. Independent of smoking status or gender, smokers who had been previously categorized as high-hostility, reported a significant reduction in anger symptoms while wearing the active as compared to the placebo patch (Jamner et al., 1999).

The relationship between anger symptoms and cessation outcomes has been less well documented. Two early studies showed that increases in post-quit anger were associated with relapse 5-days (Perkins et al., 1996) and 28-days (Swan et al., 1996) after quitting; however, in the study conducted by Swan et al. (1996), this effect was lost when other measures of craving and withdrawal were added to the model. In contrast two other studies found no relationship between levels of post-quit anger and treatment outcome (Covey et al., 1990, Hughes et al., 1991). A more recent study reported that, compared to smokers with low levels of trait anger, those with high trait anger reported greater increases in state anger, withdrawal symptoms and craving in their first day of abstinence (al’Absi et al., 2007). Furthermore, smokers with high levels of trait anger relapsed sooner than their low trait anger counterparts (al’Absi et al., 2007). Although this study identified smokers with high levels of trait anger as being a high risk population for relapse, the role that state anger and changes in anger levels following cessation has on subsequent smoking behaviors was not evaluated.

To clarify the relationship between levels of post-quit anger and address this knowledge gap, the current study sought to assess, first, whether increases in post-quit anger (as compared to pre-treatment anger) would predict relapse after 8-weeks of open-label, 21 mg nicotine patch smoking cessation treatment, and second, whether smokers with increases in post-quit anger would relapse sooner than those who did not have an increase in anger symptoms after quitting. Confirmation of these hypotheses could go toward identifying anger as an important abstinence symptom that affects cessation outcomes as well as potentially informing the content and timing of smoking cessation interventions.

Section snippets

Study participants

Smokers responding to study advertisements for free smoking cessation treatment called a study recruitment line where they completed an initial eligibility screening. Eligible participants were at least 18 years old and smoked ≥10 cigarettes per day in the last year. Exclusion criteria included current diagnosis or history of psychotic disorders, and current use of bupropion, varenicline or nicotine products other than cigarettes.

Procedures and treatment

All procedures for this smoking cessation study were approved by

Sample characteristics

Over half the sample were male (134/247; 54%), Caucasian (206/247; 83%), and college graduates (79/247; 32%). Mean Fagerstrom nicotine dependence score was 5.45 (S.D. = 2.09), and the mean number of cigarettes smoked per day was 21.4 (S.D. = 8.6). One hundred-seventeen (117/247; 47%) of the sample reported an increase in anger symptoms in the week after quitting as compared to 2 weeks pre-quit; the remainder of the sample either reported no change or a decrease in a post-quit anger symptoms (n = 

Discussion

The main finding from the current study was that treatment seeking smokers who reported an increase in anger symptoms in the first week of quitting were significantly more likely to relapse as compared to smokers who did not have an increase in post-quit anger, independent of other withdrawal symptoms. A post-hoc analysis indicated that this effect was retained when the analysis was restricted to only those who were abstinent in the first post-quit week; adding more support for increased

Role of funding source

This research was funded by a Transdisciplinary Tobacco Use Research Center grant from the National Cancer Institute and National Institutes on Drug Abuse CA/DA P5084718 (C.L.). The funders of this study did not contribute to the writing of this manuscript.

Contributors

Caryn Lerman, Ph.D. designed the study and wrote the protocol. Kia Kerrin, M.S.W. managed the literature searches and summaries of previous related work. E. Paul Wileyto, Ph.D. and Freda Patterson, Ph.D. undertook the statistical analysis, and Freda Patterson Ph.D., wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.

Conflicts of interest

Dr. Lerman has worked as a consultant for pharmaceutical companies that market smoking cessation medications, including GlaxoSmithKline. GlaxoSmithKline did not provide study medication for this trial. The other authors have not conflicts of interest to report.

Acknowledgements

The authors thank Susan Ware, Angela Pinto, Paul Sanborn and Sean Fleming for their contributions to this study. The authors would like to acknowledge the contributions of the Recruitment, Retention and Outreach Core Facility of the Abramson Cancer Center for assisting with the development and implementation of a recruitment plan.

References (21)

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