Tobacco craving and withdrawal symptoms in psychiatric patients during a motivational enhancement intervention based on a 26-hour smoking abstinence period
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Department of Mental Health and Psychiatry, Geneva University Hospitals (HUG), Geneva, Switzerland
Faculty of Medicine, University of Geneva, Geneva, Switzerland
Carrefour Addictions, CIPRET, Geneva, Switzerland
Ineke Keizer   

Department of Mental Health and Psychiatry, Geneva University Hospitals (HUG), Geneva, Switzerland
Publish date: 2019-06-17
Submission date: 2018-12-20
Final revision date: 2019-05-31
Acceptance date: 2019-06-02
Tob. Prev. Cessation 2019;5(June):22
In psychiatric patients, tobacco withdrawal symptoms are frequently seen as a barrier to smoking cessation; however, further studies are warranted in this specific population.

Patients receiving in- or out-patient mental health care participated in a motivational enhancement program including a 26-hour tobacco abstinence experience with professional support and optional nicotine replacement therapy. The study included 174 subjects, of whom 159 were evaluated 1 week before and at the end of the 26-hour abstinence period. Repeated assessments included the Minnesota Nicotine Tobacco Withdrawal Scale Revised (MNWS-R), two items of the Mood and Physical Symptoms Scale (MPSS) regarding craving, the State-Trait Anxiety Inventory (STAI-S), the Beck Depression Inventory (BDI-21), and the World Health Organization Well-Being Index (WHO-5).

More than half the participants (52.3%) succeeded in 26-hour smoking abstinence. Craving was the most frequent MNWS-R withdrawal symptom (28.3% scored ≥3 on a 0–4 scale). Comparison of pre- and post-intervention data revealed significant improvements in 13 of 16 MNWS-R symptoms as well as craving (MPSS) and well-being, and significant decreases in anxiety and depression. Increasing MNWS-R craving scores and greater depression were both significantly associated with lower success in the 26-hour smoking abstinence period.

The negative effects of tobacco withdrawal symptoms in psychiatric patients may be substantially overestimated. Participation in a supportive structured motivational intervention with a 26-hour smoking cessation experience was well tolerated and contributed to temporary improvements in mental state. Craving is an interesting symptom to evaluate during smoking cessation attempts.

We thank the following heads of services for their collaboration in the intervention: Jean-Pierre Bachetta, Javier Bartolomei, Logos Curtis, Philippe Huguelet, Othman Sentissi, and the heads of the Department of Mental Health and Psychiatry, Panteleimon Giannacopoulos and Jean-Michel Aubry for support. We thank the tobacco specialists for their interventions in the program, in particular Corinne Wahl (Carrefour addictions/ CIPRET-Geneva), who participated in all the outpatient ‘Day off’ sessions and provided detailed tobacco information, and Patricia Borrero (Directorate of Nursing Services, University Hospitals of Geneva), who provided interactive tobaccoinformation sessions for the inpatient groups.
The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported.
This study received no specific funding; the authors were employed by the University Hospitals of Geneva and/or the University of Geneva. Small funds to implement the outpatient portion of the ‘Day off’ intervention were provided by Carrefour addictions/CIPRET-Genève, Centre d’Information et de Prévention du Tabagisme. All participating institutions are funded by the state of Geneva, and the study involved no private funds.
Not commissioned; externally peer reviewed.
Moore RA, Aubin HJ. Do placebo response rates from cessation trials inform on strength of addictions? Int J Environ Res Public Health. 2012;9(1):192-211. doi:10.3390/ijerph9010192
Morissette A, Ouellet-Plamondon C, Jutras-Aswad D. [Craving as a core symptom in substance use disorders: epidemiology, neurobiological substrates and clinical relevance]. Sante Ment Que. 2014;39(2):21-37. doi:10.7202/1027830ar
Skinner MD, Aubin HJ. Craving's place in addiction theory: contributions of the major models. Neurosci Biobehav Rev. 2010;34(4):606-623. doi:10.1016/j.neubiorev.2009.11.024
Tiffany ST, Wray JM. The clinical significance of drug craving. Ann N Y Acad Sci. 2012;1248(1):1-17. doi:10.1111/j.1749-6632.2011.06298.x
Piper ME. Withdrawal: Expanding a Key Addiction Construct. Nicotine Tob Res. 2015;17(12):1405-1415. doi:10.1093/ntr/ntv048
Gritz ER, Carr CR, Marcus AC. The tobacco withdrawal syndrome in unaided quitters. Br J Addict. 1991;86(1):57-69. doi:10.1111/j.1360-0443.1991.tb02629.x
Hughes JR, Gust SW, Skoog K, Keenan RM, Fenwick JW. Symptoms of tobacco withdrawal. A replication and extension. Arch Gen Psychiatry. 1991;48(1):52-59.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: APA; 1994. doi:10.1017/s0033291700035765
Toll BA, O'Malley SS, McKee SA, Salovey P, Krishnan-Sarin S. Confirmatory factor analysis of the Minnesota Nicotine Withdrawal Scale. Psychol Addict Behav. 2007;21(2):216-225. doi:10.1037/0893-164X.21.2.216
Baker TB, Piper ME, Schlam TR, Cook J, Smith S, Loh WY, Bolt D. Are tobacco dependence and withdrawal related amongst heavy smokers? Relevance to conceptualizations of dependence. J Abnorm Psychol. 2012;121(4):909-921. doi:10.1037/a0027889
West R, Ussher M, Evans M, Rashid M. Assessing DSM-IV nicotine withdrawal symptoms: a comparison and evaluation of five different scales. Psychopharmacology (Berl). 2006;184(3-4):619-627. doi:10.1007/s00213-005-0216-z
Jackson JG, Diaz FJ, Lopez L, de Leon J. A combined analysis of worldwide studies demonstrates an association between bipolar disorder and tobacco smoking behaviors in adults. Bipolar Disord. 2015;17(6):575-597. doi:10.1111/bdi.12319
Steinberg ML, Williams JM, Li Y. Poor Mental Health and Reduced Decline in Smoking Prevalence. Am J Prev Med. 2015;49(3):362-369. doi:10.1016/j.amepre.2015.01.016
Cather C, Pachas GN, Cieslak KM, Evins AE. Achieving Smoking Cessation in Individuals with Schizophrenia: Special Considerations. CNS Drugs. 2017;31(6):471-481. doi:10.1007/s40263-017-0438-8
Vermeulen J, Schirmbeck F, Blankers M, van Tricht M, van den Brink W, de Haan L. Smoking, symptoms, and quality of life in patients with psychosis, siblings, and healthy controls: a prospective, longitudinal cohort study. Lancet Psychiatry. 2019;6(1):25-34. doi:S2215-0366(18)30424-3
Cook BL, Wayne GF, Kafali EN, Liu Z, Shu C, Flores M. Trends in smoking among adults with mental illness and association between mental health treatment and smoking cessation. JAMA. 2014;311(2):172-182. doi:10.1001/jama.2013.284985
Keizer I, Gex-Fabry M, Bruegger A, Croquette P, Khan AN. Staff representations and tobacco-related practices in a psychiatric hospital with an indoor smoking ban. Int J Ment Health Nurs. 2014;23(2):171-182. doi:10.1111/inm.12030
Prochaska JJ. Smoking and mental illness--breaking the link. N Engl J Med. 2011;365(3):196-198. doi:10.1056/NEJMp1105248
Hitsman B, Moss TG, Montoya ID, George TP. Treatment of tobacco dependence in mental health and addictive disorders. Can J Psychiatry. 2009;54(6):368-378. doi:10.1177/070674370905400604
Burns A, Webb M, Stynes G et al. Implementation of a Quit Smoking Programme in Community Adult Mental Health Services-A Qualitative Study. Front Psychiatry. 2018;9:670. doi:10.3389/fpsyt.2018.00670
Taylor G, McNeill A, Girling A, Farley A, Lindson-Hawley N, Aveyard P. Change in mental health after smoking cessation: systematic review and meta-analysis. BMJ. 2014;348:g151. doi:10.1136/bmj.g1151
Manzella F, Maloney SE, Taylor GT. Smoking in schizophrenic patients: A critique of the self-medication hypothesis. World J Psychiatry. 2015;5(1):35-46. doi:10.5498/wjp.v5.i1.35
Soyster P, Anzai NE, Fromont SC, Prochaska JJ. Correlates of nicotine withdrawal severity in smokers during a smoke-free psychiatric hospitalization. Prev Med. 2016;92:176-182. doi:10.1016/j.ypmed.2016.01.026
Gray KM, Baker NL, Carpenter MJ, Lewis AL, Upadhyaya HP. Attention-deficit/hyperactivity disorder confounds nicotine withdrawal self-report in adolescent smokers. Am J Addict. 2010;19(4):325-331. doi:10.1111/j.1521-0391.2010.00048.x
Pomerleau CS, Downey KK, Snedecor SM, Mehringer AM, Marks JL, Pomerleau OF. Smoking patterns and abstinence effects in smokers with no ADHD, childhood ADHD, and adult ADHD symptomatology. Addict Behav. 2003;28(6):1149-1157. doi:10.1016/S0306-4603(02)00223-x
Hughes JR, Hatsukami D. Signs and symptoms of tobacco withdrawal. Arch Gen Psychiatry. 1986;43(3):289-294.
Hughes JR. Background on the Minnesota Tobacco Withdrawal Scale - Revised (MTWS-R). Published March 1, 2017. Accessed February 27, 2018.
Parschau L, Fleig L, Warner LM, et al. Positive Exercise Experience Facilitates Behavior Change via Self-Efficacy. Health Educ Behav. 2014;41(4):414-422. doi:10.1177/1090198114529132
Keizer I, Gex-Fabry M, Croquette P, Khan AN. A short motivational program based on temporary smoking abstinence: Towards increased self-efficacy to quit in psychiatric inpatients. J Addict Res Ther. 2016;7(4). doi:10.4172/2155-6105.1000289
Etter JF. [Minnesosta (MNWS-R)]. Accessed December 8, 2014.
West R, Hajek P. Evaluation of the mood and physical symptoms scale (MPSS) to assess cigarette withdrawal. Psychopharmacology (Berl). 2004;177(1-2):195-199. doi:10.1007/s00213-004-1923-6
Etter JF, Vu Duc T, Perneger TV. Validity of the Fagerström test for nicotine dependence and of the Heaviness of Smoking Index among relatively light smokers. Addiction. 1999;94(2):269-281. doi:10.1046/j.1360-0443.1999.94226910.x
Kozlowski LT, Porter CQ, Orleans CT, Pope MA, Heatherton T. Predicting smoking cessation with self-reported measures of nicotine dependence: FTQ, FTND, and HSI. Drug Alcohol Depend. 1994;34(3):211-216. doi:10.1016/0376-8716(94)90158-9
Biener L, Abrams DB. The Contemplation Ladder: validation of a measure of readiness to consider smoking cessation. Health Psychol. 1991;10(5):360-365.
Spielberger CD. State-trait Anxiety Inventory: A comprehensive Bibliography. Palo Alto, CA: Consulting Psychologists Press; 1983.
Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988;56(6):893-897. doi:10.1037/0022-006X.56.6.893
World Health Organization. Indice (en 5 points) de bien-être de l'OMS (1999). Hillerod, Denmark: Psychiatric Research Unit, WHO Collaborating Center for Mental Health, Frederiksborg General Hospital; 1999. https://www.psykiatri-regionh..... Accessed March 8, 2011.
Bech P, Gudex C, Johansen KS. The WHO (Ten) Well-Being Index: validation in diabetes. Psychother Psychosom. 1996;65(4):183-190. doi:10.1159/000289073
Newnham EA, Hooke GR, Page AC. Monitoring treatment response and outcomes using the World Health Organization's Wellbeing Index in psychiatric care. J Affect Disord. 2010;122(1-2):133-138. doi:10.1016/j.jad.2009.06.005
Leventhal AM, Waters AJ, Moolchan ET, Heishman SJ, Pickworth WB. A quantitative analysis of subjective, cognitive, and physiological manifestations of the acute tobacco abstinence syndrome. Addict Behav. 2010;35(12):1120-1130. doi:10.1016/j.addbeh.2010.08.007
McCarthy DE, Piasecki TM, Fiore MC, Baker TB. Life before and after quitting smoking: an electronic diary study. J Abnorm Psychol. 2006;115(3):454-466. doi:10.1037/0021-843X.115.3.454
Boehm G, Schroeder Y, Schoberberger R. Inpatient smoking cessation therapy: truth or dare? Wien Klin Wochenschr. 2015;127(19-20):786-791. doi:10.1007/s00508-015-0820-9
Shiffman SM, Jarvik ME. Smoking withdrawal symptoms in two weeks of abstinence. Psychopharmacology (Berl). 1976;50(1):35-39.
Wray JM, Gass JC, Tiffany ST. A systematic review of the relationships between craving and smoking cessation. Nicotine Tob Res. 2013;15(7):1167-1182. doi:10.1093/ntr/nts268
Berlin I, Chen H, Covey LS. Depressive mood, suicide ideation and anxiety in smokers who do and smokers who do not manage to stop smoking after a target quit day. Addiction. 2010;105(12):2209-2216. doi:10.1111/j.1360-0443.2010.03109.x
McClave AK, Dube SR, Strine TW, Kroenke K, Caraballo RS, Mokdad AH. Associations between smoking cessation and anxiety and depression among U.S. adults. Addict Behav. 2009;34(6-7):491-497. doi:10.1016/j.addbeh.2009.01.005
Cummings KM, Giovino G, Jaen CR, Emrich LJ. Reports of smoking withdrawal symptoms over a 21 day period of abstinence. Addict Behav. 1985;10(4):373-381. doi:10.1016/0306-4603(85)90034-6
Dicpinigaitis PV. Effect of tobacco and electronic cigarette use on cough reflex sensitivity. Pulm Pharmacol Ther. 2017;47:45-48. doi:10.1016/j.pupt.2017.01.013
Utiyama DM, Yoshida CT, Goto DM, et al. The effects of smoking and smoking cessation on nasal mucociliary clearance, mucus properties and inflammation. Clinics (Sao Paulo). 2016;71(6):344-350. doi:10.6061/clinics/2016(06)10
Sitkauskiene B, Stravinskaite K, Sakalauskas R, Dicpinigaitis PV. Changes in cough reflex sensitivity after cessation and resumption of cigarette smoking. Pulm Pharmacol Ther. 2007;20(3):240-243. doi:10.1016/j.pupt.2006.08.005
Mathew AR, Robinson JD, Norton PJ, Cinciripini PM, Brown RA, Blalock JA. Affective trajectories before and after a quit attempt among smokers with current depressive disorders. Nicotine Tob Res. 2013;15(11):1807-1815. doi:10.1093/ntr/ntt036
Piper ME, Vasilenko SA, Cook JW, Lanza ST. What a difference a day makes: differences in initial abstinence response during a smoking cessation attempt. Addiction. 2017;112(2):330-339. doi:10.1111/add.13613
Parrott AC, Murphy RS. Explaining the stress-inducing effects of nicotine to cigarette smokers. Hum Psychopharmacol. 2012;27(2):150-155. doi:10.1002/hup.1247