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The International Journal of the Addictions, 27(6), 683-695, 1992
Predictors of Smoking Cessation in a Sample of Italian Smokers Antonio M. Persico, M.D. Drug Addiction and Alcoholism Unit Catholic University of the Sacred Heart Policlinico A. Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy
Abstract In this study we identify several pretreatment characteristics which predict abstinence at 6 months. Moreover, the persistence of withdrawal discomfort and of an increased frequency of night awakenings during the first month of abstinence, together with a tendency to “slip” during Weeks 11-IV, strongly predicted relapse. Our results suggest that: 1) Predictors of outcome cannot be automatically extended from one cultural context to another; 2) a careful assessment of certain variables, made while the patient is still under treatment, provides significant prognostic hints; 3) ex-smokers’ sleeping and dreaming function has been ignored by the literature, whereas they may well be involved into the maintenance of the drug-free state. Key worrls. Smoking cessation; Predictors of abstinence; Nicotine dependence; Nicotine withdrawal; Dreaming function
INTRODUCTION The issue of relapse in the field of smoking cessation has been the object of several studies. In Table 1 we list a selection of predictors of successful treatment outcome and/or absence of recidivism cited in the literature. In Table 2 we present the relative bibliography, including some of the most recent or frequently cited works. 683
Copyright 0 1992 by Marcel Dekker, Inc.
3. Middle-class or higher 4. Married
13.
11. 12.
10.
9.
8.
7.
6.
14. Less: Craving
5. Smoke fewer cig-
1. Male 2. Older
Attitude toward treafment
arettes
Habit
16. Great self-efficacy 17. Good compliance to Pleasure behavioral rules Lower nicotine intake Stimulation 18. Longer permanence in Laterooset Negative treatment Shorter duration affect 19. Active, "self-treating" Fewer failures at 15. More: Handling 20. Quitting not to "overquitting come addiction" but Longer periods of for health or other abstinence reasons support of spouse 21. Not seeking help with Fewer smokers among spouse close relatives and friends Fewer smokers at work
Reasons for smoking
Smoking behavior and history
General characteristics
28. 29.
27.
26.
23. 24. 25.
22.
No major depression/dysthymia Noobesity Less'neurotic" Less psychosomatic symptoms More gratifying family history Less defiantjconstricted Introverted Well adjusted
Psychiatric and psychological aspects
A Selection of Predictors of Successful Treatment Outcome an4'orAbsence of Recidivism
Table 1
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30. No smoking related pathologies
Physical health
cx P m
PREDICTORS OF SMOKING CESSATION IN ITALIAN SMOKERS
685
Table 2 Evidence on the Predictive Power of the Items Listed in Table 1 and Relative References (item numbers in Columns 2 and 3 are referred to Table 7 ) Predictive power (item number)
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~
Barnes et al. (1985) Benfari and Eaker (1984) Bowers and Cutts (1989) Buchkrerner et al. (1989) Campbell et al. (1987) Glassman et al. (1988) Hughes et al. (1986) Jacobs (1972) Kandel and Davies (1986) Mothersill et al. (1988) Pierce et al. (1989) Pornerleau et al. (1978) Schneider (1985) Tunstall et al. (1985) Van Reek and Adriaanse (1988) West et al. (1977)
Absent or opposite to expectations
Present
Author(s) (year)
~
2.3.5.9.14.28 5,19 5,6,30 5 1.2 22 22 3,4,5,9,26,27 22 5,8,10,14,16 1J 5,8,14,17,23 5,14,15,18,20 1,3,5,6,11,12,13,14, 16.2 1,24,28,29
8
30
2.73 7.9,12,13
17
1
1,2,5,7,12,13,24,25
17
In Italy the idea that “smoking can be dangerous to your health” is beginning to break through. In the wake of public concern, a recent law has imposed, for example, printed warning statements and nicotine content on cigarette packets. The Ministry of Health has invited both employers and trade unions to add tobacco smoke to the list of workplace pollutants. Nonetheless, this process is still at an early stage, as evidenced by the general lack of specific smoking cessation programs. Within this context, we have undertaken a study in order to reassess prognostic factors in a sample of Italian smokers, because they may not be identical, at this stage and in our cultural milieu, to those identified in other countries. Second, we wanted to establish whether the trend of single parameters, such as “craving” and “negative affect,” recorded while the patient is still under treatment, has prognostic value, allowing future relapsers to be differentiated from successful abstainers.
METHOD The initial sample included 28 smokers, recruited by the word-of-mouth referral system. They were offered a free smoking cessation program as part of a
686
PERSICO
Table 3 General Characteristics of the Sample Made from 24 Smokers Still Drug-Free 6 Months after Cessation
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Sex Mean age and range (years) Religion Environmental background Education: Elementary Middle High University Employment: Blue collar White collar Housewife Marital status: Mamed Divorced/separated Unmarried
44.5 (28-58) Catholic, 24/24 (100%); practicing, 6/24 (25%) Urban, 15 (62.5%) Suburban, 9 (37.5%) 2 (8.3%) 3 (12.5%) 14 (58.3%) 5 (20.9%) 7 (29.2%) 15 (62.5%) 2 (8.3%) 18 (75%) 5 (20.8%) 1 (4.2%)
double-blind study on nicotine gum and were then randomly allocated to form the control group. At the end of the I-month treatment program, four patients had relapsed into smoking and were excluded from our study. Because of the small number of subjects available, we decided to focus only on recidivism and to lay aside the issue of early treatment outcome. The general characteristics of the final sample of 24 subjects are listed in Table 3. The items at pretreatment are listed in Table 4.With regard to medical history, each patient received a 0-4 point score according to number and severity of illnesses as well as treatments required for their solution. The lifetime prevalence of psychiatric disorders was diagnosed according to DSM-111-R criteria (Axis I). Smokers were not included in the presence of alcohol or substance abuse/dependence (other than nicotine), schizophrenia, an ongoing acute depressive illness, or any long-term pharmacological treatment. To establish baseline scores, smokers were asked to fill out daily for 1week a questionnaire including the following items: 12 visual analog scales (range 0-5) measuring nicotine withdrawal according to DSM-111-R criteria (craving, irritability and anger, anxiety, difficulty concentrating, restlessness, increased appetite), additional DSM-I11 criteria dropped in the revised version (headache, drowsiness, gastrointestinal disturbances), and other symptoms listed by Hughes and Hatsukami (1986) (impatience, increased eating, somatic complaints); a section on sleep, with self-rated quality (visual analog scale, range 0-3),duration, presence
687
PREDICTORS OF SMOKING CESSATION IN ITALIAN SMOKERS Table 4
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Pretreatment Characteristics and Baseline Scores of 73 Relapsers (54.2%) vs 1 1 DrugFree (45.8%) Ex-Smokers (mean t standard error of the mean; for Items 3, 4, and 8: median finterquartilk semidifference; Student 1-test 22 df; x 2 1 df) Variable
Relapsers
Drug-free
Difference
1. Sex(M/F) 2. Age (years) 3. Past medical problems (range 0-4) 4. Present medical problems (range 0-4) 5 . Past psychiatric history (subjects) 6. Cigaretteslday 7. CO levels (ppm) 8. Fagerstroni score (range 0- 11) 9. Duration (years) 10. Age of onset 11. Previous failures 12. Longest drug-free period (weeks) 13. Smokers in the family (subjects) 14. Smokers at work 15. Cigarette craving (range 0-5) 16. Withdrawal symptoms (range 0-60) 17. Heart rate (beats/min) 18. Systolic blood pressure (mmHg) 19. Diastolic blood pressure (mmHg) 20. Sleep duration (h) 21. Sleep quality (range 0-3) 22. Percent of nights with awakenings 23. Awakeningslnight 24. Coffee intake (cups/day) 25. Wine (glasses/day) 26. Beer (glasseslday) 27. Other alcoholic beverages
518 44.31 rf: 2.16 1.61 f 0.66
615 44.73 f 2.67 1.01 f 0.35
x2 =
1.06 f 0.4
0.42 f 0.45
U
8
1
Fisher, p
22.3 f 2.24 64.5 f 6.2 6.01 f 1.37
25.2 f 9.3 59.8 rf: 7.9 6.34 f 1.94
t
28.8 f 2.61 15.5 rf: 0.81 2.15 f 0.61 19.16 rf: 7.17
27.3 t 3.06 17.5 f 1.1 2.27 f 1.74 25.97 ? 23.42
t t t
8
1
Fisher, p
10 3.12 ? 0.27
7 3.44 f 0.3
Fisher, p t = 0.81,
9.81 f 1.92
7.38 f 1.36
t
*
0.93, N.S.
78.8 2 2.39 125 24.26
74.42 f 2.19 124.6 rf: 4.27
t t
1.32, N.S. 0.08, N.S.
85.05 f 3.41
82.36 k 2.41
t
-
7.53 rf: 0.17 2.34 t 0.1 28.38 f 7.98
6.87 f 0.65 2.24 f 0.13 22.31 8.7
r
=
t
=
1.56 f 0.24 3.86 f 0.63 0.79 f 0.37 0.05 t 0.05 0.28 t 0.04
1.07 ? 0.05 3.39 f 0.18 1.18 f 0.31 0.06 f 0.04 0.42 2 0.17
*
0.64, N.S. 0.12, N.S. U = 1.39, N.S.
t
=
- 2.06, p < .05
-
.04
--
0.79, N.S. 1.21, N.S. U 0.78, N.S.
t
t
- 0.39, N.S.
=
-
=
1.51, N.S. 0.14, N.S. 0.30, N.S.
N.S.
.04
.27, N.S.
0.62, N.S.
2.52, p .02 0.6, N.S. t = 0.49, N.S. t
t t t t
-=
2.29, p .05 0.6, N.S. 0.76, N.S. 0.14, N.S. 0.52, N.S.
PERSICO
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688
and estimated number of awakenings, duration of daytime naps; and a section on daily intake of coffee, wine, beer, and other alcoholic beverages. Patients were trained to measure and report their heart rate, and their skill was tested by the author on several occasions. Finally, they were asked to report the daily number of cigarettes smoked. A quit date was then established and patients were instructed to start chewing placebo gums whenever necessary. For 1 month every patient had to fill out daily the same questionnaire and was weekly reevaluated. At every visit the patient received a new supply of gum and psychological support, together with behavioral and cognitive interventions. The 24 ex-smokers were reevaluated at posttreatment 3-month and 6-month follow-up. A relapse was defined as a smoking rate higher than an average of one cigarette every 2 days and/or CO levels above 12 ppm in the expired air. Self-reports on cigarette smoking were highly correlated with CO levels in the expired air (r = .9 1). Statistical analysis was carried out usingX2, Fisher, Student t, and Mann-Whitney tests. Point-biserial correlations were made whenever necessary.
RESULTS Eleven (45.8%) of the 24 ex-smokers abstinent at the end of treatment were still drug-free 6 months after quitting. All the pretreatment characteristics and baseline scores taken into consideration are listed in Table 4. In reference to medical history, psychosomatic syndromes (gastric and/or duodenal ulcer, gastritis, irritable colon, hypertension, cephalalgy) were quite evenly distributed among relapsers (5/11, 45.5%) and drug-free (6/13, 46.2%) ex-smokers. On the contrary, smoking-related disorders (emphysema, chronic bronchitis, cardiovascular heart disease, hypertension, oral or lung cancer) were significantly present in 8 (61.5%) relapsers vs 1 (9.1 X) drug-free ex-smokers (p = .01) and were almost entirely represented by emphysema and chronic bronchitis. The lifetime prevalence of psychiatric disorders was clearly higher among relapsers, with six patients referring past recurrent major depressive episodes, one patient with simple phobia, and another one with generalized anxiety disorder. Only one drug-free ex-smoker had a history of post-partum depression requiring specific pharmacological treatment. The evolution of some parameters during the 1-month treatment program showed an identical trend, with absolutely no difference between the groups (i.e., decrease in heart rate, systolic/diastolic blood pressure, intake of coffee and alcoholic beverages). The other variables evidenced a different evolution, as presented in Figs. 1-7. Interestingly, six ex-smokers referred to smoking-related dreams (regarding themselves or other characters smoking). Five of them were still drug-free at 6 months, representing 45.5% of the drug-free sample, while only one had relapsed (p = .04). Time did not significantly influence this result, because three ex-smokers
PREDICTORS OF SMOKING CESSATION IN ITALIAN SMOKERS
689
CRAVING
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4
S C 0 R E
- RELAPSEPS
3 2 1
0
I
0
I1
111
I V
WEEKS
Fig. 1. Craving scores (mean f standard error of the mean; range 0-5) at baseline and during the first month after smoking cessation.
WITHDRAWAL 10 5 C 0 R E
1-
1
(*)
12
0-0
PILAPSEUS]
DRUG-FREE
a 6 4 I
0
0
I
I1
I11
IV
1
WEEKS
Fig. 2.
Combined nicotine withdrawal symptoms' scores (range 0-60).(*): p < .1.
PERSICO
690
NEGATIVE AFFECT 4
RELAPSER
s
3
C
0 R
2
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E 1
0
I
I1
WEEKS
I11
I V
Fig. 3. Negative affect scores, combining irritability and anger, anxiety, restlessness, and impatience scores.
APPETITE 3
-DRUG-FREE
s
C 0 R E
2
1
0
I
I1
WEEKS
I11
IV
Fig. 4. Mean appetite score, combining increased hunger and eating.
PREDICTORS OF SMOKING CESSATION IN ITALIAN SMOKERS
691
I
SLEEP DURATION
I
I I
e OQ
H
7
5 U R
6
DRUG-FREE
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S
/
d
0
I
WE:&
111
IV
Fig. 5. Self-reported sleep duration (night sleep + daytime naps). (*): p < .l.*: p < .05.
i
N IG HT S W ITH A W A ti:: E N I IVG S
~
P
E R C
Q+
RELAPSERS DRUG-FREE
E
0
I
I1
I11
IV
WEEKS
Fig. 6. Percentage of nights with self-reported awakenings. *: p < .05.
PERSICO
692
CUMULATIVE S L I P S 6 C
I
5
C CI
4
E 1
3
T
2
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R
E S
1
0
**
(*I
** - RELAPSERS
*F& = -DRUG-FREE
I
I1
I11
IV
WEEKS
Fig. 7. Cumulative number of cigarettes smoked during the first month after quitting by each smoker. (*): p < . I . **: p c .01.
referred to having these dreams during Week 111 and three others during the third month, at a time when most relapses had not yet occurred.
DISCUSSION This study, though based upon a small sample, has yielded important initial evidence on several areas of interest. The presence of active medical problems, especially if smoking-related, a history of previous psychiatric (affectivelanxiety) episodes, and possibly the presence of smokers in the family predicted relapse at 6 months. This is in accordance with the findings of Bowers and Cutts (1989), Glassman et al. (1988), Hughes et al. (1986), Kandel and Davies (1986), and West et al. (1977). Mothersill et al. (1988) found no evidence of predictive power for the smoking status of family members, while Campbell et al. (1987) found a trend toward higher success rates among respiratory patients. This latter work was conducted on 985 patients of family practitioners, and this design may have strongly influenced its outcome. Much more surprising than these findings is the complete lack of predictive power of several variables which, in previous works, had demonstrated a significant weight (age, smoking duration and intensity, number of previous unsuccessful attempts, age of onset). Our data, which contradict much of the work listed in Table 2, point strongly toward a "phase" specificity of predictors of outcome in smoking cessation. In other words, during the early phase of antismoking campaigns, a significant percentage of highly dependent smokers with a long smoking history may be successful at quitting through specific smoking cessation programs not available previously. As time goes on, we may expect a process of selection, which will
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693
make our smokers more similar to “hard-core” smokers prevalent today in countries where antismoking campaigns had an earlier start. The first month of abstinence provided very useful information on the mid-/ long-term prognosis of the treatment program. Whereas both groups record a general worsening of their well-being during the first week of abstinence, successful ex-smokers present constant and steady improvement afterwards. On the other hand, except for negative effect, relapsers referred to more intense discomfort, especially during Week 111,and for several variables they reached a persistent steadystate which was closer to their smoking baseline level than to the decreasing trend of successful ex-smokers. This result is confirmed by the clear tendency among future relapsers to have single “slips” after Week I (Fig. 7). Before Day 8 there was absolutely no difference between the two groups. Starting from Week I1 and especially during Week 111, nine (62.2%)future relapsers could not refrain from slipping, whereas no drug-free ex-smoker smoked a single cigarette after Day 8. Data on appetite and withdrawal also suggest that relapsers may have a decreased tolerance threshold to physical stimuli and discomfort. This is entirely compatible with modem models of addictive processes, as underlined by Pomerleau et al. (1978), who found an increased incidence of obesity among smokers with an unsuccessful treatment outcome. Smoking cessation should be viewed as a process rather than a single event. This process implies a continuous remodeling of ex-smokers’ coping responses, dependent upon the interaction between daily life events and the patient‘s psychological resources. Shiffman (1982) indicated a negative affect as the most frequent psychological correlate of “relapse crisis.” A full-blown relapse is not so much the negative affect evoked by specific situations but rather the efficacy of the ex-smoker’s coping style. This depends upon several individual factors which together make up an “interiorized self-therapeutic function.” The extent to which this function is interiorized and becomes an integrating part of the ex-smoker’s thought processes will determine the efficacy of his coping responses. We hypothesize that the cognitive, affective, and sensitive experiences connected with smoking cessation are interiorized during REM sleep and actively modify previously established patterns of behavioral response. The efficacy of exsmokers’ coping style may thus depend, among other factors, upon their sleeping and dreaming function. This hypothesis is in accordance with Dewan’s and Jouvet’s views on REM sleep and dreaming function (Dewan, 1969; Jouvet, 1978), as well as with studies on REM sleep and learning (Smith, 1985; GigIi et al., 1987) or cerebral plasticity (Gigli et al., 1987). As shown in Table 3, relapsers seem to sleep longer than abstainers (pointbiserial correlation: r = .42 with t = 2.52,22 df,p < .02).Relapses’ sleep is also more disturbed during the first month of abstinence with regard both to duration (Fig. 5) and to the percentage of nights with awakenings (Fig. 6), which was significantly higher among future relapsers. Though self-reports on sleep characteris-
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tics are partially biased (Carskadon et al., 1976), these data provide initial evidence that, at least in some relapsers, sleeping function may be relatively disturbed. Longer sleeping duration may be interpreted as an attempt to compensate for reduced sleeping efficiency. Furthermore, this may partly explain why the modification of smoking-related cognitive, affective, and behavioral patterns seems to be impaired among relapsers (Shiffman, 1982). The presence of smoking-related dreams should be the signal that such a modification is taking place. It is highly suggestive that smoking-related dreams occurred with an elevated frequency in the same period of time (Le., Week 111) when future relapsers who, with one exception, did not remember making such dreams, referred to an increase in craving and the frequency of slips. Psychiatrists have long known that the appearance of delusional or depressive themes in the dreams of patients with psychotic or affective disorders, respectively, is usually followed by a rapid improvement of their clinical conditions. Smoking-related dreams may play the same role in smoking cessation (except when possibly functioning as conditioned cues, increasing craving the following morning). Future research will have to further clarify the characteristics of Italian smokers and of predictive factors in this population. Cross-cultural studies are needed to provide comparable data from different settings. Finally, the significance and full implications of the sleeping and dreaming function in smoking cessation should be thoroughly investigated.
REFERENCES BARNES, G. E., VULCANO, B. A., and GREAVES, L. (1985). Characteristics affecting successful outcome in the cessation of smoking. Inr. J. Addict. 20(9): 1429-1434. BENFARI, R. C., and EAKER, E. (1984). Cigarette smoking outcomes at four years of follow-up, psychosocial factors, and reactions to group intervention. J. Clin. Psychol. 40(4): 1089-1097. BOWERS, T. G., and CUTTS, T. (1989). Prognosis in a smoking cessation program. Inr. J. Addicr. 24(10): 929-939. BUCHKREMER, G., BENTS, H., HORSTMANN, M., OPITZ, K., and TOLLE, R. (1989). Brief report-combination of behavioural smoking cessation with transdermal nicotine substitution. Addict. Behav. 14: 229-238. CAMPBELL, I. A., LYONS, E., and PRESCOTT, R. J. (1987). Stopping smoking: Do nicotine chewing-gum and postal encouragement add to doctors' advice. Pracririoner 231: 114-1 17. CARSKADON, M. A., DEMENT, W. C., MITLER, M. M., GUILLEMINAULT, C., ZARCONE, V. P., and SPIEGEL, R. (1976). A m J. Psychiarry 133(12): 1382- 1388. DEWAN, E. M. (1969). The Progrurnfnirtg (P)Hyporhesis for REMs. Physical Science Research Papers, No. 388, Air Force Cambridge Research Laboratories, Project 5628. GIGLI, G. L., GRUBAR, J. C., COLOGNOLA, R. M., AMATA, M.T., POLLICINA, C., FERRI,R., MUSUMECI, S. A., and BERGONZI, P. (1987). Butoctamide hydrogen succinate and intensive learning sessions: Effects on night sleep of Down's syndrome patients. Sleep lO(6): 563-569. GLASSMAN, A. H., STETNER, F., WALSH, T., RAIZMAN, P. S., FLEISS, J. L., COOPER, T. B., and COVEY, L. S. (1988). Heavy smokers, smoking cessation, and clonidine. J. Am. Med. AsSOC. 259(19): 2863-2866.
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HUGHES, J. R., and HATSUKAMI, D. (1986).Signs and symptoms of tobacco withdrawal. Arch. Gen. Psychiatry 43:289-294. HUGHES, J. R., HATSUKAMI, D., MITCHELL, J. E., and DAHLGREN, L. A. (1986).Prevalence of smoking among psychiatric outpatients. Am. J. Psychiatry 43: 255-262. JACOBS, M. A. (1972).The addictive personality: Prediction of success in a smoking withdrawal ptogram. Psychosorn. Med. 34(1): 30-38. JOUVET, M. (1978).Le sommeil paradoxal est-il responsable d’une programmation genetique du cerveau? C.R SPances Soc. Biol. 172: 1-24. KANDEL, D. B., and DAVIES, M. (1986).Adult sequelae of adolescent depressive symptoms. Arch. Gen. Psychiarry 43:255-262. MOTHERSILL, K. J., McDOWELL, I., and ROSSER, W. (1988).Subject characteristics and long term post-program smoking cessation Addicr. B e h v . 13(1): 29-36. PIERCE, J., GIOVINO, G., HATZIANDREU, E., and SHOPLAND, D. (1989).National age and sex differences in quitting smoking. J. Psychoactive Drugs 2l(3): 293-298. POMEFUEAU, 0.. ADKINS, D., and PERTSCHUK, M. (1978).Predictors of outcome and recidivism in smoking cessation treatment. Addicr. Behav. 3: 65-70. SCHNEIDER, S. J. (1984).Who quits smoking in a behavioural treatment program? Addict. Behav. 9
373-381. SHIFFMAN, S. (1982).Relapse following smoking cessation: A situational analysis. J. Consult. Clin. Psychol. 50( 1): 71 -86. SMITH, C. (1985).Sleep states and learning: A review on the animal literature. Neurosci. Biobehav. Rev. 9: 157-168. TUNSTALL, C . D., GINSBERG, D., and HALL, S . M. (1985). Quitting smoking. Inr. J. Addicr.
20(6&7): 1089-11 12. VAN REEK, J., and ADRIAANSE, H. (1988).Cigarette smoking cessation rates by sex in five western countries. Br. J. Addicr. 83: 588. WEST, D. W., GRAHAM, S., SWANSON, M., and WILKINSON, G. (1977).Five year follow-up of a smoking withdrawal clinic population. Am. J. Public Health 67(6): 536-543.
THE AUTHOR Antonio M.Persico received his M.D. from the Catholic University of the Sacred Heart, Rome, in 1986. He is employed in the Drug Addiction and Alcoholism Unit at that institution. His principal interests include molecular genetics in psychiatry; neurophysiological responses to microiontophoretically applied psychoactive substances in vivo; neurobiology, clinical aspects, diagnosis, and treatment of drug dependence and alcoholism; and psychosocial, neuropsychological, and psychopharmacological aspects of AIDS.
The International Journal of the Addictions, 27(6), 683-695, 1992
Predictors of Smoking Cessation in a Sample of Italian Smokers Antonio M. Persico, M.D. Drug Addiction and Alcoholism Unit Catholic University of the Sacred Heart Policlinico A. Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy
Abstract In this study we identify several pretreatment characteristics which predict abstinence at 6 months. Moreover, the persistence of withdrawal discomfort and of an increased frequency of night awakenings during the first month of abstinence, together with a tendency to “slip” during Weeks 11-IV, strongly predicted relapse. Our results suggest that: 1) Predictors of outcome cannot be automatically extended from one cultural context to another; 2) a careful assessment of certain variables, made while the patient is still under treatment, provides significant prognostic hints; 3) ex-smokers’ sleeping and dreaming function has been ignored by the literature, whereas they may well be involved into the maintenance of the drug-free state. Key worrls. Smoking cessation; Predictors of abstinence; Nicotine dependence; Nicotine withdrawal; Dreaming function
INTRODUCTION The issue of relapse in the field of smoking cessation has been the object of several studies. In Table 1 we list a selection of predictors of successful treatment outcome and/or absence of recidivism cited in the literature. In Table 2 we present the relative bibliography, including some of the most recent or frequently cited works. 683
Copyright 0 1992 by Marcel Dekker, Inc.
3. Middle-class or higher 4. Married
13.
11. 12.
10.
9.
8.
7.
6.
14. Less: Craving
5. Smoke fewer cig-
1. Male 2. Older
Attitude toward treafment
arettes
Habit
16. Great self-efficacy 17. Good compliance to Pleasure behavioral rules Lower nicotine intake Stimulation 18. Longer permanence in Laterooset Negative treatment Shorter duration affect 19. Active, "self-treating" Fewer failures at 15. More: Handling 20. Quitting not to "overquitting come addiction" but Longer periods of for health or other abstinence reasons support of spouse 21. Not seeking help with Fewer smokers among spouse close relatives and friends Fewer smokers at work
Reasons for smoking
Smoking behavior and history
General characteristics
28. 29.
27.
26.
23. 24. 25.
22.
No major depression/dysthymia Noobesity Less'neurotic" Less psychosomatic symptoms More gratifying family history Less defiantjconstricted Introverted Well adjusted
Psychiatric and psychological aspects
A Selection of Predictors of Successful Treatment Outcome an4'orAbsence of Recidivism
Table 1
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30. No smoking related pathologies
Physical health
cx P m
PREDICTORS OF SMOKING CESSATION IN ITALIAN SMOKERS
685
Table 2 Evidence on the Predictive Power of the Items Listed in Table 1 and Relative References (item numbers in Columns 2 and 3 are referred to Table 7 ) Predictive power (item number)
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~
Barnes et al. (1985) Benfari and Eaker (1984) Bowers and Cutts (1989) Buchkrerner et al. (1989) Campbell et al. (1987) Glassman et al. (1988) Hughes et al. (1986) Jacobs (1972) Kandel and Davies (1986) Mothersill et al. (1988) Pierce et al. (1989) Pornerleau et al. (1978) Schneider (1985) Tunstall et al. (1985) Van Reek and Adriaanse (1988) West et al. (1977)
Absent or opposite to expectations
Present
Author(s) (year)
~
2.3.5.9.14.28 5,19 5,6,30 5 1.2 22 22 3,4,5,9,26,27 22 5,8,10,14,16 1J 5,8,14,17,23 5,14,15,18,20 1,3,5,6,11,12,13,14, 16.2 1,24,28,29
8
30
2.73 7.9,12,13
17
1
1,2,5,7,12,13,24,25
17
In Italy the idea that “smoking can be dangerous to your health” is beginning to break through. In the wake of public concern, a recent law has imposed, for example, printed warning statements and nicotine content on cigarette packets. The Ministry of Health has invited both employers and trade unions to add tobacco smoke to the list of workplace pollutants. Nonetheless, this process is still at an early stage, as evidenced by the general lack of specific smoking cessation programs. Within this context, we have undertaken a study in order to reassess prognostic factors in a sample of Italian smokers, because they may not be identical, at this stage and in our cultural milieu, to those identified in other countries. Second, we wanted to establish whether the trend of single parameters, such as “craving” and “negative affect,” recorded while the patient is still under treatment, has prognostic value, allowing future relapsers to be differentiated from successful abstainers.
METHOD The initial sample included 28 smokers, recruited by the word-of-mouth referral system. They were offered a free smoking cessation program as part of a
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Table 3 General Characteristics of the Sample Made from 24 Smokers Still Drug-Free 6 Months after Cessation
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Sex Mean age and range (years) Religion Environmental background Education: Elementary Middle High University Employment: Blue collar White collar Housewife Marital status: Mamed Divorced/separated Unmarried
44.5 (28-58) Catholic, 24/24 (100%); practicing, 6/24 (25%) Urban, 15 (62.5%) Suburban, 9 (37.5%) 2 (8.3%) 3 (12.5%) 14 (58.3%) 5 (20.9%) 7 (29.2%) 15 (62.5%) 2 (8.3%) 18 (75%) 5 (20.8%) 1 (4.2%)
double-blind study on nicotine gum and were then randomly allocated to form the control group. At the end of the I-month treatment program, four patients had relapsed into smoking and were excluded from our study. Because of the small number of subjects available, we decided to focus only on recidivism and to lay aside the issue of early treatment outcome. The general characteristics of the final sample of 24 subjects are listed in Table 3. The items at pretreatment are listed in Table 4.With regard to medical history, each patient received a 0-4 point score according to number and severity of illnesses as well as treatments required for their solution. The lifetime prevalence of psychiatric disorders was diagnosed according to DSM-111-R criteria (Axis I). Smokers were not included in the presence of alcohol or substance abuse/dependence (other than nicotine), schizophrenia, an ongoing acute depressive illness, or any long-term pharmacological treatment. To establish baseline scores, smokers were asked to fill out daily for 1week a questionnaire including the following items: 12 visual analog scales (range 0-5) measuring nicotine withdrawal according to DSM-111-R criteria (craving, irritability and anger, anxiety, difficulty concentrating, restlessness, increased appetite), additional DSM-I11 criteria dropped in the revised version (headache, drowsiness, gastrointestinal disturbances), and other symptoms listed by Hughes and Hatsukami (1986) (impatience, increased eating, somatic complaints); a section on sleep, with self-rated quality (visual analog scale, range 0-3),duration, presence
687
PREDICTORS OF SMOKING CESSATION IN ITALIAN SMOKERS Table 4
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Pretreatment Characteristics and Baseline Scores of 73 Relapsers (54.2%) vs 1 1 DrugFree (45.8%) Ex-Smokers (mean t standard error of the mean; for Items 3, 4, and 8: median finterquartilk semidifference; Student 1-test 22 df; x 2 1 df) Variable
Relapsers
Drug-free
Difference
1. Sex(M/F) 2. Age (years) 3. Past medical problems (range 0-4) 4. Present medical problems (range 0-4) 5 . Past psychiatric history (subjects) 6. Cigaretteslday 7. CO levels (ppm) 8. Fagerstroni score (range 0- 11) 9. Duration (years) 10. Age of onset 11. Previous failures 12. Longest drug-free period (weeks) 13. Smokers in the family (subjects) 14. Smokers at work 15. Cigarette craving (range 0-5) 16. Withdrawal symptoms (range 0-60) 17. Heart rate (beats/min) 18. Systolic blood pressure (mmHg) 19. Diastolic blood pressure (mmHg) 20. Sleep duration (h) 21. Sleep quality (range 0-3) 22. Percent of nights with awakenings 23. Awakeningslnight 24. Coffee intake (cups/day) 25. Wine (glasses/day) 26. Beer (glasseslday) 27. Other alcoholic beverages
518 44.31 rf: 2.16 1.61 f 0.66
615 44.73 f 2.67 1.01 f 0.35
x2 =
1.06 f 0.4
0.42 f 0.45
U
8
1
Fisher, p
22.3 f 2.24 64.5 f 6.2 6.01 f 1.37
25.2 f 9.3 59.8 rf: 7.9 6.34 f 1.94
t
28.8 f 2.61 15.5 rf: 0.81 2.15 f 0.61 19.16 rf: 7.17
27.3 t 3.06 17.5 f 1.1 2.27 f 1.74 25.97 ? 23.42
t t t
8
1
Fisher, p
10 3.12 ? 0.27
7 3.44 f 0.3
Fisher, p t = 0.81,
9.81 f 1.92
7.38 f 1.36
t
*
0.93, N.S.
78.8 2 2.39 125 24.26
74.42 f 2.19 124.6 rf: 4.27
t t
1.32, N.S. 0.08, N.S.
85.05 f 3.41
82.36 k 2.41
t
-
7.53 rf: 0.17 2.34 t 0.1 28.38 f 7.98
6.87 f 0.65 2.24 f 0.13 22.31 8.7
r
=
t
=
1.56 f 0.24 3.86 f 0.63 0.79 f 0.37 0.05 t 0.05 0.28 t 0.04
1.07 ? 0.05 3.39 f 0.18 1.18 f 0.31 0.06 f 0.04 0.42 2 0.17
*
0.64, N.S. 0.12, N.S. U = 1.39, N.S.
t
=
- 2.06, p < .05
-
.04
--
0.79, N.S. 1.21, N.S. U 0.78, N.S.
t
t
- 0.39, N.S.
=
-
=
1.51, N.S. 0.14, N.S. 0.30, N.S.
N.S.
.04
.27, N.S.
0.62, N.S.
2.52, p .02 0.6, N.S. t = 0.49, N.S. t
t t t t
-=
2.29, p .05 0.6, N.S. 0.76, N.S. 0.14, N.S. 0.52, N.S.
PERSICO
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688
and estimated number of awakenings, duration of daytime naps; and a section on daily intake of coffee, wine, beer, and other alcoholic beverages. Patients were trained to measure and report their heart rate, and their skill was tested by the author on several occasions. Finally, they were asked to report the daily number of cigarettes smoked. A quit date was then established and patients were instructed to start chewing placebo gums whenever necessary. For 1 month every patient had to fill out daily the same questionnaire and was weekly reevaluated. At every visit the patient received a new supply of gum and psychological support, together with behavioral and cognitive interventions. The 24 ex-smokers were reevaluated at posttreatment 3-month and 6-month follow-up. A relapse was defined as a smoking rate higher than an average of one cigarette every 2 days and/or CO levels above 12 ppm in the expired air. Self-reports on cigarette smoking were highly correlated with CO levels in the expired air (r = .9 1). Statistical analysis was carried out usingX2, Fisher, Student t, and Mann-Whitney tests. Point-biserial correlations were made whenever necessary.
RESULTS Eleven (45.8%) of the 24 ex-smokers abstinent at the end of treatment were still drug-free 6 months after quitting. All the pretreatment characteristics and baseline scores taken into consideration are listed in Table 4. In reference to medical history, psychosomatic syndromes (gastric and/or duodenal ulcer, gastritis, irritable colon, hypertension, cephalalgy) were quite evenly distributed among relapsers (5/11, 45.5%) and drug-free (6/13, 46.2%) ex-smokers. On the contrary, smoking-related disorders (emphysema, chronic bronchitis, cardiovascular heart disease, hypertension, oral or lung cancer) were significantly present in 8 (61.5%) relapsers vs 1 (9.1 X) drug-free ex-smokers (p = .01) and were almost entirely represented by emphysema and chronic bronchitis. The lifetime prevalence of psychiatric disorders was clearly higher among relapsers, with six patients referring past recurrent major depressive episodes, one patient with simple phobia, and another one with generalized anxiety disorder. Only one drug-free ex-smoker had a history of post-partum depression requiring specific pharmacological treatment. The evolution of some parameters during the 1-month treatment program showed an identical trend, with absolutely no difference between the groups (i.e., decrease in heart rate, systolic/diastolic blood pressure, intake of coffee and alcoholic beverages). The other variables evidenced a different evolution, as presented in Figs. 1-7. Interestingly, six ex-smokers referred to smoking-related dreams (regarding themselves or other characters smoking). Five of them were still drug-free at 6 months, representing 45.5% of the drug-free sample, while only one had relapsed (p = .04). Time did not significantly influence this result, because three ex-smokers
PREDICTORS OF SMOKING CESSATION IN ITALIAN SMOKERS
689
CRAVING
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4
S C 0 R E
- RELAPSEPS
3 2 1
0
I
0
I1
111
I V
WEEKS
Fig. 1. Craving scores (mean f standard error of the mean; range 0-5) at baseline and during the first month after smoking cessation.
WITHDRAWAL 10 5 C 0 R E
1-
1
(*)
12
0-0
PILAPSEUS]
DRUG-FREE
a 6 4 I
0
0
I
I1
I11
IV
1
WEEKS
Fig. 2.
Combined nicotine withdrawal symptoms' scores (range 0-60).(*): p < .1.
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690
NEGATIVE AFFECT 4
RELAPSER
s
3
C
0 R
2
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E 1
0
I
I1
WEEKS
I11
I V
Fig. 3. Negative affect scores, combining irritability and anger, anxiety, restlessness, and impatience scores.
APPETITE 3
-DRUG-FREE
s
C 0 R E
2
1
0
I
I1
WEEKS
I11
IV
Fig. 4. Mean appetite score, combining increased hunger and eating.
PREDICTORS OF SMOKING CESSATION IN ITALIAN SMOKERS
691
I
SLEEP DURATION
I
I I
e OQ
H
7
5 U R
6
DRUG-FREE
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S
/
d
0
I
WE:&
111
IV
Fig. 5. Self-reported sleep duration (night sleep + daytime naps). (*): p < .l.*: p < .05.
i
N IG HT S W ITH A W A ti:: E N I IVG S
~
P
E R C
Q+
RELAPSERS DRUG-FREE
E
0
I
I1
I11
IV
WEEKS
Fig. 6. Percentage of nights with self-reported awakenings. *: p < .05.
PERSICO
692
CUMULATIVE S L I P S 6 C
I
5
C CI
4
E 1
3
T
2
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R
E S
1
0
**
(*I
** - RELAPSERS
*F& = -DRUG-FREE
I
I1
I11
IV
WEEKS
Fig. 7. Cumulative number of cigarettes smoked during the first month after quitting by each smoker. (*): p < . I . **: p c .01.
referred to having these dreams during Week 111 and three others during the third month, at a time when most relapses had not yet occurred.
DISCUSSION This study, though based upon a small sample, has yielded important initial evidence on several areas of interest. The presence of active medical problems, especially if smoking-related, a history of previous psychiatric (affectivelanxiety) episodes, and possibly the presence of smokers in the family predicted relapse at 6 months. This is in accordance with the findings of Bowers and Cutts (1989), Glassman et al. (1988), Hughes et al. (1986), Kandel and Davies (1986), and West et al. (1977). Mothersill et al. (1988) found no evidence of predictive power for the smoking status of family members, while Campbell et al. (1987) found a trend toward higher success rates among respiratory patients. This latter work was conducted on 985 patients of family practitioners, and this design may have strongly influenced its outcome. Much more surprising than these findings is the complete lack of predictive power of several variables which, in previous works, had demonstrated a significant weight (age, smoking duration and intensity, number of previous unsuccessful attempts, age of onset). Our data, which contradict much of the work listed in Table 2, point strongly toward a "phase" specificity of predictors of outcome in smoking cessation. In other words, during the early phase of antismoking campaigns, a significant percentage of highly dependent smokers with a long smoking history may be successful at quitting through specific smoking cessation programs not available previously. As time goes on, we may expect a process of selection, which will
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PREDICTORS OF SMOKING CESSATION IN ITALIAN SMOKERS
693
make our smokers more similar to “hard-core” smokers prevalent today in countries where antismoking campaigns had an earlier start. The first month of abstinence provided very useful information on the mid-/ long-term prognosis of the treatment program. Whereas both groups record a general worsening of their well-being during the first week of abstinence, successful ex-smokers present constant and steady improvement afterwards. On the other hand, except for negative effect, relapsers referred to more intense discomfort, especially during Week 111,and for several variables they reached a persistent steadystate which was closer to their smoking baseline level than to the decreasing trend of successful ex-smokers. This result is confirmed by the clear tendency among future relapsers to have single “slips” after Week I (Fig. 7). Before Day 8 there was absolutely no difference between the two groups. Starting from Week I1 and especially during Week 111, nine (62.2%)future relapsers could not refrain from slipping, whereas no drug-free ex-smoker smoked a single cigarette after Day 8. Data on appetite and withdrawal also suggest that relapsers may have a decreased tolerance threshold to physical stimuli and discomfort. This is entirely compatible with modem models of addictive processes, as underlined by Pomerleau et al. (1978), who found an increased incidence of obesity among smokers with an unsuccessful treatment outcome. Smoking cessation should be viewed as a process rather than a single event. This process implies a continuous remodeling of ex-smokers’ coping responses, dependent upon the interaction between daily life events and the patient‘s psychological resources. Shiffman (1982) indicated a negative affect as the most frequent psychological correlate of “relapse crisis.” A full-blown relapse is not so much the negative affect evoked by specific situations but rather the efficacy of the ex-smoker’s coping style. This depends upon several individual factors which together make up an “interiorized self-therapeutic function.” The extent to which this function is interiorized and becomes an integrating part of the ex-smoker’s thought processes will determine the efficacy of his coping responses. We hypothesize that the cognitive, affective, and sensitive experiences connected with smoking cessation are interiorized during REM sleep and actively modify previously established patterns of behavioral response. The efficacy of exsmokers’ coping style may thus depend, among other factors, upon their sleeping and dreaming function. This hypothesis is in accordance with Dewan’s and Jouvet’s views on REM sleep and dreaming function (Dewan, 1969; Jouvet, 1978), as well as with studies on REM sleep and learning (Smith, 1985; GigIi et al., 1987) or cerebral plasticity (Gigli et al., 1987). As shown in Table 3, relapsers seem to sleep longer than abstainers (pointbiserial correlation: r = .42 with t = 2.52,22 df,p < .02).Relapses’ sleep is also more disturbed during the first month of abstinence with regard both to duration (Fig. 5) and to the percentage of nights with awakenings (Fig. 6), which was significantly higher among future relapsers. Though self-reports on sleep characteris-
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tics are partially biased (Carskadon et al., 1976), these data provide initial evidence that, at least in some relapsers, sleeping function may be relatively disturbed. Longer sleeping duration may be interpreted as an attempt to compensate for reduced sleeping efficiency. Furthermore, this may partly explain why the modification of smoking-related cognitive, affective, and behavioral patterns seems to be impaired among relapsers (Shiffman, 1982). The presence of smoking-related dreams should be the signal that such a modification is taking place. It is highly suggestive that smoking-related dreams occurred with an elevated frequency in the same period of time (Le., Week 111) when future relapsers who, with one exception, did not remember making such dreams, referred to an increase in craving and the frequency of slips. Psychiatrists have long known that the appearance of delusional or depressive themes in the dreams of patients with psychotic or affective disorders, respectively, is usually followed by a rapid improvement of their clinical conditions. Smoking-related dreams may play the same role in smoking cessation (except when possibly functioning as conditioned cues, increasing craving the following morning). Future research will have to further clarify the characteristics of Italian smokers and of predictive factors in this population. Cross-cultural studies are needed to provide comparable data from different settings. Finally, the significance and full implications of the sleeping and dreaming function in smoking cessation should be thoroughly investigated.
REFERENCES BARNES, G. E., VULCANO, B. A., and GREAVES, L. (1985). Characteristics affecting successful outcome in the cessation of smoking. Inr. J. Addict. 20(9): 1429-1434. BENFARI, R. C., and EAKER, E. (1984). Cigarette smoking outcomes at four years of follow-up, psychosocial factors, and reactions to group intervention. J. Clin. Psychol. 40(4): 1089-1097. BOWERS, T. G., and CUTTS, T. (1989). Prognosis in a smoking cessation program. Inr. J. Addicr. 24(10): 929-939. BUCHKREMER, G., BENTS, H., HORSTMANN, M., OPITZ, K., and TOLLE, R. (1989). Brief report-combination of behavioural smoking cessation with transdermal nicotine substitution. Addict. Behav. 14: 229-238. CAMPBELL, I. A., LYONS, E., and PRESCOTT, R. J. (1987). Stopping smoking: Do nicotine chewing-gum and postal encouragement add to doctors' advice. Pracririoner 231: 114-1 17. CARSKADON, M. A., DEMENT, W. C., MITLER, M. M., GUILLEMINAULT, C., ZARCONE, V. P., and SPIEGEL, R. (1976). A m J. Psychiarry 133(12): 1382- 1388. DEWAN, E. M. (1969). The Progrurnfnirtg (P)Hyporhesis for REMs. Physical Science Research Papers, No. 388, Air Force Cambridge Research Laboratories, Project 5628. GIGLI, G. L., GRUBAR, J. C., COLOGNOLA, R. M., AMATA, M.T., POLLICINA, C., FERRI,R., MUSUMECI, S. A., and BERGONZI, P. (1987). Butoctamide hydrogen succinate and intensive learning sessions: Effects on night sleep of Down's syndrome patients. Sleep lO(6): 563-569. GLASSMAN, A. H., STETNER, F., WALSH, T., RAIZMAN, P. S., FLEISS, J. L., COOPER, T. B., and COVEY, L. S. (1988). Heavy smokers, smoking cessation, and clonidine. J. Am. Med. AsSOC. 259(19): 2863-2866.
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HUGHES, J. R., and HATSUKAMI, D. (1986).Signs and symptoms of tobacco withdrawal. Arch. Gen. Psychiatry 43:289-294. HUGHES, J. R., HATSUKAMI, D., MITCHELL, J. E., and DAHLGREN, L. A. (1986).Prevalence of smoking among psychiatric outpatients. Am. J. Psychiatry 43: 255-262. JACOBS, M. A. (1972).The addictive personality: Prediction of success in a smoking withdrawal ptogram. Psychosorn. Med. 34(1): 30-38. JOUVET, M. (1978).Le sommeil paradoxal est-il responsable d’une programmation genetique du cerveau? C.R SPances Soc. Biol. 172: 1-24. KANDEL, D. B., and DAVIES, M. (1986).Adult sequelae of adolescent depressive symptoms. Arch. Gen. Psychiarry 43:255-262. MOTHERSILL, K. J., McDOWELL, I., and ROSSER, W. (1988).Subject characteristics and long term post-program smoking cessation Addicr. B e h v . 13(1): 29-36. PIERCE, J., GIOVINO, G., HATZIANDREU, E., and SHOPLAND, D. (1989).National age and sex differences in quitting smoking. J. Psychoactive Drugs 2l(3): 293-298. POMEFUEAU, 0.. ADKINS, D., and PERTSCHUK, M. (1978).Predictors of outcome and recidivism in smoking cessation treatment. Addicr. Behav. 3: 65-70. SCHNEIDER, S. J. (1984).Who quits smoking in a behavioural treatment program? Addict. Behav. 9
373-381. SHIFFMAN, S. (1982).Relapse following smoking cessation: A situational analysis. J. Consult. Clin. Psychol. 50( 1): 71 -86. SMITH, C. (1985).Sleep states and learning: A review on the animal literature. Neurosci. Biobehav. Rev. 9: 157-168. TUNSTALL, C . D., GINSBERG, D., and HALL, S . M. (1985). Quitting smoking. Inr. J. Addicr.
20(6&7): 1089-11 12. VAN REEK, J., and ADRIAANSE, H. (1988).Cigarette smoking cessation rates by sex in five western countries. Br. J. Addicr. 83: 588. WEST, D. W., GRAHAM, S., SWANSON, M., and WILKINSON, G. (1977).Five year follow-up of a smoking withdrawal clinic population. Am. J. Public Health 67(6): 536-543.
THE AUTHOR Antonio M.Persico received his M.D. from the Catholic University of the Sacred Heart, Rome, in 1986. He is employed in the Drug Addiction and Alcoholism Unit at that institution. His principal interests include molecular genetics in psychiatry; neurophysiological responses to microiontophoretically applied psychoactive substances in vivo; neurobiology, clinical aspects, diagnosis, and treatment of drug dependence and alcoholism; and psychosocial, neuropsychological, and psychopharmacological aspects of AIDS.
