Vol.4. pp. 345 to 348 © PergamonPressLtd 1979, Printedin Great Britain
0306-4603,79/I 101-0345502.00/0
Addictire Behariors.
SMOKING
CESSATION:
THE
PSYCHOLOGICAL
COSTS
MICHAEL J. PERTSCHUK, OVIDE F . POMERLEAU, D A V I D ADKINS a n d CELIA HIRSH Center for Behavioral Medicine, University of Pennsylvania Al~traet--To assess the psychological effects of smoking cessation, 21 subjects in a smoking treatment program were evaluated at the beginning of therapy and 4 months later. No differences were observed in reported affect, use of mental health facilities, psychotropic medications, or alcohol. A statistically but not clinically significant weight increase was observed. It is concluded that within some contexts smoking cessation need not be as stressful as popularly depicted.
The lore surrounding smoking cessation suggests that giving up smoking is an emotionally wrenching experience. Descriptions in the lay press ("Despite the warnings", 1973; Whitebook, 1976) have represented the first weeks of abstinence as torture. The ex-smoker is said to undergo intense feelings of anxiety, irritability, and "oral deprivation," the last being compensated through the consumption of immense quantities of food. While smoking-cessation treatments and physiologic signs of tobacco withdrawal have been the subjects of extensive research (Bernstein & McAlister, 1976; Pomerleau et al., 1978; Jarvik, 1979) there has been extremely limited inquiry into the psychological impact of the process. In one early study (Knapp et al., 1963), no psychological difficulties were observed among a group giving up cigarettes for a brief period (subjects had minimal intention of prolonged abstinence). There has been little work subsequently, beyond informal descriptions (Schachter et al., 1977) of assumed psychological stresses. In the course of conducting group treatment for smoking cessation, we gained the impression that, while giving up cigarettes was an unpleasant experience, it was not as devastating as popularly depicted. We therefore decided to undertake a formal investigation of the psychological complications which might be associated with smoking cessation. If major problems were found, the implications would be considerable, given the recent burgeoning of commercial smoking clinics with little or no professional supervision (Brody, 1974; Francke, 1973). On the other hand, if only minor problems were observed, then the findings might provide some reassurance and encouragement to smokers who have postponed quitting for fear of incurring major emotional difficulties. METHOD
Subjects
Subjects were drawn from participants in a smoking cessation program at the Center for Behavioral Medicine of the University of Pennsylvania. Participants were largely self-referred, predominantly middle class, and sufficiently motivated to pay a $50 fee for service. Exclusion criteria were limited to (1) inability to comprehend program instructions, (2) emotional or personal problems of sufficient magnitude (e.g., pending divorce) to interfere with concentration on program objectives. A history of psychiatric treatment, as such, was not a basis for exclusion. Thirty-one smokers were screened for the program during this study. No one was excluded but 3 decided against treatment. Of the 28 participants in the smoking program, 24 completed the study. Three subjects dropped out and one could not be reached at follow-up. The mean subject age was 40.0yr (SD = 12.5); mean number of years smoking was 21.5 yr (SD = 13.4); mean smoking rate was 34.7 cigarettes per day (SD = 11.6). Compared to a national survey of smokers (USDHEW, 1975), the subjects of the study were about the same age and had smoked for a similar number of years but at a greater rate (34.7 cig./day vs 19.5 cig./ day). The higher smoking rate may reflect a difference between smokers entering treatment versus untreated smokers in the national sample. Also, there was a larger represen345
346
MICHAELJ. PERTSCHUKet
al.
tation of females in our sample (62.5~ vs 45~ nationally) and a higher educational level (16 vs 12 yr of school). The preponderance of females in the program probably relates to the fact that treatment was given during working hours; the higher educational level may reflect the university setting of the treatment facility. Procedure
All subjects participated in the smoking treatment program. This program has been described in detail elsewhere (Pomerleau & Pomerleau, 1977). In brief, the treatment consisted of 8 weekly group sessions and 5 follow-up meetings. Subjects were instructed in keeping careful smoking records. Patterns of tobacco use were identified. Smoking was gradually reduced through a variety of stimulus control and contingency management techniques. Abstinence was expected by the fifth week and the remainder of the sessions were directed towards helping subjects maintain non-smoking status. At the first treatment session, having given informed consent, subjects completed a questionnaire inquiring into past psychiatric treatment and use of psychotropic medications, alcohol, and marijuana. Questions were asked about change in therapy and use of these substances for the 4 months prior to entering the program. Subjects reported any overall change in anxiety, depression, anger, or irritability experienced during the previous 4 months. Subjects were also asked to indicate the occurrence of a range of symptoms over the 4 month period, including appetite loss, insomnia, nightmares, hopelessness, tension, apathy, difficulty in concentration, and temper outbursts. The symptoms selected were derived from anecdotal descriptions of the cigarette withdrawal experience. Two months after the completion of the treatment program, at a scheduled follow-up visit, the same questionnaire was administered but with reference to the 4 month period in which cigarette withdrawal had occurred. Subjects who failed to attend follow-up sessions were contacted by mail or phone and the same questionnaire was given. Additional data used in the investigation included weight records of each subject based on measurement prior to each treatment session and information on smoking status from smoking records and follow-up inquiries. Thus, the experiment consisted of a before and after design with each subject as his or her own control. RESULTS Questionnaires were reviewed with reference to psychiatric history: 12 subjects acknowledged previous psychotherapy. One subject had begun therapy during the 4 month pre-treatment interval. One other subject started therapy during the 4 month cigarette withdrawal phase. Ten subjects reported the use of psychotropic medication (chiefly minor tranquilizers). Five had used these drugs during the 4 months pre-treatment and continued to use them with essentially no change during the next 4 months. Subjects who were medication free prior to treatment, remained so during treatment. Four subjects increased alcohol intake compared to pre-treatment levels and 4 decreased intake. No subject admitted to marijuana use. Subject ratings of affect and symptoms were compared in the pre-treatment and treatment intervals: no significant differences were found on any measure by McNemar tests for significance of changes. There was, however, a significant average weight gain of 1.2 k from the first to last treatment session (Wilcoxin T = 39.5, P < 0.005). Data were also analyzed using Chi square tests to compare the 16 subjects who successfully stopped smoking during treatment with the eight who didn't: no significant differences were found between the groups for any reported affect or symptom; nor was there a significant difference in observed weight change between the groups by the Mann Whitney U test. DISCUSSION The study was directed toward documenting psychological stress undergone in the course of giving up cigarettes. To this end, a within subject design was utilized to
Smoking cessation: the psychologicalcosts
347
record possible change in emotional functioning prior to and during treatment. In addition, data were also analyzed across subject groups divided on the basis of success or failure in the program. As stated previously, the subject population had a greater proportion of women and a higher educational level than the national sample. The influence of gender and education on complications of tobacco withdrawal is unknown. The subjects' considerably higher rate of smoking relative to the national sample, however, should have biased the study in the direction of showing greater, rather than fewer, side effects. The results indicate that, within the context of the present smoking-cessation program, giving up cigarettes did not generate major psychological problems. The absence of significant changes, given the number of statistical tests performed, is striking. The fact that subjects who actually achieved abstinence fared no worse emotionally than those who did not go through tobacco withdrawal, strengthens the conclusion. It is also worth noting that the present therapeutically experienced subject population did not find it necessary to resort to increased use of mental health services or psychotropic medication during treatment. The only observed negative side effect of the program was weight gain. While statistically significant, the average weight gain of 1.2 kg is not of clinical importance. The gain appeared to be more a result of attempting to give up cigarettes, rather than actually achieving withdrawal, as weight gains did not differ between those who succeeded and those who did not. Finally, the possibility was considered that the 3 drop-outs, who were not reached for evaluation, could have experienced psychological difficulties which led to the discontinuation of treatment. All 3, however, dropped out prior to the second session which was before smoking reduction began. Whatever their motivation for leaving therapy, it could not have been in response to the effects of tobacco withdrawal. The results are consistent with a preliminary study on a group of 50 previously treated subjects. In this purely retrospective investigation, there were also no significant differences between smokers and non-smokers in reported symptoms and affect during treatment. Weight gained during the program was 1.1 kg with no significant difference between smokers and non-smokers. Overall, our initial impression was confirmed. For these subjects, going through this particular program, smoking cessation was accomplished without noteable stress. If smoking cessation can be such a benign process, why then does quitting have such a bad reputation? It may have been that the relatively low keyed supportive, non-punative approach used in the program served to counter many of the more negative effects of the process. Certainly, it is not difficult to conceive of treatment using electric shock or forced smoke inhalation generating more anxiety in participants. It may also be that, for the general public, the stories circulating about the agony of abstinence serve as a self fulfilling prophesy: smokers expect it to be painful and therefore it is. Many give up their attempts to break the habit at the first sign of discomfort, anticipating greater pain, which in reality is not forthcoming. Others may use the prospect of cessation side effects (particularly weight gain) as a rationale for continuing smoking. The present study demonstrates that it is possible to go through cigarette withdrawal, under some circumstances, without major complications.
REFERENCES Bernstein, D. A., & McAlister, A. The modificationof smoking behavior: progress and problems. Addictive Behaviors, 1976, l, 89-102. Brody, J. E. A smoking program yields some encouraging data. The New York Times, January 12, 1974, p. 22. Despite the warnings, millions can't or won't give up smoking. The New York Times, November 5, 1973, p. 45. Francke, L. Smokers who seek help to quit have come a long way, maybe. The New York Times, October 10, 1973, p. 37. Jarvik, M. Biologicalinfluenceson cigarette smoking. In Smoking and Health, a Report of the Surgeon General, Bethesda, MD; USDHEW, U.S. Public Health Service, 1979.
348
MICHAEL J. PERTSCHUKet al.
Knapp, P. H., Bliss, C. M., & Wells, H. Addictive aspects in heavy cigarette smoking. American Journal of Psychiatry, 1963, 119, 966-972. Pomerleau, O. F., Adkins, D., & Pertschuk, M. J. Predictors of outcome and recidivism in smoking cessation treatment. Addictive Behaviors, 1978, 3, 65-70. Pomerleau, O. F., & Pomerleau, C. S. Break the Smoking Habit. Champaign, IL: Research Press, 1977. Schachter, S., Silverstein, B., Kozlowski, L., Perlick, D., Herman, P., & Liebling, B. Studies of the interaction of psychological and pharmacological determinants of smoking. Journal of Experimental Psychology, 1977, 106, 3-40. United States Department of Health, Education, and Welfare. Adult Use of Tobacco--1975. Atlanta, GA: Public Health Service, Center for Disease Control, 1975. Whitebook, B. Confessions of an ex-smoker. Harper's Magazine, 1976, 252, 94-97.
0306-4603,79/I 101-0345502.00/0
Addictire Behariors.
SMOKING
CESSATION:
THE
PSYCHOLOGICAL
COSTS
MICHAEL J. PERTSCHUK, OVIDE F . POMERLEAU, D A V I D ADKINS a n d CELIA HIRSH Center for Behavioral Medicine, University of Pennsylvania Al~traet--To assess the psychological effects of smoking cessation, 21 subjects in a smoking treatment program were evaluated at the beginning of therapy and 4 months later. No differences were observed in reported affect, use of mental health facilities, psychotropic medications, or alcohol. A statistically but not clinically significant weight increase was observed. It is concluded that within some contexts smoking cessation need not be as stressful as popularly depicted.
The lore surrounding smoking cessation suggests that giving up smoking is an emotionally wrenching experience. Descriptions in the lay press ("Despite the warnings", 1973; Whitebook, 1976) have represented the first weeks of abstinence as torture. The ex-smoker is said to undergo intense feelings of anxiety, irritability, and "oral deprivation," the last being compensated through the consumption of immense quantities of food. While smoking-cessation treatments and physiologic signs of tobacco withdrawal have been the subjects of extensive research (Bernstein & McAlister, 1976; Pomerleau et al., 1978; Jarvik, 1979) there has been extremely limited inquiry into the psychological impact of the process. In one early study (Knapp et al., 1963), no psychological difficulties were observed among a group giving up cigarettes for a brief period (subjects had minimal intention of prolonged abstinence). There has been little work subsequently, beyond informal descriptions (Schachter et al., 1977) of assumed psychological stresses. In the course of conducting group treatment for smoking cessation, we gained the impression that, while giving up cigarettes was an unpleasant experience, it was not as devastating as popularly depicted. We therefore decided to undertake a formal investigation of the psychological complications which might be associated with smoking cessation. If major problems were found, the implications would be considerable, given the recent burgeoning of commercial smoking clinics with little or no professional supervision (Brody, 1974; Francke, 1973). On the other hand, if only minor problems were observed, then the findings might provide some reassurance and encouragement to smokers who have postponed quitting for fear of incurring major emotional difficulties. METHOD
Subjects
Subjects were drawn from participants in a smoking cessation program at the Center for Behavioral Medicine of the University of Pennsylvania. Participants were largely self-referred, predominantly middle class, and sufficiently motivated to pay a $50 fee for service. Exclusion criteria were limited to (1) inability to comprehend program instructions, (2) emotional or personal problems of sufficient magnitude (e.g., pending divorce) to interfere with concentration on program objectives. A history of psychiatric treatment, as such, was not a basis for exclusion. Thirty-one smokers were screened for the program during this study. No one was excluded but 3 decided against treatment. Of the 28 participants in the smoking program, 24 completed the study. Three subjects dropped out and one could not be reached at follow-up. The mean subject age was 40.0yr (SD = 12.5); mean number of years smoking was 21.5 yr (SD = 13.4); mean smoking rate was 34.7 cigarettes per day (SD = 11.6). Compared to a national survey of smokers (USDHEW, 1975), the subjects of the study were about the same age and had smoked for a similar number of years but at a greater rate (34.7 cig./day vs 19.5 cig./ day). The higher smoking rate may reflect a difference between smokers entering treatment versus untreated smokers in the national sample. Also, there was a larger represen345
346
MICHAELJ. PERTSCHUKet
al.
tation of females in our sample (62.5~ vs 45~ nationally) and a higher educational level (16 vs 12 yr of school). The preponderance of females in the program probably relates to the fact that treatment was given during working hours; the higher educational level may reflect the university setting of the treatment facility. Procedure
All subjects participated in the smoking treatment program. This program has been described in detail elsewhere (Pomerleau & Pomerleau, 1977). In brief, the treatment consisted of 8 weekly group sessions and 5 follow-up meetings. Subjects were instructed in keeping careful smoking records. Patterns of tobacco use were identified. Smoking was gradually reduced through a variety of stimulus control and contingency management techniques. Abstinence was expected by the fifth week and the remainder of the sessions were directed towards helping subjects maintain non-smoking status. At the first treatment session, having given informed consent, subjects completed a questionnaire inquiring into past psychiatric treatment and use of psychotropic medications, alcohol, and marijuana. Questions were asked about change in therapy and use of these substances for the 4 months prior to entering the program. Subjects reported any overall change in anxiety, depression, anger, or irritability experienced during the previous 4 months. Subjects were also asked to indicate the occurrence of a range of symptoms over the 4 month period, including appetite loss, insomnia, nightmares, hopelessness, tension, apathy, difficulty in concentration, and temper outbursts. The symptoms selected were derived from anecdotal descriptions of the cigarette withdrawal experience. Two months after the completion of the treatment program, at a scheduled follow-up visit, the same questionnaire was administered but with reference to the 4 month period in which cigarette withdrawal had occurred. Subjects who failed to attend follow-up sessions were contacted by mail or phone and the same questionnaire was given. Additional data used in the investigation included weight records of each subject based on measurement prior to each treatment session and information on smoking status from smoking records and follow-up inquiries. Thus, the experiment consisted of a before and after design with each subject as his or her own control. RESULTS Questionnaires were reviewed with reference to psychiatric history: 12 subjects acknowledged previous psychotherapy. One subject had begun therapy during the 4 month pre-treatment interval. One other subject started therapy during the 4 month cigarette withdrawal phase. Ten subjects reported the use of psychotropic medication (chiefly minor tranquilizers). Five had used these drugs during the 4 months pre-treatment and continued to use them with essentially no change during the next 4 months. Subjects who were medication free prior to treatment, remained so during treatment. Four subjects increased alcohol intake compared to pre-treatment levels and 4 decreased intake. No subject admitted to marijuana use. Subject ratings of affect and symptoms were compared in the pre-treatment and treatment intervals: no significant differences were found on any measure by McNemar tests for significance of changes. There was, however, a significant average weight gain of 1.2 k from the first to last treatment session (Wilcoxin T = 39.5, P < 0.005). Data were also analyzed using Chi square tests to compare the 16 subjects who successfully stopped smoking during treatment with the eight who didn't: no significant differences were found between the groups for any reported affect or symptom; nor was there a significant difference in observed weight change between the groups by the Mann Whitney U test. DISCUSSION The study was directed toward documenting psychological stress undergone in the course of giving up cigarettes. To this end, a within subject design was utilized to
Smoking cessation: the psychologicalcosts
347
record possible change in emotional functioning prior to and during treatment. In addition, data were also analyzed across subject groups divided on the basis of success or failure in the program. As stated previously, the subject population had a greater proportion of women and a higher educational level than the national sample. The influence of gender and education on complications of tobacco withdrawal is unknown. The subjects' considerably higher rate of smoking relative to the national sample, however, should have biased the study in the direction of showing greater, rather than fewer, side effects. The results indicate that, within the context of the present smoking-cessation program, giving up cigarettes did not generate major psychological problems. The absence of significant changes, given the number of statistical tests performed, is striking. The fact that subjects who actually achieved abstinence fared no worse emotionally than those who did not go through tobacco withdrawal, strengthens the conclusion. It is also worth noting that the present therapeutically experienced subject population did not find it necessary to resort to increased use of mental health services or psychotropic medication during treatment. The only observed negative side effect of the program was weight gain. While statistically significant, the average weight gain of 1.2 kg is not of clinical importance. The gain appeared to be more a result of attempting to give up cigarettes, rather than actually achieving withdrawal, as weight gains did not differ between those who succeeded and those who did not. Finally, the possibility was considered that the 3 drop-outs, who were not reached for evaluation, could have experienced psychological difficulties which led to the discontinuation of treatment. All 3, however, dropped out prior to the second session which was before smoking reduction began. Whatever their motivation for leaving therapy, it could not have been in response to the effects of tobacco withdrawal. The results are consistent with a preliminary study on a group of 50 previously treated subjects. In this purely retrospective investigation, there were also no significant differences between smokers and non-smokers in reported symptoms and affect during treatment. Weight gained during the program was 1.1 kg with no significant difference between smokers and non-smokers. Overall, our initial impression was confirmed. For these subjects, going through this particular program, smoking cessation was accomplished without noteable stress. If smoking cessation can be such a benign process, why then does quitting have such a bad reputation? It may have been that the relatively low keyed supportive, non-punative approach used in the program served to counter many of the more negative effects of the process. Certainly, it is not difficult to conceive of treatment using electric shock or forced smoke inhalation generating more anxiety in participants. It may also be that, for the general public, the stories circulating about the agony of abstinence serve as a self fulfilling prophesy: smokers expect it to be painful and therefore it is. Many give up their attempts to break the habit at the first sign of discomfort, anticipating greater pain, which in reality is not forthcoming. Others may use the prospect of cessation side effects (particularly weight gain) as a rationale for continuing smoking. The present study demonstrates that it is possible to go through cigarette withdrawal, under some circumstances, without major complications.
REFERENCES Bernstein, D. A., & McAlister, A. The modificationof smoking behavior: progress and problems. Addictive Behaviors, 1976, l, 89-102. Brody, J. E. A smoking program yields some encouraging data. The New York Times, January 12, 1974, p. 22. Despite the warnings, millions can't or won't give up smoking. The New York Times, November 5, 1973, p. 45. Francke, L. Smokers who seek help to quit have come a long way, maybe. The New York Times, October 10, 1973, p. 37. Jarvik, M. Biologicalinfluenceson cigarette smoking. In Smoking and Health, a Report of the Surgeon General, Bethesda, MD; USDHEW, U.S. Public Health Service, 1979.
348
MICHAEL J. PERTSCHUKet al.
Knapp, P. H., Bliss, C. M., & Wells, H. Addictive aspects in heavy cigarette smoking. American Journal of Psychiatry, 1963, 119, 966-972. Pomerleau, O. F., Adkins, D., & Pertschuk, M. J. Predictors of outcome and recidivism in smoking cessation treatment. Addictive Behaviors, 1978, 3, 65-70. Pomerleau, O. F., & Pomerleau, C. S. Break the Smoking Habit. Champaign, IL: Research Press, 1977. Schachter, S., Silverstein, B., Kozlowski, L., Perlick, D., Herman, P., & Liebling, B. Studies of the interaction of psychological and pharmacological determinants of smoking. Journal of Experimental Psychology, 1977, 106, 3-40. United States Department of Health, Education, and Welfare. Adult Use of Tobacco--1975. Atlanta, GA: Public Health Service, Center for Disease Control, 1975. Whitebook, B. Confessions of an ex-smoker. Harper's Magazine, 1976, 252, 94-97.
