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I I Addictive Behaviors, Vol. 11, pp. 49-53, 1986 0306-4603/86 $3.00 t.00 Printed in the USA. All rights reserved. Copyright cl 1986 Pergamon Press Ltd I I I I I I BRIEF REPORT REACTIONS TO WITHDRAWAL SYMPTOMS AND SUCCESS IN SMOKING CESSATION CLINICS ROBERT C. GUNN Ann Arbor VA Medical Center Abstract-This study reports on 285 smokers in cessation clinics who answered self-report measures of withdrawal symptoms and craving after quitting cigarettes "cold turkey." Almost all the subjects reported discomfort after stopping, but no particular symptom pattern emerged. Women reporting intense withdrawal symptoms and craving were less likely to remain stopped by the clinic's end. Althougn men were generally heavier smokers and reported as many symp- toms as women, withdrawal distress was not related to their clinic outcomes. This sex dif- ference may be explained by cultural learning which teaches men to be stoic in bearing discom- fort and women to avoid small doses to pain. In the smoking literature the occurrence of a clear tobacco withdrawal syndrome is not ~ well documented. Reported smoking withdrawal symptoms in most studies are usually subjective descriptions of nonspecific internal states (e.g., "nervous", "grouchy") that are not easy to quantify objectively. Certainly smokers who give up smoking for even  brief periods of time show slight to moderate changes by physiological measurement (e.g., slight body temperature changes, possible blood pressure changes, and many microlevel system changes) (Myrsten, Elgerot, & Edgren, 1977). These changes, how- = ever, are rarely reported by subjects because they cause no discernible discomfort.  What subjects often do report after stopping smoking is a list of symptoms extending through many systems of the body, symptoms that cannot be easily related to objective physical changes. In fact, "there is no characteristic repeatable physiological abstinence ~ syndrome produced by the abrupt withdrawal of tobacco" (Chessick, 1964, p. 932). Surprisingly, a number of stoppers claim no symptoms at all, leading some writers to conclude that it is "generally considered that abstinence symptoms are mainly psychic" - (Larson, Haag, & Silvette, 1961). Schacter (1982), in an interview study of smokers who , quit on their own, notes that 29% of even heavy smokers reported "no problems" as did ' 88% of light smokers, who said they had "no withdrawal symptoms, no craving ..." (p. 439). ~ Based on this evidence, withdrawal symptoms are most likely complicated psycho- physiological reactions to giving up a highly valued substance, rather than clear-cut physical reactions to a drug depletion in the stopper's system. If true, this leads us to expect nb clear correlation between amount smoked before quitting and subjective suf- fering fering once stopped. Shiffman (1979) supports this view in his literature review, noting that both symptoms and cravings after stopping do not differ in heavy and light smok- ing groups, although he believes the issue not resolved. A notable finding by Guilford (1967) in her often quoted study of sex differences in successful and unsuccessful stopping smokers concludes that women experience more intense cravings than men after the first few days of quitting cigarettes. (The term crav- ing will be considered here as another subjective withdrawal symptom.) She also found ~ that such cravings in women predicted relapse. Other studies have generally not found 49

50 ROBERT C. GUNN I I I I I I I I I I I I I I I I I gender differences in either severity of withdrawal symptoms or successful outcomes (Gritz & Bierman, 1980). The present study addresses whether or not withdrawal symptoms during a cessation clinic int,-rfere with stopping and what factors, including sex differences, may influence developing withdrawal symptoms. METHOD Subjects Subjects were 285 smokers who enrolled in one of a number of American Cancer Society Freshstart smoking cessation clinics in southern Michigan. There were 173 females and 112 males in the sample. (Sample sizes vary in some analyses because of in- complete data.) Ages ranged from 19 to 74, with a mean age of nearly 30. Subjects represented a wide spectrum of socioeconomic and educational backgrounds. In the Freshstart program, which varied in length in these groups from four to eight sessions, smokers were asked to stop cold turkey at the second or third session. Measures Clinic participants took a brief demographic and history questionnaire at the outset of the clinic. Clinic success was measured by participants appearing at the last clinic session and reporting themselves no longer smoking for at least 2 days. Previous study has shown that participants dropping out of a clinic before the last session are failures who continue smoking (Gunn, 1983). Successful stoppers were contacted by telephone 3 months after the end of their clinic to answer a standardized interview about their progress. Interviewers were volunteers who had not participated in the clinics. During the clinics, subjects claiming that they had stopped smoking were given two self-report tests about their subjective withdrawal symptoms and craving experiences. The Symptom Check List (Gunn, 1973) contains 20 items covering complaints in many body systems (e.g., constipation, ear ringing, hunger) and affective reactions (e.g., sadness, anxiety). Subjects checked the presence or absence of each symptom and its intensity on a 4-point scale. These ratings resulted in a general symptom intensity score, created by summing ratings on all items, and a total symptoms score which only con- sidered number of symptoms present rather than intensity. The craving measure was the Impact of Event Scale (IES) (Zilberg, Weiss, & Horowitz, 1982). This scale purports to measure subject's experience of intrusions into their thoughts from some specific traumatic event they have undergone, in this case stopping smoking. Three scores are derived from the IES, based on the intensity ratings of its 15 items: an intrusion (I) score, an avoidance (A) score, and a combined A and I score. This test was administered to 105 of the subjects. Both the symptoms checklist and the IES were tested against outcome, sex, age, amount smoked before the clinic, and each other. RESULTS Symptom Check List general intensity scores appear strongly related to graduating as a stopper from the clinic (t = 2.62, p < .01, n = 268). Smokers checking either many symptoms or several intense withdrawal signs tended to be unable to stay stopped. This was true also when total number of symptoms checked was tested against clinic outcome (t = -2.25, p = .02, n = 268). Further analysis of these scores by sex showed that the relationship between low symptom reports and ability to stop smoking ~ O lob ~ ~ !Mb _W WX

I I I Smoking cessation clinics 51 I I I I I I I I I I I I I I I was significant only in women (t = -2.23, p = .02, n = 164; males: t=-1.42, n.s., n = 104). Neither intensity nor number of symptoms on the Check List was related to sex, sug- gesting that males were as bothered by withdrawal symptoms as females. For the 269 subjects, mean reported symptoms was 7.26 (SD = 3.85), modal symptom report was 7, and median symptoms checked, 6.5. Only 2% (N = 5) of these clinic participants claimed no symptoms. The most frequently reported symptoms were nervous (82.5%) and hungry (78.1%). Next in order were: sad (63.9%), tired (61.3%), confused (48.7%), sleep problems (47.2%), dizzy (43.5%), dry mouth (42.4%), headaches (35.5%), and shakiness (33.8%). The least reported symptom was throwing up (8.2%). No symptom was with- out sufferers. Subjects were encouraged to write in additional discomforts they be- lieved related to their stopping. The most common sign added was angry or irritable (7%). Other complaints were drawn from widely disparate body organ systems, e.g., tingling tongue, gas, tight throat, water retention, pain in lungs. Next, amount subjects smoked was analyzed. Males were clearly heavier smokers in this sample (Xz = 13.53, p < .01, n = 261). Amount smoked itself, however, did not predict stopping success for the group (X= = 7.38, n.s., n = 261) or for.either sex. For males, amount smoked was not significantly related to symptom intensity (X2 = 3.98, n.s., n = 103). For women, heavier smoking increased reports of more withdrawal symptoms (X2 = 14.38, p < .01, n = 158). If age is considered an index of number of years of smoking, older males reported significantly more withdrawal symptoms than younger males (X2 = 3.64, p < .05, n = 99), a finding not true for women. Older males tended to report more withdrawal signs than older females (40 and over) (Xz = 4.49, p < .05, n = 118). For men, how- ever, age was not related to ability to stop. From these results it appears that withdrawal symptoms are related to stopping in a different pattern for each sex. Although males tend to be heavier smokers, amount smoked was not related to reported withdrawal symptoms or stopping ability. Men smoking more years did report more symptoms-even more than older smoking women-but this did not affect their rate of stopping. Among females, heavier smok- ing older women were most bothered by withdrawal signs and had most trouble stop- ping, although time smoked itself did not predict this. Generally, clinic women report- ing intense withdrawal symptoms tended not to stop smoking. Results from the IES produced a similar pattern. High scores on the Intrusiveness scale (I) related to not being able to stop by the clinic's end (t = 1.97, p = .05, n = 104). This effect was pronounced in women (t =-2.10, p = .03, n = 64) and not significant for men. In fact, women's I scores predicted who would still be stopped 3 months after the clinic (t = -3.70, p < .01, n = 23), a result to be treated cautiously because of the small sample size. The Avoidance scale (A) failed to significantly relate to stopping ability, amount smoked, age of smoker, or sex, although it correlated modestly with the I scale (r = .32, n = 105). In summary, low I scores tended to predict women being stopped at the end of a clinic, and even remaining stopped 3 months later. This was not the case for men, whose I scores distributed themselves similarly to women's scores, but were not predic- tive of stopping. Higher I scores were more frequent in women who smoked heavily and had higher reported withdrawal symptom scores, a finding similar to Guilford (1967). I

52 ROBERT C. GUNN I I I I I I I I I I I I I I I I I I DISCUSSdQN Although all clinic participants when stopping smoking are equally prone to experi• encing physical withdrawal symptoms and cravings for cigarettes, a surprising result from this data is that it is women who are most likely to react to these discomforts by returning to smoking. Men, who are as successful-or unsuccessful-at giving up smoking as Romen in the clinics seem less affected by withdrawal symptoms or crav- ing, despite the fact that they are as a group heavier smokers. Once having given up cigarettes, withdrawal symptoms seem to have much to do with whether women will re- main stopped. while these symptoms have little to do with men's continued nonsmok- ing. That the participants in these clinics who stopped were suffering is readily apparent in the relatively high mean number of symptoms reported. In considering the Symptom Check List, any combination of seven items, even if experienced for a short time and only to a modest degree, can only be thought of as painful. Similarly, being besieged by obsessive desires to smoke, as reflected in subject's I scores, must be anguishing. One may speculate that women, as a group, are tending to give in to these trying experiences and relieving themselves of them by returning to smoking. Men, on the other hand, seem to be reacting stoically to their symptoms. This is not unexpected given cultural values that most people have been reared under, values teaching men to withstand pain and be "tough," while women are allowed squeamishness about physical discomfort. This study also lends support to thinking of withdrawal symptoms as complicated psychophysiological responses to being deprived of a highly valued substance and behavior. This is seen in the lack of any coherent symptom pattern among a fairly large group of stoppers and the prevalence of emotional symptoms (nervousness, sadness, confusion, etc.) in this sample's reports of discomfort. This was true even among those subjects who filled out the Check List and IES as "stoppers" only hours after last smok- ing. For many clinic participants, withdrawal symptoms began as soon as the last cigarette was extinguished, long before nicotine left the body. Of course for most people, withdrawal distress is seemingly of fairly short duration. Apparently if such discomfort lasts indefinitely, the chances of returning to smoking should increase. In this sample, high craving scores among women predicted,relapse when they were followed up at 3 months. Although they had all successfully finished the clinic as nonsmokers, we can only surmise that the continued bombardment of thoughts about cigarettes was partially responsible for their relapse. We really know very little about which smokers are prone to withdrawal symptoms or what factors pro- long such symptoms. One often hears of ex-smokers still occasionally craving or dreaming about cigarettes 20 years after stopping, but no longer physically experienc- ing discomfort. The ability to dismiss such thoughts from one's mind in either the short or long run is probably related to differing individual internal defensive coping styles. The finding that men endured withdrawal symptoms better than women does not im- ply that men were more successful at finishing clinics or remaining stopped some months later, since they were not. Obviously, other reasons than symptoms push many men to return to smoking. An earlier study (Gunn, 1983), suggested that undergoing several significant life changes at the time of beginning a clinic was predictive for men of not finishing the stopping process. Such life changes did not affect success in clinic women. Can it be that clinic men are obdurate to internal pain, but less well able to cope with external pressure, while clinic women manage external changes in their lives more easily, only submitting to internal uncomfortable states based on their cultural learning?

I I I I I I I I I I I I I I I I Smoking cessation clinics 53 REFERENCES Chessick, R. (1964). The problem of tobacco habituation. Journal of the American Medical Association, 188,932-933. Gritz, E.R., & Bierman, K.L. (1980). Smoking cessation in women. World Smoking and Health, (1967) 5, 18-23. Guilford, J.S. (1967). Sex differences between successful and unsuccessful abstainers from smoking. In S.V. Zagona (Ed.), Studies and issues in smoking behavior. Tucson: University of Arizona Press. Gunn, R.C. (1973). Hangovers and attitudes toward drinking. Quarterly Journal of Studies on Alcohol, 34, 194-198. Gunn, R.C. (1983). Smoking clinic failures and recent life stress. Addictive Behaviors, 8, 83-87. Larson, P.S., Haag, H.B., & Silvette, H. (1961). Tobacco: Experimental and clinical studies. Baltimore: Williams and Wilkins. Myrsten, A., Elgerot, A., & Edgren, B. (1977). Effects of abstinence from tobacco smoking on physiological and psychological arousal levels in habitual smokers. Psychosomatic Medicine, 39, 25-38. Schacter, S. (1982). Recidivism and self-cure of smoking and obesity. American Psychologist, 37, 436-444 Shiffman, S.M. (1979). The tobacco withdrawal syndrome. In N.A. Krasnegor (Ed.), Cigarette smoking as a dependence process (NIDA Research Monograph 23). Zilberg, N., Weiss, D., & Horowitz, M. (1982). Impact of event scale: A cross-validation study. Journal of Clinical and Consulting Psychology, 50, 407-414. '©'