Tobacco Withdrawal Symptoms Before and After Nicotine Deprivation in Veteran Smokers with Posttraumatic Stress Disorder and with Major Depressive Disorder

Introduction The high smoking prevalence amongst individuals with psychiatric disorders constitutes a major public health disparity. Negative reinforcement models of addiction posit that severe tobacco withdrawal symptoms, related to the affective vulnerabilities of these smokers, may thwart their quitting smoking successfully. However, relatively few studies have prospectively examined the effects of nicotine deprivation on withdrawal symptoms in these groups. Methods This study compared the level of withdrawal symptoms both before and after nicotine deprivation in those diagnosed with posttraumatic stress disorder (PTSD) or major depressive disorder (MDD) and in those without psychiatric diagnoses. Participants were US veterans who smoked (≥10 cigarettes/day) and met diagnostic criteria for PTSD (n = 38), MDD (n = 43), or no psychiatric diagnosis (“controls” n = 44). Participants attended study visits before and during 48-hour nicotine deprivation to report tobacco withdrawal symptoms. Analyses evaluated withdrawal symptom levels (baseline and during nicotine deprivation) and the change in symptoms related to nicotine deprivation and compared (1) participants with a psychiatric diagnosis versus controls, and (2) participants with PTSD versus MDD. Results Contrary to hypotheses, nicotine deprivation produced greater increases in most withdrawal symptoms amongst controls than in those with psychiatric diagnoses. Compared with controls, those with PTSD or MDD reported elevated symptom levels both before and after tobacco deprivation for most withdrawal symptoms. Conclusions These findings suggest that chronically high levels of distress and craving, rather than acute increases in withdrawal symptoms because of nicotine deprivation, may account for the quitting difficulties of those with comorbid conditions such as PTSD and MDD. Implications Severe tobacco withdrawal may account for the higher quitting difficulties of smokers with either posttraumatic stress disorder (PTSD) or major depressive disorder (MDD). Paradoxically, this study showed that individuals with no psychiatric diagnosis had greater increases in tobacco withdrawal severity because of nicotine deprivation than did those with either PTSD or MDD. Those with either PTSD or MDD showed high stable levels of withdrawal symptom severity both before and during two days of abstinence, suggesting that their quitting difficulties may be related to their chronically high levels of distress rather than nicotine deprivation per se.

Smoking, Implicit Attitudes, and Context-Sensitivity

This chapter focuses on implicit attitudes toward smoking and provides the first systematic review of research in this domain. Implicit attitudes are suggested to guide automatic behavior, thereby playing a pivotal role for automatic processes inherent in addictive behaviors. This chapter further explores the extent to which implicit attitudes are context-sensitive. More specifically, it reviews studies that have focused on the differential effects of external cues such as warning labels and internal cues (e.g., deprivation). Results of 32 studies show that although smokers generally have more positive implicit attitudes than non-smokers, the valence of implicit attitudes varies as a result of the applied method or stimuli. Studies reveal that implicit attitudes toward smoking partly depend on external cues, especially outcome expectancies. Similarly, internal cues affect implicit attitudes whereby the level of nicotine deprivation seems vital. Implications for intervention and future research are indicated in the discussion.

Possible New Symptoms of Tobacco Withdrawal II: Anhedonia—A Systematic Review

Introduction When animals undergo nicotine deprivation, rewards become less rewarding (ie, anhedonia occurs). We searched for tests of whether anhedonia occurs in abstinent smokers. Methods The major inclusion criterion was a within-participants comparison of behavioral measures of reward sensitivity or self-reported anhedonia during smoking versus during abstinence among daily smokers. A computerized search of PubMed, PsychInfo, and Cochrane databases and other methods located 13 studies. All but one were laboratory studies. Results The number of studies and participants were small and the results mixed. In terms of anticipatory anhedonia (ie, wanting a reward), abstinence appeared to decrease willingness to work for immediately available rewards, but did not appear to influence how much adding rewards to a task increased responding. Abstinence also appeared to produce small increases in self-reported anticipatory anhedonia. In terms of consummatory anhedonia (ie, liking a reward), self-report measures found anhedonia decreased pleasure from rewards in some but not all tests. In terms of learning (ie, learning to choose a more frequent reward), abstinence did not reliably decrease allocating responding to high versus low frequency reward options. Conclusions Although results were mixed, abstinence appears to increase anticipatory anhedonia. It is unclear if abstinence increases consummatory or reward learning-based anhedonia. Further studies of anhedonia in clinical settings are needed (1) to estimate the reliability and clinical significance of anhedonia as a symptom of tobacco withdrawal, (2) to assess if effects represent withdrawal versus offset processes, and (3) to assess if anhedonia interferes with the ability to stop smoking. Implications Anticipatory anhedonia appears to be a symptom of tobacco withdrawal and should be added to tobacco withdrawal checklists and diagnostic criteria. Further study of consummatory and learning-based anhedonia is warranted.

Acute effects of inhaled menthol on the rewarding effects of intravenous nicotine in smokers

Objective: This double-blind, placebo controlled study examined whether menthol inhaled from an electronic cigarette (e-cigarette) would change subjective and withdrawal alleviating effects of intravenous nicotine in young adult smokers. Methods: A total of 32 menthol-preferring smokers and 25 non-menthol-preferring smokers participated in the study that consisted of a random sequence of three different inhaled menthol conditions (0.0%, 0.5%, and 3.2%) across three test sessions (a single menthol condition per session). In each test session (performed at least 24 hours apart), a random order of saline, and two different nicotine infusions of 0.25 mg and 0.5 mg/70 kg of bodyweight were administered, one hour apart, concurrent with menthol inhalation. Results: While menthol did not alter the positive subjective effects of nicotine, menthol significantly enhanced aversive effects of nicotine in non-menthol-preferring smokers and reduced smoking urges in menthol-preferring smokers. In addition, menthol-preferring smokers reported blunted positive subjective responses to nicotine and less severe nicotine withdrawal after overnight nicotine deprivation. Finally, compared to non-menthol-preferring smokers, menthol-preferring smokers had a significantly lower baseline nicotine metabolite ratio indicating slower nicotine metabolism within our sample of menthol-preferring smokers. Conclusions: Our findings did not support an enhancement of nicotine’s positive subjective effects from inhaled menthol. However, as compared to non-menthol-preferring smokers, menthol-preferring smokers had blunted positive subjective responses to nicotine and reduced overnight withdrawal severity that may be partly due to inhibition of nicotine metabolism from chronic exposure to inhaled menthol. Collectively, these results reveal a more complex and nuanced role of inhaled menthol in smokers than previously recognized.