Study shows unrelenting grip of nicotine withdrawal

EDITOR’S NOTE: Timothy Baker will present his research at a symposium June 5 at the annual meeting of the American Psychological Society in Denver.

For smokers trying to kick the habit, it’s an article of faith that the worst comes first, and persistence will help tame the beast of withdrawal.

Unfortunately, researchers are discovering that nicotine withdrawal symptoms can behave more like characters in a bad horror flick: Just when you think you’ve killed them, they’re back with a vengeance.

Researchers with the UW–Madison Center for Tobacco Research and Intervention (CTRI) have found surprising variation in the “withdrawal trajectory” — or the length and intensity of symptoms – across smokers attempting to quit. Their studies of hundreds of smokers in cessation programs have shown that many experience intense spikes of withdrawal symptoms months after their initial quit attempts.

Timothy Baker, UW–Madison psychology professor and CTRI scientist, said the work challenges assumptions about withdrawal being a gradually subsiding phenomenon. The study also helps explain more clearly why relapses occur weeks or months after quitting.

“Withdrawal may be a more complicated thing than we thought – and we may be wrong in looking at it as a unique syndrome,” Baker said.

Baker will present the research Saturday, June 5, at a symposium of the American Psychological Society (APS), which is holding its annual conference in Denver. He led a symposium on addiction motivation, exploring questions such as why people persist in using a drug even after it ceases to be pleasurable.

The “classic notion” of addiction, Baker said, is that the anguish of withdrawal makes the person go back to using. Yet there has been little evidence to support the connection between relapse and withdrawal, and no explanation for why many relapses occur months after first giving up a substance.

In the recent study in the Journal of Abnormal Psychology, Baker and CTRI co-investigators Thomas Piasecki and Michael Fiore examined withdrawal data from 800 subjects in two clinical trials of the nicotine patch. In both groups, they identified three common patterns, or clusters, of withdrawal response over a two-month period.

In one of those clusters, the withdrawal symptoms followed a predictable path of starting strong, then gradually declining. A second cluster reported a gradual increase in withdrawal severity over 60 days. A third cluster experienced a small improvement over two weeks, but then their symptoms leveled off and persisted.

Baker said the two “atypical” clusters experienced higher relapse rates than the first group. “Smokers who showed increasing or prolonged withdrawal had double or triple the risk of relapse as other patients,” he said.

The study also found that the “atypical” patterns are actually quite common. In the first study, 39 percent of subjects fell into the second or third clusters; in the second study, the number was 68 percent.

Common withdrawal symptoms measured by the study included irritability, depression, difficulty concentrating, disturbed sleep and hunger. The subjects self-reported these symptoms over the course of the study.

The findings could be important in finding the right cessation program for smokers, Baker said. They suggest that, for many smokers, the duration or pattern of withdrawal symptoms is more difficult to overcome than the initial intensity of withdrawal.

The study also points to the affective or emotional nature of withdrawal. Symptoms related to emotion and mood are the ones most in need of relief. Baker said effective smoking cessation treatments all tend to alleviate negative moods, and it may be a key to why antidepressants such as Zyban are so effective.

Withdrawal symptoms may also become harder to differentiate from other stresses in life, Baker said. Rather than looking at withdrawal as a unique physical response, Baker said withdrawal shares much in common with other emotional reactions such as mourning the loss of a loved one.

“There is tremendous variation in the intensity and persistence of mourning,” he said. “Just as a person may suffer from a social loss for many months, the ex-smoker may suffer persistent bouts of mourning over the loss of smoking.”

Smoking cessation efforts are consistently improving. Treatments such as the nicotine patch and Zyban can double or triple the likelihood that a person will eventually kick the habit. But even with help, Baker said, the majority of smokers in any treatment program will still relapse.