relapse back to smoking: the core role of the tobacco withdrawal syndrome with thomas piasecki...
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Relapse Back to Smoking: The Core Role of the Tobacco Withdrawal Syndrome
WITHTHOMAS PIASECKI
MICHAEL FIORE
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SMOKING IS BAD ABOUT 24% OF ADULT AMERICANS
SMOKE A LEADING PREVENTABLE CAUSE
OF MORTALITY & MORBIDITY ACCOUNTS FOR 430,000+
DEATHS/YEAR IN THE US ALONE ON AVERAGE SMOKERS LOSE 14
YEARS OF LIFE
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RELAPSE: GORDIAN KNOT SMOKERS ARE MOTIVATED TO
QUIT ABOUT HALF OF SMOKERS TRY TO
QUIT EACH YEAR ONLY ABOUT 5% ARE SUCCESSFUL MOST WHO BECOME ABSTINENT,
EVENTUALLY RELAPSE
WHAT CAUSES OR LEADS UP TO RELAPSE BACK TO SMOKING?
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TRADITIONAL ACCOUNT WITHDRAWAL SYMPTOMS
ABSTINENCE FROM TOBACCO CAUSES STRONG INCREASES IN WITHDRAWAL SYMPTOMS
DEPRESSION, ANXIETY, IRRITABILITY, URGES, INABILITY TO CONCENTRATE
THE SMOKER IS MOTIVATED TO USE TOBACCO TO MEDICATE THESE SYMPTOMS
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BUT, ACCORDING TO SOME RESEARCH …
HOWEVER, MUCH RESEARCH OVER THE PAST 20 YEARS CASTS DOUBT ON A WITHDRAWAL ACCOUNT
“IT IS CONCLUDED THAT THE RESEARCH TO DATE DOES NOT APPEAR TO STRONGLY IMPLICATE NICOTINE WITHDRAWAL IN ADVERSELY AFFECTING SMOKING CESSATION OR MAINTENANCE OF ABSTINENCE.” (PATTON & MARTIN, 1996)
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BUT, SMOKERS TELL US…1. “IT HAS BEEN 2 MONTHS SINCE I QUIT AND THE
URGES ARE WORSE THAN EVER”
2. “QUITTING SMOKING HAS CHANGED MY PERSONALITY…I AM ALWAYS CRABBY AND HAVE BEEN EVER SINCE I QUIT.”
3. “MY WITHDRAWAL WENT AWAY AFTER 3 WEEKS, AND NOW IT IS BACK.”
FOR YEARS WE TOLD THE SMOKER THAT THESE REPORTS CANNOT BE CORRECT SINCE WITHDRAWAL GOES AWAY IN TWO-THREE WEEKS!
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0 10 20 30 40 50 60
-3
-2
-1
-0
1
2
3
4
5Z-
SCO
RE
DAY
Withdrawal Heterogeneity: SMOKERS ARE RIGHT!
• In -- acute drug removal.
• At the level of the individual, idiosyncracies may be observed
• Which day do you pick for measuring withdrawal?
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IMPOSING SIMPLE MEASUREMENT MODELS ON A COMPLEX PHENOMENON
SIMPLISTIC MEASUREMENT IS AT HEART OF SCIENCE’S FAILURE
WITHDRAWAL HAS BEEN ASSUMED TO BE A STEREOTYPIC PHYSIOLOGIC REACTION TO ABSTINENCE THAT PRODUCES A PROTOTYPIC SYMPTOM WAVEFORM ACROSS TIME
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MEASUREMENT STRATEGY 55 DAYS OF DAILY POST-
CESSATION WITHDRAWAL RATINGS SUBMITTED TO DYNAMIC CLUSTER ANALYSES
CLUSTERED DISTINCT GROUPS OF INDIVIDUALS WHOSE PATTERNS OF SYMPTOMS WERE SIMILAR OVER TIME
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0 10 20 30 40 50 60
0.5
0.7
0.9
1.1
1.3
1.5
1.7
1.9
WIT
HD
RA
WA
L S
EV
ER
ITY
Cluster I (N=71)Cluster II ( N=31)Cluster III (N=122)
DAY
From: Piasecki, Fiore & Baker, 1998; Study 2
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RESULTS ATYPICAL PATTERN ASSOCIATED
WITH 2-4 TIMES HIGHER RISK OF RELAPSE NO OTHER VARIABLE PREDICTS
RELAPSE AS WELL WOMEN & PREVIOUSLY DEPRESSED
MORE LIKELY TO HAVE SUSTAINED OR WORSENING WITHDRAWAL
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ADDITIONAL MEASUREMENT MODEL
PROFILES CAN ALSO BE CAPTURED BY 3 COMPONENTS YIELDED BY GROWTH CURVE MODELING elevation over time shape/trajectory volatility/scatter
WRINGING INFORMATION FROM PROFILES
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0 10 20 30 40 50DAY
0
2
4
6
8
10
12
14
0
2
4
6
8
10
12
14W
ITH
DR
AW
AL
SE
VE
RIT
Y
PARTICIPANT 1001 RAW SYMPTOM REPORTSMOKING-COVARIED PREDICTED FUNCTION SMOKING RECORD
15.77-2.40
7.690.12
NU
MB
ER
OF
CIG
AR
ET
TE
S S
MO
KE
D
GROWTH PARAMETERS
INTERCEPT:
LINEAR SLOPE:
QUADRATIC:
VOLATILITY:
CIGARETTE:
6.54
0 10 20 30 40 50
DAY
0
5
10
15
20
25
0
5
10
15
20
25
WIT
HD
RA
WA
L S
EV
ER
ITY
PARTICIPANT 1004 RAW SYMPTOM REPORTSMOKING-COVARIED PREDICTED FUNCTIONSMOKING RECORD
-10.68
10.91
11.140.32
NU
MB
ER
OF
CIG
AR
ET
TE
S S
MO
KE
D
GROWTH PARAMETERS
INTERCEPT:
LINEAR SLOPE:
QUADRATIC:
VOLATILITY:
CIGARETTE:
7.20
0 10 20 30 40 50DAY
0
5
10
15
20
25
0
5
10
15
20
25
WIT
HD
RA
WA
L S
EV
ER
ITY
PARTICIPANT 1003 RAW SYMPTOM REPORTSMOKING-COVARIED PREDICTED FUNCTIONSMOKING RECORD
-19.63
20.66
9.74
0.96
NU
MB
ER
OF
CIG
AR
ET
TE
S S
MO
KE
D
GROWTH PARAMETERS
INTERCEPT:
LINEAR SLOPE:
QUADRATIC:
VOLATILITY:
CIGARETTE:
5.98
0 10 20 30 40 50DAY
0
2
4
6
8
10
12
14
16
0
2
4
6
8
10
12
14
16
WIT
HD
RA
WA
L S
EV
ER
ITY
PARTICIPANT 1010 RAW SYMPTOM REPORTSMOKING-COVARIED PREDICTED FUNCTIONSMOKING RECORD
-4.11
11.81
3.94-0.17
WIT
HD
RA
WA
L S
EV
ER
ITY
NU
MB
ER
OF
CIG
AR
ET
TE
S S
MO
KE
D
GROWTH PARAMETERS
INTERCEPT:
LINEAR SLOPE:
QUADRATIC:
VOLATILITY:
CIGARETTE:
7.92
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Individual Projected WD Curves
1.00
1.20
1.40
1.60
1.80
2.00
2.20
2.40
2.60
2.80
3.00
-4 -3 -2 -1 0 1 2 3 4
Time from Quit Date (weeks)
83
59
77
30
17
3
Es
tim
ate
d W
D S
core
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WHAT DOES GROWTH CURVE MODELING TELLS US? WITHDRAWAL DRAMATICALLY INCREASES ALL 3
DIMENSIONS OF WITHDRAWAL SYMPTOMS, E.G., 2-3 TIMES THE EMOTIONAL VOLATILITY VS.
PRE-CESSATION (WOMEN & PREVIOUSLY DEPRESSED)
ALL 3 DIMENSIONS ARE HIGHLY PREDICTIVE OF RELAPSE
SMOKERS SHOULD NOT BE TOLD THAT WITHDRAWAL WILL GET BETTER IN 2 WEEKS!
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IMPLICATIONS & GOALS WE ARE TRACKING WITHDRAWAL &
INTERVENING BEFORE RELAPSE: JUST IN TIME TREATMENT
IDENTIFYING SPECIFIC GENES THAT ASSOCIATED WITH WITHDRAWAL DIMENSIONS
DEVELOPING INTERVENTIONS DESIGNED TO ADDRESS ALL 3 COMPONENTS OF WITHDRAWAL