Consistent with our prediction, smokers with a current diagnosis of a mood disorder, anxiety disorder, SUD, or AUD reported a greater number of tobacco withdrawal symptoms than smokers without a current diagnosis of the respective disorder. This finding is consistent with previous work reporting greater levels of nicotine withdrawal for smokers with psychiatric symptoms or a lifetime Axis I diagnosis (e.g., Breslau et al., 1992
; Covey et al., 1990
; Madden et al., 1997
; Marks et al., 1997
; Pomerleau et al., 2000
; Pomerleau et al., 2005
). Further, smokers with current mood disorders, anxiety disorders, and SUDs were more likely to report withdrawal-related discomfort and smoking relapse. High levels of tobacco withdrawal symptoms and discomfort may lead adults with current Axis I disorders to relapse in greater numbers and after shorter periods of smoking abstinence. A number of withdrawal symptoms (e.g., sleep and appetite changes, anxiety, depression) overlap with symptoms of Axis I disorders so it is unclear whether these smokers experience higher levels of withdrawal symptoms, attribute symptoms of Axis I disorders to smoking abstinence, or have less tolerance for symptoms consistent with their Axis I disorder.
Contrary to expectation, smokers with current AUDs reported a greater number of withdrawal symptoms but were not more likely to report withdrawal-related discomfort or relapse than smokers without a current AUD. Interestingly, studies of smokers in Germany found that some aspects of smoking withdrawal were associated with alcohol dependence while other aspects of withdrawal were not (John et al., 2003a
). Both alcohol and nicotine demonstrate a number of commonalities in terms of cross-tolerance (Balough et al., 2002
; Collins, 1990
; Funk et al., 2006
), brain systems (e.g., dopamine and GABA; Dani and Harris, 2005
; Funk et al., 2006
), and pain relief (Dani and Harris, 2005
). Based on cross-tolerance, it is possible that consuming alcohol may reduce tobacco withdrawal symptoms (e.g., cravings) or reduce the subjective discomfort from tobacco withdrawal symptoms. While nicotine deprivation increases alcohol consumption (McKee et al., 2008
), alcohol consumption is a risk factor for smoking
cessation failure (McKee et al., 2006
There were no differences in terms of tobacco withdrawal symptoms or withdrawal-related relapse comparing participants with a single substance use or psychiatric disorder and participants with both a psychiatric disorder and an AUD or SUD. These analyses suggest that while a current diagnosis of a mood disorder, anxiety disorder, SUD, and AUD is a risk factor for increased relapse to withdrawal symptoms, there is no significant interactive effect of having co-morbid disorders.
These findings suggest a number of clinical implications. Clinicians working with patients with current Axis I disorders who want to quit smoking may need to provide enhanced treatments that include pharmacotherapy to relieve withdrawal symptoms as well as behavioral treatments that focus on coping with tobacco withdrawal symptoms and relapse prevention skills to improve long-term success at smoking cessation. Clinicians may also need to work with patients to recognize, differentiate, and manage symptoms relating to withdrawal and Axis I disorders. Based on our results, clinicians should not expect patients with an AUD or SUD in addition to a mental health disorder to have more difficulty than patients experiencing a single mood disorder, anxiety disorder, SUD, or AUD. Finally, clinicians working with smokers in primary care settings should assess for mood disorders, anxiety disorders, SUDs, and AUDs to identify smokers who may have a more difficult time quitting and tailor treatments or make refers for additional services as needed.
Several limitations of the current study must be noted. While the AUDADIS has been shown to have adequate reliability and validity for the assessment of Axis I disorders and smoking behavior (Grant et al., 2003b
), the data relies on participant self-report and cross-sectional data. Biases exist in the retrospective recall of tobacco withdrawal symptoms and smokers might be biased to recall greater or more severe withdrawal symptoms as a way to explain previous failed attempts to quit (Hughes, 2007
). Past research has found gender differences in the retrospective recall of withdrawal symptoms (Pomerleau et al., 1994
) and it is possible that other groups of smokers (e.g., smokers with a current Axis I disorders) also have a bias to recall more severe withdrawal symptoms. This bias could increase differences between smokers with and without psychiatric disorder in the retrospective report of withdrawal-related discomfort and relapse. Future studies can examine whether recall bias differentially affects the report withdrawal symptoms by psychiatric status through prospective examinations of smokers with and without psychiatric disorder during smoking cessation attempts. Prospective studies would also allow the assessment of withdrawal-related discomfort, time to relapse, and reasons for relapse (e.g., due to withdrawal symptoms) for smokers with and without Axis I disorders. Second, because the NESARC study surveyed smokers in the United States, these results may not generalize to smokers from other countries. The majority of daily smokers (91%) in the NESARC database were under the age of 65; therefore, these results may also not generalize to older smokers whose rates of current disorders were too low (0.5–8.6%) to allow for subgroup analyses. Third, while the NESARC includes careful assessment of Axis I disorders and smoking behavior, the dataset is limited in other respects. For example, the database does not include an assessment of the severity of withdrawal symptoms, the number of quit attempts, duration of quit attempts, nor the types of pharmacological or behavioral smoking cessation treatments were utilized by participants over the previous year. Assessment of the number and length of quit attempts would provide more detailed information about the differences in the experience of withdrawal for smokers with and without Axis I disorders. In addition, examining the differences in the utilization and efficacy of smoking cessation treatments in relation to withdrawal symptoms and withdrawal-related relapse would be useful to determine how to best treat smokers who are likely to relapse due to withdrawal symptoms.
Smokers with current Axis I disorders may have a more difficult time quitting smoking due to a greater number of withdrawal symptoms and a greater experience of withdrawal-related discomfort. As a result, smokers with Axis I disorders would benefit from treatments that are more intensive and of longer duration. Intensive pharmacotherapy may aid participants by relieving withdrawal symptoms while behavioral therapies can teach smokers how to manage withdrawal symptoms and discomfort and how to deal with lapses. By emphasizing ways to manage withdrawal symptoms other than smoking or unhealthy coping strategies (e.g., using alcohol), programs may help to increase cessation success with this refractory group of smokers.