Anger and psychobiological changes during smoking abstinence and in response to acute stress: Prediction of smoking relapse

Abstract

Nicotine may be used to manage negative emotions, and recent research suggests that smokers with high levels of hostility may use cigarettes to cope with anger provoking situations. This study evaluated the extent to which a high level of trait anger is associated with risk for relapse among smokers interested in cessation. Chronic smokers with different levels of trait anger provided reports of withdrawal symptoms, craving, and state anger, and collected saliva samples for cortisol during 24-hour ad libitum smoking and the first 24-hour abstinence period of a quit attempt. They also attended a laboratory session conducted after the 24-hour abstinence during which they performed brief mental and social stress challenges and provided blood samples for adrenocorticotropin (ACTH) and cortisol assays. High trait anger was associated with greater increases in state anger, withdrawal symptoms, and craving during the first 24 h of abstinence. It was also associated with greater ACTH concentrations during the laboratory session. High trait anger was also associated with increased risk for early relapse. The findings support the hypothesis that smokers high in anger trait may have greater mood difficulties during abstinence and may be more vulnerable to early relapse than smokers with low anger trait.

Introduction

We examined the extent to which trait anger predicts intensity of craving, withdrawal symptoms, and neuroendocrine changes during the first day of a quit attempt. One of the important reinforcing qualities of smoking is its effects in managing negative affect (Gilbert, 1995, Kassel et al., 2003) and studies have demonstrated that nicotine reduces reports of anger (Jamner et al., 1999). Also, smokers who experience anger situations are likely to increase their smoking behaviors (Jamner et al., 1999, Kalman, 2002, Kenford et al., 2002). However, the extent to which negative affect influences smoking behavior is highly variable between individuals and is influenced by various situational factors (Gilbert, 1995, Abrams et al., 1988, Gilbert et al., 2002, Hughes et al., 1991).

High levels of trait anger may contribute to maladaptive behavioral responses, including a greater likelihood of seeking out substances such as nicotine and alcohol (Whalen et al., 2001, Brady and Sonne, 1999). It is therefore possible that smokers who are high in trait anger draw enhanced benefits from smoking, and may consequently experience more difficulties during abstinence. Consistent with this hypothesis, one study assessed ambulatory anger reports in both smokers and non-smokers who were classified as high or low in hostility (Jamner et al., 1999). Results of that study showed that nicotine administration was associated with reports of reduced anger in people who were high in hostility. Another study showed that response to provocation was reduced in smokers after use of nicotine compared with placebo gum (Cherek et al., 1991). On the other hand, it has been shown that trait hostility predicts higher cigarette smoking rates (Barefoot et al., 1987, Whiteman et al., 1997, Siegler et al., 1992). Also, smokers as a group have been characterized as being higher in neurotic traits, including anger (Gilbert and Gilbert, 1995), and children who are high in anger are prone to take up smoking as college students and be still smoking 20 years later (Lipkus et al., 1994). Considered together, these studies suggest that high levels of anger are likely to contribute to increased tobacco use, and situational factors may accentuate anger-related traits in increasing risk for tobacco use or relapse.

Abstinence from smoking is associated with increased negative affect, including anger and irritability, that begins within 4 to 24 h of abstinence (al'Absi et al., 2002, Piasecki et al., 1998, Swan et al., 1996, Gulliver et al., 1995). The intensity of these symptoms peaks within the first three days (Ward et al., 2001) and may not resolve even after 30 days of abstinence (Gilbert et al., 2002). It is possible that these mood alterations are particularly pronounced among smokers who are high in trait anger. As such, these smokers may also have greater difficulties in their attempt to quit and may relapse earlier than smokers low in anger and hostility. Studies have also shown that enhanced experience of anger is associated with increased physiological responses to acute stress (Bongard et al., 1997, Engebretson et al., 1989). In laboratory studies, effects of anger seem to be more consistently present when provocation of anger is applied (Everson et al., 1995, Engebretson et al., 1989, Larson and Langer, 1997). While the present study does not include a specific anger provocation procedure, it focuses on nicotine withdrawal among smokers, a phenomenon known to increase irritability and anger (Hughes et al., 1991). This natural manipulation may be more relevant to the experience of these individuals than circumscribed laboratory provocation. The study includes multiple measures of mood and hormonal activation to carefully examine these changes during the initial stage of a smoking cessation attempt and their relevance to the risk for relapse.

Smoking relapse rates remain disturbingly high, with approximately 50% of smokers relapsing within 3 days and 75% within the first 2 weeks (Garvey et al., 1992, Law and Tang, 1995, Rose, 1996). Studies have shown that personality traits (e.g., related to depression and anxiety) may also predict risk for smoking relapse (Hall et al., 1993, Hughes et al., 1991, Killen and Fortmann, 1997). Research also suggests that subjects who relapse within the first week of a quit attempt experience greater negative affect than those who successfully abstain (al'Absi et al., 2004). It is therefore possible that individuals prone to increased anger during abstinence are most susceptible to early relapse. Supporting this possibility, a recent study has shown an association between increased trait hostility and risk of early relapse (Kahler et al., 2004). This increased risk of relapse may be related to increased proneness to experience situational irritants, leading to increase in their craving for cigarettes.

The present study addresses the extent to which trait anger is associated with deterioration in mood and hormonal changes during the first day of abstinence and with increased risk of early relapse. Data reported here are part of a larger longitudinal project conducted to examine psychophysiological and biological stress responses, and withdrawal symptoms as markers of relapse (al'Absi et al., 2005).