Addictive Behaviors, Vol. 25, No. 5, pp. 653–662, 2000 Copyright © 2000 Elsevier Science Ltd. Printed in the USA. All rights reserved 0306-4603/00/$–see front matter

Pergamon

PII S0306-4603(00)00067-8

RELATIONSHIPS BETWEEN SENSATION SEEKING AND EMOTIONAL SYMPTOMATOLOGY DURING SMOKING CESSATION WITH NICOTINE PATCH THERAPY S. CARTON,*† J. LE HOUEZEC,* G. LAGRUE,†† and R. JOUVENT* *Hôpital de la Salpêtrière; †Université René Descartes; and ††Hôpital Henri Mondor

Abstract — This study explored relationships between the sensation-seeking trait and the development of emotional symptomatology during smoking cessation with nicotine transdermal patches. Twenty-five subjects were evaluated before they stopped smoking, on Day 8, Day 30, Day 90, and Day 120. Initial motives for smoking and the sensation-seeking personality trait were tested as possible predictors for the development of specific mood disturbances. Our subjects scored very high on sensation seeking, consistent with previous results on smokers. This may also be due to the well-known tendency of high sensation-seekers to be willing to try new experiences. The sensation-seeking trait did not predict the issue of cessation. However, it was related to emotional deficit (anhedonia, affective blunting), tiredness, and a lack of energy, before and during smoking cessation. Two different interpretations of emotional deficit are proposed. © 2000 Elsevier Science Ltd.

Key Words. Smoking cessation, Sensation seeking, Emotions.

Various social, familial, and individual risk factors may predispose the individual to nicotine dependence. Of these, personality factors making individuals susceptible to the rewarding properties of nicotine may play a crucial role. There is strong evidence that vulnerability to nicotine dependence is a function of a high initial sensitivity to nicotine, which produces reinforcing consequences that lead to chronic use (Pomerleau, 1995; Pomerleau, Collins, Shiffman, & Pomerleau, 1993). These strong reinforcers of tobacco dependence include regulation of mood and improvement of cognitive function. They can be controlled by smokers probably because they directly modulate nicotine availability to the dopaminergic and cholinergic systems (e.g., Clarke, 1991; Levin, 1992; Vezina, Hervé, Glowinski, & Tassin, 1991). Personality factors related to this sensitivity may then have a major effect determining who starts, continues, and quits smoking. Two of the most explored personality factors are sensation seeking and extraversion traits. Their relationships to alcohol, tobacco, and illegal drug use may be due to their biological and psychophysiological determinants: low monoamine oxidase (MAO) and overreactive dopaminergic systems in Zuckerman’s theory (1994, 1995); cortical arousal in Eysenck’s theory (1967, 1980). The general hypothesis is that sensation seekers are chronically underaroused and seek stimulation to activate these systems. In our previous studies, we have suggested that high sensation seekers are particularly sensitive to the stimulant properties of nicotine, and are thus particularly likely to become dependent smokers. These properties may be especially reinforcing for high sensation seekers who are also vulnerable to depression (Carton, Jouvent, & Widlöcher, 1994a, 1994b). We have shown that the search for stimulations, especially through psychoactive substances, may be used to counterbalance depressive tendenThis study was supported by a grant from CNAMTS-INSERM (a government institution). Transdermal patch systems were provided by CIBA-GEIGY, France. Requests for reprints should be sent to S. Carton, PhD, CNRS-UMR 7593, Hôpital de la Salpêtrière, Pavillon Clérambault, 47, bd de l’Hôpital, 75013 Paris, France. 653

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cies, and particularly emotional deficits such as anhedonia and affective blunting (Carton, Jouvent, Bungener, & Widlöcher, 1992). Studies exploring sensation seeking have clearly shown that it is strongly related to smoking behavior. Longitudinal studies using the Minnesota Multiphasic Personality Inventory (MMPI) scales have shown that smoking initiation is associated with impulsiveness, sensation seeking, hostility, and rebellion (Barefoot, Smith, Dahlstrom, & Williams, 1989; Lipkus, Barefoot, Williams, & Siegler, 1994). Lipkus’ consistent longitudinal study showed that sensation seeking assessed in men and women at college was predictive of the onset and maintenance of smoking 20 years later in both sexes. These findings did not depend on sex, suggesting that these personality variables had the same influence on smoking initiation and cessation in both men and women. In early studies focusing on sensation seeking, a positive correlation with smoking was reported for men only (Zuckerman, Bone, Neary, Mangelsdorff, & Brustman, 1972; von Knorring & Oreland, 1985). Subsequent studies showed an association for both sexes (Kohn & Coulas, 1985; Thieme & Feij, 1986). The first comparison study by Zuckerman and Neeb (1980) showed that women who smoked moderately or even only occasionally, scored higher on sensation seeking than nonsmoking women. An effect for men, but not for women, was found by Golding, Harpur, and Brent-Smith (1983). In 1990, Zuckerman, Ball, and Black (1990) found a relationship between sensation seeking and smoking status in both sexes. Similar results were reported in France, smokers of both sexes scoring higher on sensation seeking than their nonsmoking counterparts (Carton et al., 1994a). Thus, there is considerable evidence that the sensation-seeking trait constitutes a risk factor for the development of smoking dependence and possibly for relapse during attempts to quit. It is clear that smoking abstinence impairs mood and cognitive performance, and that this impairment is a relapse factor in attempts to stop smoking (American Psychiatric Association, 1994; U.S. Department of Health and Human Services, 1988). This article presents results that form part of a large study designed to assess relationships between a history of depression, sensation seeking, and the development of psychopathological and cognitive deficits during smoking cessation using standard nicotine replacement therapy. Preliminary results on cognitive impairment assessed using event-related potentials have been presented elsewhere (Le Houezec, Carton, & Jouvent, 1996). No difference was found in the level of sensation seeking between subjects with and without a history of depression. This article therefore focuses independently on the results concerning sensation seeking. The purpose of this study was to analyze relationships between impairment of mood and the sensation-seeking trait during attempts to stop smoking using standard nicotine replacement therapy. We hypothesized that this trait would be related to the occurence of specific emotional troubles during cessation: anhedonia, affective blunting, and lack of activation. We also investigated the previous motives for smoking, as predictors for the development of specific emotional troubles. We tested whether there was a relationship between stimulant smoking and the development of affective blunting, and between sedative smoking and the development of anxious symptomatology. M E T H O D

Subjects The sample consisted of 25 smokers: 13 women (mean age 34, SD 5.2) and 12 men (mean age 33,4, SD 6,4) covering a large socioprofessional status spectrum. They were

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enrolled over 120 days in an open trial with nicotine substitution therapy using transdermal nicotine patches: 21 mg/day for 8 weeks, followed by a period in which the dose was adjusted according to subject (21 mg/day, 14 mg/day, or 7 mg/day).

Procedure Subjects were recruited via consultations about smoking cessation at Henri Mondor Hospital in Paris (France). They first attended an information session, at which general information was provided about smoking and nicotine dependence. At the end of the session, the research was described and it was announced that transdermal patches would be offered to subjects volunteering to take part in the study. Patches were provided by Ciba-Geigy, France. Subjects were screened and only those with scores on the Fagerström Tolerance Questionnaire of least 7, that is, those who were highly dependent on nicotine, were included. Subjects with a history of alcoholism, drug dependence, or psychiatric illness other than depression were excluded. The subjects selected filled in the consent form and decided the date on which they would stop smoking. Each subject came to the research unit at the Salpêtrière Hospital (Paris) a few days before stopping smoking for the first evaluation (D0). An extensive psychiatric interview was conducted in the afternoon by an experienced clinician, to evaluate possible symptomatology, its intensity and form. Patients were then asked to complete questionnaires. Subjects were reassessed three times during the substitution treatment (D8, D30, D90), and at the end of treatment (D120). The procedure was identical to that on Day 0 (except that subjects did not fill in the sensation seeking and smoking questionnaires a second time). Abstinence at each assessment point was validated by alveolar carbon monoxide measurement. Subjects were also followed clinically by medical consultations at Henri Mondor Hospital, for adjustment of the nicotine dose. Multiple scales widely used for clinical evaluation were used: • Intensity of depressive symptomatology was measured with the Hamilton Depressive Rating Scale (HDRS)—17-item version (Hamilton, 1967). • Two scales were used to assess anxiety: the Covi Anxiety Brief Scale (Lipman, 1982), and a more detailed scale, the Tyrer Anxiety Scale (Tyrer, Owen, & Cicchetti, 1984). • To differentiate multiple emotional disturbances, we used the Jouvent Depressive Mood Scale (Jouvent, Vindreau, Montreuil, Bungener, & Widlöcher, 1988; LyonCaen, Jouvent, & Hauser, 1986): This includes 20 items filled in by the clinician using a 5-point rating scale. It has been demonstrated to be very reliable for all 20 items, and has a coherent factorial structure with 5 clearcut and clinically relevant components. These components include Anhedonia, Sadness, (Observed) Irritability, (Felt) Hypersensitivity, Hyperesthesia, and Hypo/Hyper-Expressiveness. • The multiple facets of emotional blunting, including anhedonia, the inability to experience pleasure, were explored with one heteroevaluation scale and one selfquestionnaire: 1. The Abrams-Taylor Scale for Emotional Blunting (Abrams & Taylor, 1978), which was originally constructed to assess affective blunting in schizophrenia and includes 3 subscores: lack of pleasure seeking behavior, affective blunting, and cognitive blunting.

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2. The questionnaire used Chapman’s Physical Anhedonia Scale (Chapman, Chapman, & Raulin, 1976; Chapman & Chapman, 1978; French translation and validation, Loas, Salinas, Guelfi, & Lajeunesse, 1992), focused on a specific aspect of anhedonia. Subjects were also asked to complete other questionnaires: • The French version of the Sensation Seeking Scale. Zuckerman’s Form IV Scale was translated into French and validated (Carton, Lacour, Jouvent, & Widlöcher, 1990). This version was constructed on the basis of a principal components analysis (Carton, Jouvent, & Widlöcher, 1992) and closely resembles the Sensation Seeking Scale-Form V (Zuckerman, Eysenck, & Eysenck, 1978). It includes 4 subscales: Disinhibition (DIS), Thrill and Adventure Seeking (TAS), Experience Seeking (ES), and Boredom Susceptibility (BS). • A subjective activation autoevaluation scale, the Thayer Activation-Deactivation Adjective Check List (AD ACL short form; Thayer, 1989). This consists of 20 selfdescriptive adjectives, leading to 4 subscores: Energy, Tiredness, Tension, and Calmness. Energy and Tension factors are indicators of energetic and tense arousal, whereas Tiredness and Calmness factors indicate low arousal states in both dimensions. Smoking variables: • The Fagerström Tolerance Questionnaire (FTQ; Fagerström, 1978) translated into French and used as an index of nicotine dependence. • The Classification of Smoking by Motives (CSM; Russell, Peto, & Patel, 1974), which identifies seen “types” of smoking which are factors that motivate people to smoke (Stimulant, Indulgent, Psychosocial, Sensorimotor, Addictive, Automatic, and Sedative). The 34 items of the scale are translated into French, and a 5-point frequency scale is used; the original factor structure emerged from a principal component analysis. Statistical analysis Men and women were compared to smoker and nonsmoker control groups from the general population for each subscale of sensation seeking by ANOVA. Like the quitters, control groups were primarily upper-middle-class and consisted of active professionals and students. Age was included as a covariate in all analyses because sensation seeking decreases with age. Sex was also introduced as a covariate in analyses because there are differences between the sexes in sensation seeking. The value of sensation seeking and motives for smoking for predicting clinical symptomatology at each assessment was tested by logistic regressions, with p values ⬍ .05 considered significant.

R E S U L T S

Smoking variables Mean FTQ was 8.2 (SD ⫽ 0.8), with a mean self-reported daily smoking rate of 31.7 cigarettes (SD ⫽ 8.2). The subjects had smoked for a mean of 17.2 years (SD ⫽ 6.7), with a mean of 1.83 lifetime quit attempts (SD ⫽ 1.6). Mean age at the time of the first cigarette was 14.5 (SD ⫽ 2.6).

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Outcome of attempt to quit Ten of the 25 subjects had maintained abstinence by Day 120; 15 had relapsed. No subjects relapsed during the first week of abstinence. Five subjects relapsed between Day 8 and Day 30, 7 subjects relapsed between Day 30 and Day 90, and 3 subjects relapsed after Day 90. Sensation-seeking scores. Comparison between the three groups. Comparisons were made between quitters, smokers, and nonsmokers for all subscales of the sensation-seeking scale (SSS), with age and sex introduced as covariates. For all components of sensation seeking, quitters scored higher than nonsmokers, and quitting men scored even higher than smokers for the Disinhibition component. Table 1 shows the LS means (adjusted mean for age) and SD for each subscale. Groups were compared using t tests on LS means. For all subscales, there was a significant main effect for age (F[1, 181], respectively, for each component, F value ⫽ 15.65 (DIS); 40.73 (TAS); 15.58 (ES); 19.34 (BS), with p ⬍ .0001. The ANCOVA model was significant for Disinhibition, (F [6, 181] ⫽ 6.92, p ⬍ .0001). There was a significant main effect for sex, with men scoring higher than women (F [1, 181] ⫽ 12.80, p ⬍ .0004) and for smoking category (F [2, 181] ⫽ 8.50, p ⫽ .0003), with no significant interaction. Quitting men scored higher than nonsmoking men (p ⫽ .0008) and smoking men (p ⫽ .001). Quitting women scored higher than nonsmoking women (p ⫽ .04). The ANCOVA model was also significant for Thrill and Adventure seeking (F [6, 181] ⫽ 9.79, p ⬍ .0001). There was a significant main effect for sex, with men scoring higher than women (F [1, 181] ⫽ 15.50, p ⬍ .0001) and for smoking category (F [2, 181] ⫽ 5.69, p ⫽ .004), with no significant interaction effect. Quitting men scored higher than nonsmoking men (p ⫽ .008) and quitting women scored higher than nonsmoking women (p ⫽ .03). For Experience seeking, the ANCOVA model was significant (F [6, 181] ⫽ 6.57, p ⬍ .0001). There was no significant main effect for sex but there was a significant main effect for smoking category (F [2, 181] ⫽ 7.38, p ⫽ .0008), with no significant interaction.

Table 1. LS means (adjusted means for age) on each subscale of the Sensation Seeking Scale: Quitters, smokers and nonsmokers Men

DIS M SD TAS M SD ES M SD BS M SD

Women

Quitters

Smokers

Nonsmokers

Quitters

Smokers

Nonsmokers

6.8 1.7

5.1 2.3

4.4 2.3

4.5 1.8

4.5 2.5

2.9 2.7

8.1 1.7

6.9 2.5

5.9 2.8

6.3 2.7

5.0 3.0

4.5 2.4

7.0 1.9

6.2 2.1

5.7 2.1

7.4 2.0

6.9 2.3

5.1 2.5

4.6 1.9

4.1 2.0

3.3 2.1

3.9 1.8

3.7 1.9

2.6 1.6

DIS ⫽ Disinhibition; TAS ⫽ Thrill and Adventure Seeking; ES ⫽ Experience Seeking; BS ⫽ Boredom Susceptibility.

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Quitting men scored higher than nonsmoking men (p ⫽ .08) and quitting women scored higher than nonsmoking women (p ⫽ .004). The ANCOVA model was also significant for Boredom Susceptibility, (F [6, 181] ⫽ 5.71, p ⬍ .0001). There was no significant main effect for sex but there was a significant main effect for smoking category (F (2, 181) ⫽ 6.30, p ⫽ .002), with no significant interaction. Quitting men scored higher than nonsmoking men (p ⫽ .05) and quitting women scored higher than nonsmoking women (p ⫽ .004). Sensation seeking and issue of cessation Sensation seeking, motives for smoking, and previous quitting attempts were tested by simple regressions as possible predictors of the issue of cessation (expressed as a binary variable) and of the data of relapse (after Day 8, Day 30, or Day 90): Subsequent relapse was predicted only by the strength of addiction as a motive for smoking (R ⫽ .398, SE ⫽ .469, R2 ⫽ .158, p ⫽ .04). Sensation seeking and emotional symptomatology Russell’s stimulant and sedative factor scores and sensation seeking 4 factor scores were evaluated as possible predictors of the development of emotional symptomatology at each assessment. Simple regressions were used to test the following clinical variables: depression (Hamilton Scale total score), anxiety (Tyrer and Covi Scales total scores), affective blunting (Abrams-Taylor three factors, Anhedonia factor of the

Table 2. Predictors of development of clinical symptomatology at Baseline, Day 8, Day 30 and Day 90; univariate relationships Predictor variable (A) Baseline ES BS DIS Stimulant Sedative Stimulant BS Sedative (B) Day 8 DIS TAS Stimulant (C) Day 30 TAS Sedative (D) Day 90 DIS TAS ES

Predicted variable Physical anhedonia Lack of pleasure-seeking behavior Affective blunting Affective blunting Tension Tension Tension Hamilton (F) Sadness Tyrer Affective blunting Calmness (F) Hypersensitivity Physical anhedonia Tiredness Physical anhedonia Tension Energy Energy Tension

Regression coefficient

Standard error

R2

p value

.437 .468 .378 .359 .504 .389 .415 .490 .430 .380

6.0 .574 .568 .561 3.44 3.66 3.72 3.10 1.3 4.32

.191 .219 .143 .219 .254 .152 .172 .240 .193 .144

.04 .02 .07 .08 .02 .08 .06 .01 .03 .06

.439 .380 ⫺.360 .383 .502

.412 2.63 3.83 6.7 1.407

.193 .144 .129 .147 .252

.03 .08 .08 .07 .01

.571 .415

5.9 3.244

.327 .172

.01 .10

.763 .661 ⫺.778

1.856 2.155 2.335

.583 .437 .605

.02 .07 .02

ES ⫽ Experience Seeking; BS ⫽ Boredom Susceptibility; DIS ⫽ Disinhibition; TAS ⫽ Thrill and Adventure Seeking.

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Depressive Mood Scale and Chapman’s Physical Anhedonia scale total score) and activation (Thayer Scale 4 scores). Table 2 shows the significant univariate relationships at p ⬍ .05 (and tendencies with p ⬍ .10). When further predictor variables showed univariate relationships to one clinical variable (p ⬍ .10), they were included in a multiple logistic regression. • At baseline, Experience seeking predicted anhedonia and Boredom susceptibility predicted affective blunting (pleasure-seeking behavior factor of the Abrams-Taylor scale). Disinhibition and Stimulant motive for smoking tended to be related to affective blunting (multiple regression: R ⫽ .468, SE ⫽ .556, R2 ⫽ .219, p ⫽ .08). Tension was predicted by Sedative motive for smoking, and there was a trend towards an interaction with Boredom susceptibility and Stimulant motive for smoking (multiple regression: R ⫽ .627, SE ⫽ 3.37, R2 ⫽ .394, p ⫽ .04). Finally, Sedative motive for smoking predicted depression, sadness and anxiety. • On Day 8, Disinhibition was related to affective blunting, whereas Thrill and Adventure seeking tended to be related to physical anhedonia. Disinhibition also tended to be related to the calmness factor of the activation scale. Disinhibition and Thrill and Adventure seeking tended to be conversely related to hypersensitivity. Stimulant motive for smoking predicted Tiredness. • On Day 30, Thrill and Adventure seeking predicted physical anhedonia, and Sedative smoking tended to be related to Tension. • On Day 90, Disinhibition and Thrill and Adventure seeking predicted Energy (multiple regression: R ⫽ .8, SE ⫽ .1, 8, R2 ⫽ .64, p ⫽ .07), and Experience seeking was negatively related to Tension.

D I S C U S S I O N

Sensation seeking scores were much higher in our group of smokers than in nonsmokers from the general population, consistent with previous studies. The men scored even higher than smokers from the general population for Disinhibition. These results may be due to the selection of our sample: subjects volunteered for a heavy battery of tests and multiple evaluations over 4 months with no financial remuneration. Their very high sensation-seeking scores may therefore be accounted for by the well-known propensity of high sensation-seekers to volunteer for new experiences. Our sample is therefore likely to include the most extreme sensation seekers among smokers. Sensation-seeking levels did not predict the outcome of cessation. Relapse was predicted only by the addictive factor of Russell’s scale, consistent with previous reports of lower quitting rates in highly dependent smokers. In contrast, emotional symptomatology seems to differ according to sensation-seeking levels and initial motives for smoking. Two types of results must be differentiated. First, for the findings before the beginning of cessation, sensation seeking appeared to be related to the negative emotional symptomatology at baseline assessment. Experience seeking and Boredom susceptibility predicted physical anhedonia at baseline. The disinhibition component of sensation seeking and the stimulant motive for smoking tended to be related to affective blunting. Two interpretations of these results are possible: (1) the relationships between sensation seeking and emotional deficits may constitute in these subjects a pattern of pre-existent personality dimensions, that may in part explain the need for stimulant substances or activities to counterbalance a lack

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of activation and anhedonia, as found for some depressive patients (Carton, Jouvent, Bungener, et al., 1992, Carton, Morand, Bungener, & Jouvent, 1995); (2) the onset of anhedonia before stopping smoking may represent anticipation of the withdrawal process. The observed relationships at baseline between sedative smoking, anxiety, and tension may also indicate that subjects who smoke mainly for sedative motives have anticipated these particular withdrawal symptoms. In addition, emotional deficit may be considered to be a preparation for withdrawal difficulties, a sort of coping strategy designed to tolerate pain, as is sometimes observed in depressive episodes or during HIV infection (Bungener, Le Houezec, Pierson, & Jouvent, 1996; Jouvent et al., 1988). Emotional deficit is thus an adaptative process, with subjects trying to protect themselves emotionally by keeping away negative emotions and feelings. The second type of finding concerns relationships that appear when the subjects stop smoking. Sensation seeking and stimulant motives for smoking seem to be particularly involved in development of anhedonia and affective blunting. Disinhibition predicted affective blunting on Day 8 and was negatively related to hypersensitivity to unpleasant stimulation. The stimulant motive for smoking was related to tiredness. The Thrill and Adventure seeking component of sensation seeking also tended to predict physical anhedonia on Day 8 and Day 30. The emergence of this pattern of relationships suggests that individuals who smoke mainly for stimulant effects are at greater risk of developing negative emotional symptomatology when they quit smoking. There is considerable evidence that nicotine stimulates Dopamine release in mesolimbic structures, producing strong reinforcing effects, especially for people presenting emotional deficits (for a review, Le Houezec, in press). Smoking, like other sources of stimulation, may then be of special interest for high sensation-seekers, who may be more susceptible to present emotional deficits during abstinence. The development of anhedonia during attempts to stop may be considered to be a withdrawal symptom; but it is not a pejorative factor for issue of cessation. If tolerated, this symptomatology seems to disappear later on and the relationships observed on Day 90 between DIS, TAS, and positive feelings of energy supports the view that these subjects recover energy and activation while having a growing confidence that they can become nonsmokers. Methodological issues must be considered in interpreting these results: Our sample of subjects was small and studies with a larger population are required to verify these relationships. Furthermore, clinical scores at each day assessment were low, especially on Day 8, and this may be due to the characteristics of our sample: The subjects were highly motivated to quit and highly prepared and informed about the withdrawal symptoms that they might experience. During interviews on Day 8, most expressed surprise that withdrawal was not as difficult as they had anticipated. We focused on early symptoms (Day 0–Day 8) because a major bias was introduced by the long-time interval between Day 8 and Day 30, and Day 30 and Day 90. This prevented us from picking up withdrawal symptoms and mood deterioration in the days immediately before relapse, although the consultation for clinical follow-up of the subjects showed that some subjects presented intense depressive symptoms before relapsing and they then switched off the protocol. In conclusion, our results first emphasize facilitation of smoking cessation with nicotine replacement, the efficacy of which has been confirmed in about 20 meta-analyses (for a review, Hugues, 1996). However, as many studies have shown, substitution therapy does not eliminate all of the withdrawal symptoms. Two major patterns of emotional symptomatology appeared: The first involved affective blunting, anhedonia

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