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Contents lists available at ScienceDirect

Addictive Behaviors
journal homepage: www.elsevier.com/locate/addictbeh

A retrospective analysis of the association between providing nicotine 7

replacement therapy at admission and motivation to quit and nicotine
withdrawal symptoms during an inpatient psychiatric hospitalization
⁎
Chizimuzo T.C. Okolia, , Yazan D. Al-Mrayata, Charles I. Shelton Jrc, Milan Kharab
a
University of Kentucky College of Nursing, Lexington, KY 40536, USA
b
Vancouver General Hospital, Smoking Cessation Clinic, Vancouver, BC V5Z 1M9, Canada
c
University of Kentucky College of Medicine, Lexington, KY, USA

H I GH L IG H T S

• Psychiatric patients experience nicotine withdrawal in a tobacco-free hospitalization.

• Reporting of the withdrawal symptom of anxiety varies by psychiatric diagnosis.
• Nicotine replacement at admission is associated with nicotine withdrawal severity.
• Nicotine replacement at admission is not associated with motivation to quit.

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Psychiatric patients have high tobacco use prevalence, dependence, and withdrawal severity. A
Nicotine replacement therapy tobacco-free psychiatric hospitalization necessitates the management of nicotine withdrawal (NW) for tobacco
Nicotine withdrawal using patients. NW management often requires the provision of approved nicotine replacement therapy (NRT) to
Tobacco treatment patients, which may also motivate tobacco users towards cessation. However, few studies have examined the
Psychiatric hospital
associations between providing NRT, motivation to quit, and NW among psychiatric patients.
Objective(s): To examine the associations between providing NRT at admission and motivation to quit smoking
and severity of NW symptoms.
Design: A retrospective review of the medical records of 255 tobacco using patients on whom NW was assessed
during their hospital stay. The time when NRT was provided (i.e., at admission vs. not provided vs. on the unit),
motivation to quit smoking, and 8-item Minnesota Nicotine Withdrawal Scale were assessed.
Results: The primary NW symptom was ‘craving’ (65.1%); reporting of ‘anxiety’ varied by psychiatric diagnosis.
Providing NRT at admission was not associated with motivation to quit. Patients receiving NRT on the unit (i.e.,
delayed receipt) had significantly higher NW than those who received NRT at admission. In multivariate ana-
lyses, receiving NRT on the unit was significantly associated with greater NW severity (β = .19, p = .002).
Conclusions: Among psychiatric patients, providing NRT at admission is associated with greater severity of NW.
The provision of NRT for NW management may be considered as standard practice during tobacco-free psy-
chiatric stays. Future studies may consider the effect of other tobacco treatment medications (such as vareni-
cline, bupropion) on managing NW.

1. Introduction
Tackling tobacco use among people with mental illnesses (MI) re-
mains critical to public health.(Prochaska, Das, & Young-Wolff, 2017)
About 36%–75% of adults receiving mental healthcare services cur-
rently use tobacco.(Chandra et al., 2005; Diaz et al., 2009; FCRd et al.,
2014; Kalman, Morissette, & George, 2005; Michopoulos et al., 2015)
This alarming prevalence persists(Centers for Disease Control and
Prevention, 2013; Lê Cook et al., 2014) despite declining tobacco use
rates in the U.S.(Jamal et al., 2016; U.S. Department of Health and
Human Services, 2014); resulting in disproportionate morbidity and
mortality among people with MI.(Bandiera, Anteneh, Le, Delucchi, &

⁎
Corresponding author at: University of Kentucky College of Nursing, 315 College of Nursing Building Lexington, KY 40536-0232, USA.
E-mail addresses: ctokol1@uky.edu (C.T.C. Okoli), ydal222@uky.edu (Y.D. Al-Mrayat), charles.shelton1@uky.edu (C.I. Shelton), Milan.Khara@vch.ca (M. Khara).

https://doi.org/10.1016/j.addbeh.2018.06.005
Received 13 December 2017; Received in revised form 5 June 2018; Accepted 6 June 2018
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C.T.C. Okoli et al.
Guydish, 2015; Williams, Steinberg, Griffiths, & Cooperman, 2013)
Despite a pervasive culture of tobacco use,(Prochaska, 2011; Thomas &
Richmond, 2017) people with MI are willing(Siru, Hulse, & Tait, 2009)
and able(Anthenelli, Benowitz, West, et al., 2016; Prochaska et al.,
2017; Roberts, Eden Evins, Mcneill, & Robson, 2016) to quit when
provided tobacco treatment (TT). Quitting reduces risks for several
diseases(U.S. Department of Health and Human Services, 2014) and is
associated with improvement in some psychiatric symptoms.(Taylor
et al., 2014) Engaging providers, policymakers and mental health ad-
vocates to increase access to TT must be addressed in psychiatric in-
patient settings.(Prochaska, 2011)
The U.S. Clinical Practice Guideline for TT urges systematic pro-
cesses for TT delivery during healthcare encounters.(U.S. Preventive
Services Task Force, 2015) In addition, the U.S. Center of Medicare and
Medicaid Services implemented TT measures as a part of Inpatient
Psychiatric Facility Quality Report requirements.(CMS, 2016) These
measures require psychiatric institutions to report the tobacco use
status of patients, provide practical cessation counseling and Food and
Drug Administration approved medication, and refer patients for fur-
ther treatment at discharge.(CMS, 2016) These and similar government-
led requirements can enhance TT provision in psychiatric facilities.
(Carrillo, Nazir, Howser, et al., 2017; Rigotti, Tindle, Regan, et al.,
2016)
When hospitalized, TT often requires managing nicotine withdrawal
(NW) for tobacco users that experiencing withdrawal symptoms. NW
symptoms may occur around 4–24 h following stopping tobacco- or
nicotine-containing products(McLaughlin et al., n.d); and may include
anxiety, difficulty concentrating, restlessness, increased appetite, in-
somnia, depressed mood, and irritability, frustration, or anger.
(American Psychiatric Association, 2013) As compared to those without
MI, those with MI have greater NW severity.(Breslau, Kilbey, &
Andreski, 1992; Smith, Homish, Giovino, & Kozlowski, 2014) Among
hospitalized psychiatric patients, higher NW severity is further asso-
ciated with being female, African American, having greater tobacco
dependence and psychiatric symptom severity, and co-occurring sub-
stance use disorders.(Soyster, Anzai, Fromont, & Prochaska, 2016)
As enhancing motivation for quitting smoking is a strong predictor
of engagement and success in TT,(Lindson-Hawley, Thompson, & Begh,
2015; Vangeli, Stapleton, Smit, Borland, & West, 2011) understanding
its relationship with NW is important to enhance cessation in psychia-
tric patients. Studies have shown that both the occurrence of specific
NW symptoms (for example, insomnia(Zhou et al., 2009)) and the se-
verity of symptoms(West, Hajek, & Belcher, 1989) are predictive of
cessation success in non-psychiatric patients. In addition, intolerance to
NW discomfort is negatively correlated with motivation to quit
smoking.(Rohsenow et al., 2015) Tobacco users with MI report high
frequency or occurrence of particular symptoms (e.g., agitation and
irritation) resulting from NW.(Prochaska, Gill, & Hall, 2004) Population
based studies have also found that individuals with depressive and
anxiety disorders report higher frequency of individual NW symptoms
and severity of symptoms as compared to those without those disorders.
(Breslau et al., 1992) However, there is a dearth of studies that have
examined the severity of NW in hospitalized psychiatric patients or its
association with motivation for quitting.
With increasing numbers of tobacco-free psychiatric hospitals,(Ortiz
& Schacht, 2015; Stockings, Bowman, Prochaska, et al., 2014) there are
concerns that inadequate management of NW can have adverse beha-
vioral outcomes during hospitalization. For example, Lawn and col-
leagues(Lawn & Pols, 2003) found that staff at a smoke-free psychiatric
hospital were often unable to recognize NW symptoms in patients. This
misidentification of NW was a potential risk for increased patient agi-
tation and acting out behaviors.(Lawn & Pols, 2003) Indeed, not ad-
dressing NW among psychiatric patients may further hinder opportu-
nities for providing TT. This is because greater severity of NW
symptoms during cessation attempts may predict failure and sub-
sequent relapse.(Allen, Bade, Hatsukami, & Center, 2008; Zhou et al.,

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2009)
Furthermore, personalized management of tobacco use for patients
during psychiatric hospitalizations requires clarification. On the one
hand, 21–79% of tobacco users want cessation,(Siru et al., 2009) and
tobacco-free psychiatric hospitalizations are an opportunity for TT en-
gagement. Conversely, some tobacco users are unprepared to quit, and
thus, tobacco-free hospitalizations necessitate managing of potential
NW. Current TT approaches were developed for tobacco use cessation,
(Bader, Mcdonald, & Selby, 2009; Hughes, 2008) and not, necessarily,
NW management. Thus, evidence remains equivocal on NW manage-
ment during hospitalization and how this process may inform TT. For
instance, protocols have been developed to ease transitioning to a non-
smoking status during long-term tobacco-free hospitalization, but such
practices do not necessarily address NW management for short-term
hospitalizations.(Bittoun, Nynycz, Ross, Foley, & Ross, 2013) Studies
are required to bridge this gap, particularly in psychiatric settings.
With a scarcity of NW management research among patients with
MI, the purpose of this study was to examine the associations between
providing tobacco cessation pharmacotherapy on motivation to quit
smoking and NW in a state psychiatric facility. Specifically, we ex-
amined the associations between providing nicotine replacement
therapy (NRT) at admission and:
1. Motivation to quit,
2. Severity of NW symptoms
2. Methods
2.1. Setting
The sample was obtained from a 239-bed inpatient psychiatric fa-
cility in Kentucky, a state with the second highest adult tobacco use
prevalence in the U.S.(Nguyen, 2016) Approximately 87–90% of pa-
tients were admitted involuntarily due to psychological distress. Pa-
tients were mostly admitted without or with unknown insurance status
(53.9%) or Medicaid/Medicare (40.1%). Admission criteria included
being > 18 years and being evaluated by a qualified mental health
professional. Once admitted, a patient received care under an attending
psychiatrist/physician in consort with a multidisciplinary team of
nurses, social workers, psychologists, and other specialized health
professionals.
2.2. Procedure
This retrospective analysis was based on medical records of patients
hospitalized between January 1st to December 31st 2016. In adhering
to the brief intervention model,(U.S. Preventive Services Task Force,
2015) after admission, a trained TT nurse assessed patients for NW,
asked more details about their tobacco use, advised them to quit, as-
sessed for their readiness to quit, and assisted them in quitting by
providing practical cessation counseling and resources. Tobacco using
patients were engaged in TT only if willing. Several attempts were
made to engage patients until the patient either refused, or assented, or
was discharged.
2.3. Ethical considerations
The retrospective analysis was approved by the ethical review board
of the University of Kentucky (Exemption Certification for Protocol No.
17-0064-X2B). A waiver of the documentation for informed consent
was obtained.
2.4. Measures
The study measures were as follows:
C.T.C. Okoli et al.
Demographic, hospitalization history, and tobacco use:
Demographics obtained from the medical records included sex, age,
ethnicity/race, education, substance use history, and primary psy-
chiatric diagnoses (based on International Classification of
Diagnoses 10th edition that were determined by the attending
psychiatrist during hospitalization). Also, we obtained information
on prior hospitalizations and length of hospital stay, and current
tobacco products used by the patients. Because of the variety of
products, non-cigarette products were converted to cigarette pack
equivalents such that 1 can/tin of moist tobacco was equivalent to
2.5 packs (i.e., 30 cigarettes/day equivalent),(Agaku & Alpert,
2016) 1 cigar was equivalent to 4 cigarettes,(Anantharaman,
Chabrier, Gaborieau, et al., 2014) and, conservatively, 1 can of chew
tobacco was equivalent to 1 pack.
Timing of nicotine replacement therapy (NRT): The time at which
NRT was first provided to patients was categorized as ‘at admission’
vs. ‘not provided’ vs. ‘on the unit’ (i.e., after admission, but before
discharge). Patients were offered either 2 mg gum, 14 mg patch,
21 mg patch or a combination, daily, during their stay. However, the
actual total dose or frequency of NRT used by patients was not
measured. Nineteen patients (7.5%) refused NRT and were included
in the ‘not provided’ category. In addition, we assessed the length of
time between admission and the documented date when patients
received NRT in days.
2.5. Motivation to quit
Information on patient motivation to quit tobacco was obtained
with two measures as follows:
1) The motivational ruler(Boudreaux et al., 2012; Rollnick, Butler, &
Stott, 1997) is based on a three-item measure asking patients about
their perceived ‘importance’, ‘confidence’, and ‘readiness’ to quit
smoking/using tobacco, each on a scale from ‘0’ (not at all) to ‘10’
(very much).
2) The Stage of Change in tobacco use cessation was measured by a
single item. Those not thinking about quitting in the next six months
were categorized as ‘pre-contemplators’; those thinking about quit-
ting in the next six months were categorized as ‘contemplators’; those
preparing to quit in the next month were categorized as ‘preparers’;
and those who had quit within the last six months were categorized
as in ‘action’.(Prochaska & Velicer, 1997) Due to the low variability
in some of the categories (i.e., pre-contemplators = 60.4%, con-
templators = 19.6%, Preparers = 14.9% and action = 5.1%), for
analysis, the pre-contemplators and contemplators were categorized
into ‘pre-contemplator/contemplator” and the preparers and those
in action were categorized into ‘preparers/action’. Similar categor-
izations have been performed in other recent studies.(Figueiró,
Barros, Ferigolo, & Dantas, 2017; Kumar, Tiwari, Gadiyar, Gaunkar,
& Kamat, 2018)
2.6. Minnesota nicotine withdrawal scale (MNWS)
The MNWS is an 8-item questionnaire that assesses NW symptoms
based on the DSM-IV criteria.(American Psychiatric Association, 1994;
Hughes & Hatsukami, 1986) These self-reported items included crav-
ings for tobacco, depressed mood, insomnia, anger/irritability, anxiety,
poor concentration, restlessness, and change/loss in appetite. These
symptoms are scored on a scale of ‘0’ (not present), ‘1’ (slight), ‘2’
(mild), ‘3’ (moderate), and ‘4’ (severe). A summary score was calculated
with a possible range of 0 to 32. The MNWS scale demonstrated ade-
quate internal consistency (α = .76).
2.7. Data analysis
Of all admissions in 2016 (N = 2751), 61.9% were tobacco users;

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4.2% (n = 115) refused NW assessment and 72.3% (n = 1231) could
not be assessed due to the severity of their psychiatric symptoms, being
unavailable at the time of the TT nurse visit, and short length of stay
(i.e., < 3 days, 38.1%). Of the remaining 356 assessments, 28.4%
(n = 101) were repeated evaluations on the same person (due to re-
peated admissions in the year). To reduce potential confounding, the
final sample was based on 255 individuals with single admissions.
Among the 255 assessments, 5.5% did not respond to the Stage of
Change questions; 3.9%, 4.3%, and 4.3% did not respond to the im-
portance, confidence, and readiness to quit smoking questions respec-
tively; and 2.0% did not report tobacco product use. Those who lacked
responses primarily had a psychotic disorder. Because of the low
number of missing values, for each missing response, a modal or mean
response was used to replace missing values.
Sample demographics were described using frequencies (N) with
percentages (%) for nominal and ordinal variables and means (M) with
standard deviations (SD) for interval/ratio data. Differences in patient
demographics, hospitalization history, motivation to quit, and NW se-
verity by psychiatric disorder categorizations were examined using chi-
square tests for nominal and ordinal variables and Analysis of Variance
(ANOVA) with Levene's test for equality of variance or Kruskal-Wallis
tests for interval/ratio data. Furthermore, differences in motivation to
quit and NW scores by when NRT was provided to patients were ex-
amined using ANOVA's; whereas differences in Stage of Change by re-
ceiving NRT at admission were examined using chi-square analyses. To
limit the risk for type 1 errors as a result of multiple tests within in-
dividual NW symptoms, we applied a Bonferroni correction by setting a
significance level of .006 (i.e., alpha = .05 divided by 8 individual
symptom tests).
Finally, multiple linear regression analyses were employed to ex-
amine factors associated with NW severity (i.e., total score of MNWS).
For the regression analyses, a two-step model building process was
employed.(Hosmer & Lemeshow, 2000) First, univariate associations
were examined between demographic, hospitalization history, moti-
vation to quit, and when NRT was provided to patients and the main
outcome variables. Then all variables associated with NW severity (at
α = .05) in the first step, were entered into a final model. Model fit for
the multiple linear regression analysis was determined by the Adjusted
R2 and related F-test. Data were analyzed with and without the im-
putations to determine whether there were any significant differences
in the models. All analyses were conducted using IBM SPSS statistics
version 23.
3. Results
3.1. Sample description
The mostly male and white sample (mean age = 42 years), pri-
marily had a high school or greater education. Psychotic disorders were
the most frequent diagnosis and a majority of the sample had a past
history of substance use. Cigarettes were the primary tobacco products
used (Mean = 23 cigarette equivalents/day). On average, participants
had 1.4 prior hospitalizations (average length of stay = 16 days). Sixty-
eight percent received NRT at admission, and 57.3% were provided
with 21 mg or more of patch. The average length of time between ad-
mission and being assessed for NW was 4.6 (SD = 4.9) days. Nearly
three-quarters reported at least one NW symptom; ‘cravings’ were the
most prevalent and ‘insomnia’ the least reported symptom (Fig. 1).
As compared to other groups, those with depressive/anxiety dis-
orders had higher education; those with cognitive disorders were older,
had greater NW frequency, and fewer prior hospitalizations; and those
with substance use disorders had the shortest length of stays, the least
time between receiving NRT and NW assessment, and the highest NW
severity (Table 1).
C.T.C. Okoli et al.
Fig. 1. Frequency of reported nicotine withdrawal symptoms (N = 255).
3.2. Motivation to quit smoking and receiving NRT at admission
The sample had moderate average scores on importance (M = 6.2,
SD = 4.1) but low confidence (M = 3.8, SD = 4.2) and readiness
(M = 3.0, SD = 4.1) to quit. Individuals with substance use disorders
had the highest average scores on importance (M = 7.3, SD = 3.7),
confidence (M = 4.3, SD = 4.4) and readiness (M = 4.6, SD = 4.7);
those with cognitive disorders had the lowest average scores on im-
portance (M = 5.3, SD = 4.0), confidence (M = 2.9, SD = 3.7) and
readiness (M = 2.1, SD = 3.8) to quit. These scores did not significantly
differ across psychiatric diagnoses groups. There were no significant
differences in motivation for quitting by receiving NRT at admission
groups.
Most of the sample were in the pre-contemplation/contemplation
Stages of Change (80%). Those with substance use disorders were most
likely to be in the preparation/action stages and those with cognitive
disorders were the least likely (30% vs. 0%); but the differences be-
tween psychiatric disorder groups were non-significant (χ2 = 12.4
[DF = 12], p = .411). There were no significant differences in Stage of
Change by receiving NRT at admission groups.
3.3. Nicotine withdrawal symptom severity and psychiatric diagnosis
Summing across NW symptoms, the sample reported low levels of
NW (M = 3.2, SD = 4.2); with the highest scores on cravings (M = 1.9,
SD = 1.7), then anger (M = 0.3, SD = 0.8), then anxiety (M = 0.3,
SD = 0.7) and restlessness (M = 0.3, SD = 0.8), then depressed mood
(M = 0.2, SD = 0.7), then appetite (M = 0.2, SD = 0.6), and then poor
concentration (M = 0.1, SD = 0.5) and insomnia (M = 0.1, SD = 0.5)
(see Table 2). NW symptom severity differed among psychiatric diag-
nosis groups in anger (χ2 = 12.4 [DF = 4], p = .014), anxiety
(χ2 = 15.0 [DF = 4], p = .005), and poor concentration (χ2 = 9.4
[DF = 4], p = .052); but these differences were only significant for
‘anxiety’ when applying Bonferroni corrections.
3.4. Nicotine withdrawal symptom severity and receiving NRT at admission
NW severity scores for patients provided NRT on the units were
significantly higher than for both those provided and not provided NRT
at admission (χ2 = 14.8 (DF = 2), p = .001) (Fig. 2). In post hoc ana-
lysis, there were no significant mean differences in any NW symptom
severity scores between those provided NRT or not provided NRT at

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admission. But, as compared to those not provided NRT at admission,
those provided NRT on the units had higher mean scores on craving
(χ2 = 10.1 [DF = 1], p = .001), depression (χ2 = 4.6 [DF = 1],
p = .032), anger (χ2 = 4.8 [DF = 1], p = .029), anxiety (χ2 = 11.8
[DF = 1], p = .001), and restlessness (χ2 = 8.1 [DF = 1], p = .005);
only craving, anxiety, and restlessness were significantly different after
applying Bonferroni corrections. However, as compared to those pro-
vided NRT at admission, those provided NRT on the units did not have
any significant differences after applying the Bonferroni corrections.
In bivariate linear regression analysis, variables associated with NW
severity included being white (vs. non-white), being provided NRT on
the unit (vs. being provided NRT at admission), providing 21 mg of NRT
(vs. none), being in the pre-contemplation/contemplation Stage of
Change (vs. action/preparation), shorter duration of time between
when patient was admitted and NRT was provided, greater cigarette
equivalents per day, and lower confidence in quitting. In multivariate
regression analysis, when regressing the NW severity on significant
variables from the bivariate analysis, being provided NRT on the units
(vs. being provided NRT at admission) and lower confidence in quitting
remained significantly associated with greater NW severity (Adjusted
R2 = .12, F = 4.86 [9, 245], p < .0001) (Table 3). We performed this
analysis with and without the imputed missing values and there were
no significant differences in model parameters.
4. Discussion
We assessed the relationship between providing NRT at admission,
motivation to quit tobacco, and NW severity. Although providing NRT
was not associated with motivation to quit, on-unit NRT provision was
associated with decreased NW severity. These associative findings may
have explained the overall low ratings of NW in the sample, given that
the majority of patients were offered NRT at admission or on the unit
(80.3%). However, caution must be taken in inferring any causal re-
lationship from these findings. Nonetheless, they may be important for
tobacco policy and evidence-based practice within psychiatric facilities.
Failing to address NW may impede clinical management of hospitalized
smokers with serious MI.(Benowitz et al., 2009; Kobayashi et al., 2010;
Tsopelas, Kardaras, & Kontaxakis, 2008)
We found NW symptom severity score differences by psychiatric
diagnoses in anger, anxiety, and poor concentration. This finding sup-
ports an earlier study reporting that anxiety or nervousness may be
important indicators of NW among people with depressive/anxiety
C.T.C. Okoli et al. $GGLFWLYH%HKDYLRUV²

Table 1
Differences in sample characteristics by psychiatric diagnosis categorizations.
Total (N = 255) Adjustmentc (n = 20) Cognitivec (n = 16) Depressive/Anxietyc Psychoticc (n = 98) Substance usec
(n = 81) (n = 40)

N % n % n % n % n % n %

Female 113 44.3 7 35.0 8 50.0 42 51.9 38 38.8 18 45.0

White 228 89.4 19 95.0 13 81.3 76 93.8 82 83.7 38 95.0
Greater than high school⁎ 157 61.6 11 55.0 5 31.3 58 71.6 57 58.2 26 65.0
Ever used substances ⁎⁎⁎ 171 67.1 13 65.0 10 62.5 52 64.2 56 57.1 40 100.0
Type of Tobacco usea
Cigarettes 228 89.4 18 90.0 14 87.5 73 90.1 88 89.8 35 87.5
Chew/moist 18 7.1 1 5.0 1 6.3 6 7.4 6 6.1 4 10.0
Electronic Cigs 1 0.4 0 0.0 0 0.0 0 0.0 1 1.0 0 0.0
Cigars 7 2.7 0 0.0 1 6.3 2 2.5 3 3.1 1 2.5
Pipes 1 0.4 1 5.0 0 0.0 0 0.0 0 0.0 0 0.0
Time medication provided to
patient
At admission 173 67.8 16 80.0 11 68.8 60 74.1 60 61.2 26 65.0
Not provided 50 19.6 3 15.0 4 25.0 10 12.3 28 28.6 5 12.5
On Unit 32 12.5 1 5.0 1 6.3 11 13.6 10 10.2 9 22.5
Amount of NRT providedb
None 48 18.8 3 15.0 4 25.0 10 12.3 26 26.5 5 12.5
14 mg 61 23.9 5 25.0 5 31.3 22 27.2 22 22.4 7 17.5
21 mg 146 57.3 12 60.0 7 43.8 49 60.5 50 51.0 28 70.0
Reporting any nicotine 184 72.2 12 60.0 14 87.5 65 80.2 62 63.3 31 77.5
withdrawal symptoms⁎

M SD m sd m sd m sd m sd m sd
Age (in years)⁎ 42.1 14.1 40.1 15.0 50.3 20.3 40.6 13.6 44.1 12.7 37.7 13.3
# of prior hospitalizations⁎⁎ 1.4 3.5 0.5 1.0 0.4 1.3 1.2 2.9 2.2 4.4 0.6 2.9
Length of hospital stay (days)⁎⁎⁎ 16.2 28.3 20.4 57.5 32.5 39.8 8.8 7.9 22.4 31.0 7.7 8.4
Assessment time frame (days)⁎⁎ 4.6 4.8 4.4 5.8 7.2 6.5 3.5 3.4 5.8 5.5 3.2 2.1
Cigarette equivalent per day 23.7 16.7 26.2 16.8 19.5 11.0 23.9 19.5 22.5 14.6 26.6 16.9
MNWS total score⁎ 3.2 4.2 3.8 5.6 2.0 1.4 3.9 4.7 2.4 3.4 4.1 4.8

Differences between groups are based on chi-square analyses for categorical and ordered-categorical variables and Analysis of Variance (ANOVA, with Levene's Test
for Equality of Variance) for continuous variables; however, for continuous variables that did not demonstrate Equality of Variance, Kruskal-Wallis Tests were
employed.
a
Of those using chew/moist tobacco, 3 individuals concurrently used cigarettes. The individuals who used a pipe also used cigarettes.
b
One individual was offered 2 mg gum at admission and was added to the 14 mg group; 2 individuals were provided 42 mg on the unit and were added to the
21 mg group.
c
The psychiatric diagnoses are classified into adjustment disorder group (including 16 with adjustment, 1with a personality disorder, and 1 with a conversion
disorder, and 1 with malingering, cognitive disorder group) (including 11 with a cognitive disorder like Alzheimer's or dementia, 3 with a medical illness like
Huntington's disease, and 2 with an unspecified mental health problem with cognitive features), depressive/anxiety group (6 with anxiety disorders like generalized
anxiety, 25 with major depressive disorder, 24 with unspecified mood disorder, and 26 with bipolar disorder), psychotic (including 30 with unspecified psychosis and
68 with schizophrenia or schizoaffective disorder), and substance use disorder (4 with alcohol & sedative hypnotics, 1 with cannabis, 9 with cocaine or other
stimulants, and 26 with poly-substance use).
⁎
p < .05.
⁎⁎
p < .01.
⁎⁎⁎
p < .001.

disorders.(Smith et al., 2014) In fact, our current analysis found that
‘anxiety’ scores from the MNWS significantly differed across psychiatric
diagnoses groups. This finding may suggest that NW symptoms can be
experienced differentially among psychiatric diagnoses. To optimize
treatment, future studies may assess the salience and/or specificity of
NW symptoms by psychiatric groups.
Recent research suggests that providing NRT at admission is un-
related to motivation to quit tobacco.(Leyro et al., 2013) This lack of
association may be explained by low confidence and readiness to quit,
based on our current analysis. However, it could indicate that

Table 2
Differences in MNWS symptoms by psychiatric diagnosis categorizations.
Cravings Depressive Insomnia Anger Anxietya Concentration Restlessness Appetite

Psychiatric diagnoses m sd m sd m sd m sd m sd m sd m sd m sd

Adjustment and malingering 1.6 1.9 0.4 0.7 0.3 1.0 0.5 0.9 0.6 0.9 0.2 0.4 0.3 0.9 0.1 0.2
Cognitive and altered mental status 1.8 1.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.3 0.8
Depressive/Anxiety 2.2 1.7 0.1 0.5 0.1 0.6 0.5 1.1 0.3 0.8 0.2 0.7 0.3 0.8 0.2 0.7
Psychotic 1.5 1.6 0.2 0.7 0.0 0.2 0.1 0.5 0.2 0.7 0.1 0.3 0.2 0.7 0.1 0.5
Substance use 2.2 1.7 0.3 0.9 0.2 0.7 0.3 0.8 0.3 0.8 0.3 0.6 0.3 0.8 0.3 0.7

Differences between groups on symptom scores are based on Analysis of Variance (ANOVA, with Levene's Test for Equality of Variance) for continuous variables;
however, for continuous variables that did not demonstrate Equality of Variance, Kruskal-Wallis Tests were employed.
a
Significant differences between groups in the table are based on applying Bonferroni corrections (alpha = .006).



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Fig. 2. Mean MNWS scores by time of receiving NRT (Kruskal-Wallis χ2 = 12.7 (DF = 2)), p = .002.

Table 3 assess the effect of pharmacotherapy on motivation to quit tobacco

Multivariate linear regression analysis of associations with NW severity. during hospitalization.
Total MNWS Score
We also found an association between NW severity and whether
patients were provided NRT at admission or on the unit. These findings
Bivariate Multivariatea differ from those of Leyro and colleagues,(Leyro et al., 2013) who re-
ported that patients, in a psychiatric hospital, receiving NRT at ad-
Beta p-Value Beta p-Value
mission experienced greater NW as compared to those whose receipt of
Female −.06 .307 – – NRT was delayed. The difference in our findings was likely due to the
White .18** .004 .10 .114 time of NW assessments. Where Leyro and colleagues(Leyro et al.,
Greater than high school .03 .611 – – 2013) assessed NW within 24 h of admission, on average we assessed
Ever used substances (yes) .08 .201 – –
withdrawal 4.6 days after admission. The greater variability in asses-
Type of Tobacco use
Cigarettes (referent) 1.00 – – – sing NW in our study reflects the ‘real-world’ clinical situation in which
Chew/moist .05 .439 – – patients are often affected by severe psychiatric symptoms that may
Electronic Cigs/Cigars/Pipes −.10 .098 – – initially prevent adequate assessment. To optimize treatment duration,
Time NRT provided to patient future longitudinal studies are needed to assess the time-course of NW
At admission (referent) 1.00 – 1.00 –
Not provided −.10 .131 .17 .516
symptoms among tobacco using psychiatric patients.
On Unit .19** .002 .15* .017 It is interesting to note that a subset of our sample, for whom NRT
Amount of NRT offered was not provided (n = 50), reported lower NW severity. Of these in-
None 1.00 – 1.00 – dividuals, 56.0% (n = 28) had no documented reason for not being
14 mg .04 .614 .20 .505
provided NRT, 32.0% (n = 19) refused NRT, and 6.0% (n = 3) were
21 mg .24** .003 .33 .333
Psychiatric Diagnoses either pregnant or consumed < 5 cigarettes per day. Most of these in-
Adjustment and Malingering (referent) 1.00 – – – dividuals had a psychotic disorder (56%) and on average had a longer
Cognitive and Altered Mental Status −.10 .199 – – length of time between admission and assessing for NW symptoms
Depressive/Anxiety .01 .941 – – (M = 5.8, SD = 5.7 days). It is conceivable that the severity of psy-
Psychotic −.16 .184 – –
Substance use .02 .810 – –
chiatric symptoms may have affected their reporting of NW symptoms.
Stage of Change In other words, the self-reporting of NW symptoms may have been
Pre-contemplation/Contemplation 1.00 – subject to recall bias. Given the average lag time (4 to 6 days) between
(referent) admission and assessment of NW, it is possible that patients with more
Preparation/Action −.18** .004 −.07 .314
severe levels of NW could recall their symptoms as worse since ad-
Age (in years) −.02 .801 – –
# of prior hospitalizations .01 .835 – – mission compared to those with less severe NW symptoms. Nonetheless,
Length of hospital stay (days) −.08 .205 – – this paradoxical associative finding needs to be verified with future
Assessment time frame (days) −.15* .019 −.11 .058 longitudinal research to appropriately draw conclusions.
Cigarette per day equivalent .19** .003 .10 .093 Finally, our analysis indicated that receiving NRT on the units (vs. at
Importance −.07 .283 – –
admission) and lower confidence in quitting were associated with
Confidence −.20** .002 −.14* .039
Readiness −.08 .192 – – greater NW severity. Other studies have reported differing covariates of
NW. For example, a recent study of patients derived from an inpatient
a
Adjusted R2 = 0.12, F = 4.86 [9, 245], p < .0001. psychiatric facility found that specific predictors of NW severity in-
cluded being female, African American, greater psychiatric symptom
pharmacotherapy, by itself, does not impact motivation to quit. Al- severity, greater nicotine dependence scores, and having alcohol and
though no trials have examined the effects of pharmacotherapy alone other drug abuse disorders.(Soyster et al., 2016) Similar to this prior
on tobacco cessation during hospitalization, adding pharmacotherapy study by Soyster et al.,(Soyster et al., 2016) in our bivariate regression
to counseling can increase tobacco cessation (Rigotti et al., 2012). analysis, we found that being non-white and greater cigarette equiva-
Hence, pharmacotherapy may only be effective for those actively en- lents per day were related to NW severity scores. However, in multi-
gaging in cessation. More studies are warranted, potentially using other variate analysis, these correlates were no longer associated with NW
cessation medications (such as varenicline or bupropion), to better severity scores. Some of the differences in covariates of NW symptom



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C.T.C. Okoli et al.
severity in our study and that by Soyster et al. may be due to the dif-
ferences in measures employed in the studies. In addition, our relatively
smaller sample size may have increased the risk for type 2 errors. Fu-
ture, adequately powered, studies may re-examine the measures em-
ployed in our current study in addition to others shown to be associated
with NW severity.
A few important limitations should be considered in interpreting
our findings. As a retrospective review, some variables were unavail-
able that may have affected the results of our study. For example, we
did not have information on psychiatric symptom severity (such as
using the Behavior and Symptom Identification Scale(Eisen, Normand,
Belanger, Spiro, & Esch, 2004)) which is associated with NW severity.
(Soyster et al., 2016) In addition, as a cross-sectional analysis, we did
not assess changes in NW symptoms over the course of the hospitali-
zation, thus no causality can be inferred. In a related issue, the as-
sessment of NRT provided at admission and on the unit was based on
program records, with no determination that the patient actually used
the NRT. Furthermore, the categorizations of the psychiatric disorders
was based on the primary discharge diagnosis; we did not have in-
formation on comorbid psychiatric disorders, which may have had an
effect on main outcomes. Finally, our sample was based on a con-
venience sample of only 15% of current tobacco users admitted to the
hospital. This low sample proportion limits the generalizability of the
current findings to other similar populations. Future, adequately pow-
ered, robust studies employing longitudinal designs should be con-
sidered to better understand the effect of providing NRT at admission
on NW symptoms among diverse patient populations with psychiatric
disorders.
During tobacco-free hospitalizations, tobacco-using patients may be
assessed for NW and provided appropriate treatment to mitigate pos-
sible discomfort. Our findings suggest an association between providing
patients with NRT at admission and lowered NW severity. Not ad-
dressing NW may confound the clinical inpatient management of
people with serious MI.(Kobayashi et al., 2010; Leyro et al., 2013;
Tsopelas et al., 2008) These findings support current governmental
policies that require the provision of TT in inpatient psychiatric facil-
ities.(Carrillo et al., 2017; CMS, 2016) Nonetheless, to enhance TT,
future longitudinal studies are needed to examine the time-course of
NW after admission. These studies can better provide treatment
guidelines on the length of time needed for NRT administration to
manage NW. Such studies can enhance emerging tobacco control po-
licies and treatment approaches that target the reduction of the dis-
parate tobacco use morbidity and related mortality among people with
MI.
Author disclosure/conflict of interest
The authors have no financial relationships with commercial in-
terests with regard to this manuscript.
Author roles in research/writing of manuscript
C. Okoli conceived, planned, and drafted the methods, results, and
discussion sections of the manuscript. Y. Al-Mrayat drafted the in-
troduction and assisted in the methods section. C. Shelton contributed
to advanced interpretation of data, reviewed and revised the manu-
script critically for important intellectual content. M. Khara contributed
intellectually to drafts of the manuscript. All authors approved the final
manuscript as submitted.
References
Agaku, I. T., & Alpert, H. R. (2016). Trends in annual sales and current use of cigarettes,
cigars, roll-your-own tobacco, pipes, and smokeless tobacco among US adults,
2002–2012. Tobacco Control, 25(4), 451–457.
Allen, S. S., Bade, T., Hatsukami, D., & Center, B. (2008). Craving, withdrawal, and

Downloaded for Anonymous User (n/a) at Health Sciences Center - New Orleans from ClinicalKey.com by Elsevier on September 07, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
$GGLFWLYH%HKDYLRUV²
smoking urges on days immediately prior to smoking relapse. Nicotine & Tobacco
Research, 10(1), 35–45.
American Psychiatric Association (1994). Diagnostic and statistical manual of mental dis-
orders (4th ed.). Washington, DC: American Psychiatric Association.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental dis-
orders (DSM-5®). American Psychiatric Pub.
Anantharaman, D., Chabrier, A., Gaborieau, V., et al. (2014). Genetic variants in nicotine
addiction and alcohol metabolism genes, oral Cancer risk and the propensity to
smoke and drink alcohol: A replication study in India. PLoS One, 9(2), e88240.
Anthenelli, R. M., Benowitz, N. L., West, R., et al. (2016). Neuropsychiatric safety and
efficacy of varenicline, bupropion, and nicotine patch in smokers with and without
psychiatric disorders (EAGLES): A double-blind, randomised, placebo-controlled
clinical trial. The Lancet, 387(10037), 2507–2520.
Bader, P., Mcdonald, P., & Selby, P. (2009). An algorithm for tailoring pharmacotherapy
for smoking cessation: Results from a Delphi panel of international experts. Tobacco
Control, 18(1), 34–42.
Bandiera, F. C., Anteneh, B., Le, T., Delucchi, K., & Guydish, J. (2015). Tobacco-related
mortality among persons with mental health and substance abuse problems. PLoS
One, 10(3), e0120581.
Benowitz, N. L., Schultz, K. E., Haller, C. A., Wu, A. H. B., Dains, K. M., & Jacob, P. (2009).
Prevalence of smoking assessed biochemically in an urban public hospital: A ratio-
nale for routine cotinine screening. American Journal of Epidemiology, 170(7),
885–891.
Bittoun, R., Nynycz, S., Ross, D., Foley, K., & Ross, L. (2013). A protocol for a smoke-free
mental health facility. Journal of Smoking Cessation, 8(1), 57–59.
Boudreaux, E. D., Sullivan, A., Abar, B., Bernstein, S. L., Ginde, A. A., & Camargo, C. A.
(2012). Motivation rulers for smoking cessation: A prospective observational ex-
amination of construct and predictive validity. Addiction Science & Clinical Practice,
7(1), 8.
Breslau, N., Kilbey, M., & Andreski, P. (1992). Nicotine withdrawal symptoms and psy-
chiatric disorders: Findings from an epidemiologic study of young adults. American
Journal of Psychiatry, 149(4), 464–469.
Carrillo, S., Nazir, N., Howser, E., et al. (2017). Impact of the 2015 CMS inpatient psy-
chiatric facility quality reporting rule on tobacco treatment. Nicotine & Tobacco
Research, 19(8), 976–982.
Centers for Disease Control and Prevention (2013). Vital signs: Current cigarette smoking
among adults aged ≥18 years with mental illness — United States, 2009—2011.
Morbidity and Mortality Weekly Report, 62(05), 81–87.
Chandra, P. S., Carey, M. P., Carey, K. B., Jairam, K. R., Girish, N. S., & Rudresh, H. P.
(2005). Prevalence and correlates of tobacco use and nicotine dependence among
psychiatric patients in India. Addictive Behaviors, 30(7), 1290–1299.
CMS (2016). Inpatient psychiatric facility quality reporting program manual.
Diaz, F. J., James, D., Botts, S., Maw, L., Susce, M. T., & de Leon, J. (2009). Tobacco
smoking behaviors in bipolar disorder: A comparison of the general population,
schizophrenia, and major depression. Bipolar Disorders, 11(2), 154–165.
Eisen, S. V., Normand, S.-L., Belanger, A. J., Spiro, A. I., & Esch, D. (2004). The revised
behavior and symptom identification scale (BASIS-R): Reliability and validity.
Medical Care, 42(12), 1230–1241.
FCRd, B., Melo, A. P. S., Cournos, F., Cherchiglia, M. L., Peixoto, E. R. M., & Guimarães,
M. D. C. (2014). Cigarette smoking among psychiatric patients in Brazil. Cadernos de
Saúde Pública, 30(6), 1195–1206.
Figueiró, L. R., Barros, H. M. T., Ferigolo, M., & Dantas, D. C. M. (2017). Assessment of
factors related to smokers' adherence to a short-term support group for smoking
cessation: A longitudinal study in a developing country. Trends in Psychiatry and
Psychotherapy, 39(1), 19–28.
Hosmer, D., & Lemeshow, S. (2000). Applied logistic regression (2nd ed.). New York: Wiley.
Hughes, J. (2008). An algorithm for choosing among smoking cessation treatments.
Journal of Substance Abuse Treatment, 34(4), 426–432.
Hughes, J. R., & Hatsukami, D. (1986). Signs and symptoms of tobacco withdrawal.
Archives of General Psychiatry, 43(3), 289–294.
Jamal, A., Brian, A. K., Linda, J. N., Whitmill, J., Stephen, D. B., & Corinne, M. G. (2016).
Current cigarette smoking among adults—United States, 2005–2015. MMWR.
Morbidity and Mortality Weekly Report, 65.
Kalman, D., Morissette, S. B., & George, T. P. (2005). Co-morbidity of smoking in patients
with psychiatric and substance use disorders. The American Journal on Addictions,
14(2), 106–123.
Kobayashi, M., Ito, H., Okumura, Y., Mayahara, K., Matsumoto, Y., & Hirakawa, J. (2010).
Hospital readmission in first-time admitted patients with schizophrenia: Smoking
patients had higher hospital readmission rate than non-smoking patients. The
International Journal of Psychiatry in Medicine, 40(3), 247–257.
Kumar, A., Tiwari, A., Gadiyar, A., Gaunkar, R. B., & Kamat, A. K. (2018). Assessment of
readiness to quit tobacco among patients with oral potentially malignant disorders
using transtheoretical model. Journal of Education and Health Promotion, 7(1), 9.
Lawn, S., & Pols, R. (2003). Nicotine withdrawal: Pathway to aggression and assault in
the locked psychiatric ward? Australasian Psychiatry, 11(2), 199–203.
Lê Cook, B., Wayne, G., Kafali, E., Liu, Z., Shu, C., & Flores, M. (2014). Trends in smoking
among adults with mental illness and association between mental health treatment
and smoking cessation. Journal of the American Medical Association, 311(2), 172–182.
Leyro, T. M., Hall, S. M., Hickman, N., Kim, R., Hall, S. E., & Prochaska, J. J. (2013).
Clinical Management of Tobacco Dependence in inpatient psychiatry: Provider
practices and patient utilization. Psychiatric Services, 64(11), 1161–1165.
Lindson-Hawley, N., Thompson, T. P., & Begh, R. (2015). Motivational interviewing for
smoking cessation. The Cochrane Database of Systematic Reviews, 3, Cd006936.
McLaughlin, I., Dani, J. A., & De Biasi, M. (2015). Nicotine withdrawal. The neuro-
pharmacology of nicotine dependence. Springer99–123.
Michopoulos, I., Rizos, E., Gournellis, R., Karvouni, A., Kotsioumpa, I., & Douzenis, A.
C.T.C. Okoli et al.
(2015). Smoking reduction in psychiatric inpatients is feasible: Results from a 12-
month prospective study. Annals of General Psychiatry, 14(1), 4.
Nguyen, K. H. (2016). State-specific prevalence of current cigarette smoking and smo-
keless tobacco use among adults—United States, 2014. MMWR. Morbidity and
Mortality Weekly Report, 65(39), 1045–1051.
Ortiz, G., & Schacht, L. (2015). Smoking ban implementation in psychiatric inpatient
hospitals: Update and opportunity for performance improvement. J Fam Med, 2(5),
1039.
U.S. Preventive Services Task Force. Final recommendation statement: Tobacco smoking ces-
sation in adults, including pregnant women: Behavioral and pharmacotherapy interven-
tions. (2015). https://www.uspreventiveservicestaskforce.org/Page/Document/
UpdateSummaryFinal/tobacco-use-in-adults-and-pregnant-women-counseling-and-
interventions1 (Accessed February 25th, 2017).
Prochaska, J. J. (2011). Smoking and mental illness — breaking the link. New England
Journal of Medicine, 365(3), 196–198.
Prochaska, J. J., Das, S., & Young-Wolff, K. C. (2017). Smoking, mental illness, and public
health. Annual Review of Public Health, 38(1), 1.1–1.21.
Prochaska, J. J., Gill, P., & Hall, S. M. (2004). Treatment of tobacco use in an inpatient
psychiatric setting. Psychiatric Services, 55(11), 1265–1270.
Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior
change. American Journal of Health Promotion, 12(1), 38–48.
Rigotti, N. A., Clair, C., Munafò, M. R., & Stead, L. F. (2012). Interventions for smoking
cessation in hospitalised patients. The Cochrane Library, 1–74.
Rigotti, N. A., Tindle, H. A., Regan, S., et al. (2016). A post-discharge smoking-cessation
intervention for hospital patients: Helping hand 2 randomized clinical trial. American
Journal of Preventive Medicine, 51(4), 597–608.
Roberts, E., Eden Evins, A., Mcneill, A., & Robson, D. (2016). Efficacy and tolerability of
pharmacotherapy for smoking cessation in adults with serious mental illness: A sys-
tematic review and network meta-analysis. Addiction, 111(4), 599–612.
Rohsenow, D. J., Tidey, J. W., Kahler, C. W., Martin, R. A., Colby, S. M., & Sirota, A. D.
(2015). Intolerance for withdrawal discomfort and motivation predict voucher-based
smoking treatment outcomes for smokers with substance use disorders. Addictive
Behaviors, 43, 18–24.
Rollnick, S., Butler, C. C., & Stott, N. (1997). Helping smokers make decisions: The en-
hancement of brief intervention for general medical practice. Patient Education and
Counseling, 31(3), 191–203.

Downloaded for Anonymous User (n/a) at Health Sciences Center - New Orleans from ClinicalKey.com by Elsevier on September 07, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
$GGLFWLYH%HKDYLRUV²
Siru, R., Hulse, G. K., & Tait, R. J. (2009). Assessing motivation to quit smoking in people
with mental illness: A review. Addiction, 104(5), 719–733.
Smith, P. H., Homish, G. G., Giovino, G. A., & Kozlowski, L. T. (2014). Cigarette smoking
and mental illness: A study of nicotine withdrawal. American Journal of Public Health,
104(2), e127–e133.
Soyster, P., Anzai, N. E., Fromont, S. C., & Prochaska, J. J. (2016). Correlates of nicotine
withdrawal severity in smokers during a smoke-free psychiatric hospitalization.
Preventive Medicine, 92, 176–182.
Stockings, E. A., Bowman, J. A., Prochaska, J. J., et al. (2014). The impact of a smoke-free
psychiatric hospitalization on patient smoking outcomes: A systematic review.
Australian and New Zealand Journal of Psychiatry, 48(7), 617–633.
Taylor, G., Mcneill, A., Girling, A., Farley, A., Lindson-Hawley, N., & Aveyard, P. (2014).
Change in mental health after smoking cessation: Systematic review and meta-ana-
lysis. British Medical Journal, 348.
Thomas, M., & Richmond, R. (2017). Addressing the arguments against implementation
of smoke-free policies in psychiatric facilities. Journal of Psychiatric and Mental Health
Nursing, 24(5), 322–331.
Tsopelas, C., Kardaras, K., & Kontaxakis, V. (2008). Smoking in patients with psychiatric
disorders: Effects on their psychopathology and quality of life.
Psychiatrike = Psychiatriki, 19(4), 306–312.
U.S. Department of Health and Human Services (2014). The health consequences of
smoking-50 years of progress: A report of the surgeon general. Atlanta, GA: US
Department of Health and Human Services, Centers for Disease Control and
Prevention, National Center for Chronic Disease Prevention and Health Promotion,
Office on Smoking and Health17.
Vangeli, E., Stapleton, J., Smit, E. S., Borland, R., & West, R. (2011). Predictors of at-
tempts to stop smoking and their success in adult general population samples: A
systematic review. Addiction, 106(12), 2110–2121.
West, R., Hajek, P., & Belcher, M. (1989). Severity of withdrawal symptoms as a predictor
of outcome of an attempt to quit smoking. Psychological Medicine, 19(4), 981–985.
Williams, J. M., Steinberg, M. L., Griffiths, K. G., & Cooperman, N. (2013). Smokers with
behavioral health comorbidity should be designated a tobacco use disparity group.
American Journal of Public Health, 103(9), 1549–1555.
Zhou, X., Nonnemaker, J., Sherrill, B., Gilsenan, A. W., Coste, F., & West, R. (2009).
Attempts to quit smoking and relapse: Factors associated with success or failure from
the ATTEMPT cohort study. Addictive Behaviors, 34(4), 365–373.