Quitting smoking: Managing the associated mood changes

• Mood changes associated with quitting smoking
• What causes the mood changes?
  • Psychology
  • Neurobiology
• Management of mood changes
  • Psychotherapy
  • Pharmacology
  • Lifestyle

Mood changes associated with quitting smoking

For some, smoking is used as an avenue to relieve negative moods, to relax and reduce emotional distress. While smoking may appear to provide these psychological benefits, it is also associated with increased levels of stress and depression. Smokers report high or very high levels of psychological distress 20% of the time, compared to 10% of the time in non-smokers. Smokers also report lower mental wellbeing and a decreased satisfaction with life compared to non-smokers.

When smokers abstain from smoking, this distress does not instantaneously disappear, in fact the opposite occurs. Withdrawal from smoking is associated with negative mood changes which are one of the most difficult aspects of quitting. The distressing emotional state that follows smoking cessation is thought to be a combination of low positive mood and elevated negative mood.

The overall negative mood elevates cigarette cravings and is associated with over half of all smoking relapses. This makes learning to cope with and managing these adverse effects a priority for quitting treatment.

In the initial withdrawal stages, abstinence from smoking is associated with:

• Anxiety;
• Depression;
• Irritability;
• Restlessness;
• Difficulty concentrating;
• Low mood;
• Decreased motivation;
• Cognitive disturbance;
• Impaired inhibitory control;
• Reductions in positive affect; and
• Diminished capacity to experience rewarding feelings (anhedonia).

Most studies report the negative mood changes reduce substantially after one to three months after quitting in those smokers who are not clinically depressed. By six months anhedonia is also comparable to never smokers.

What causes the mood changes?

The mechanisms responsible for mood changes associated with quitting smoking remains largely undetermined.

Psychology

As with all psychology, mood changes will vary widely between different people that have abstained from smoking. Studies have shown that a large number of people who smoke were depressed or anxious before they started smoking and may have even been the reason they took up smoking in the first place. Smokers who do have underlying depression are more likely to experience:

• Greater nicotine dependence;
• Greater nicotine withdrawal symptoms including heightened negative mood; and
• Reduced likelihood of quitting.

Neurobiology

Some of the emotional and cognitive deficits that constitute nicotine withdrawal are believed to be a result of adaptations to brain pathways (neuroadaptation) as a consequence of chronic nicotine use.

These neuroadaptations are believed to effect:

• Thinking patterns;
• Motivation;
• Inhibition (so you are less likely to resist the urge for a cigarette);
• Attention; and
• Concentration.

All of these factors can reduce positive mood.

Researchers believe that these neuroadaptations which cause mood changes are likely to be largely reversible as symptoms do minimise with time after quitting smoking. So do not be disheartened if you are feeling down when you immediately quit smoking, the feeling will not last forever. 

Managing the mood changes

Psychotherapy

Self-efficacy is holding the belief that you are capable of achieving a task. This is a very important aspect of successful smoking cessation. Self-efficacy and coping strategies go hand in hand, and play a role in dealing with the negative mood changes that are associated with acute nicotine withdrawal.

For some people self-efficacy does not come naturally; it needs to be built up. If you struggle to cope with the negative moods associated with nicotine withdrawal your doctor can help.

Your doctor may try and teach you some mood management skills you can use to help improve your self-efficacy and mood which in turn will help reduce the risk of relapse. Most standard smoking cessation interventions will involve a degree of mood management. Some people will need a greater focus on mood management than others, for example those with recurrent depression.

Skills training is most effective when combined with therapist support and counselling.

Pharmacology

Pharmacological quit aids have been shown to lessen mood changes.

Nicotine replacement therapy (NRT) has been shown to reduce cravings and withdrawal symptoms and as a consequence enables people to better cope with the psychological features of quitting smoking. Because it is replacing some of the nicotine that is lost after smoking cessation NRT may also provide a similar effect to smoking and therefore help to relieve stress.

For more information, see Nicotine Replacement Therapy (NRT)

 Smokers who have a generally positive mood before cessation tend to report lower levels of post-cessation negative mood when treated with nortriptyline (e.g. Allegron) or bupropion (e.g. Zyban) than those who do not receive these treatments. These agents are thought to soothe the negative mood changes but do not necessarily elevate positive mood.

There is some evidence to suggest that a three week course of fluoxetine (e.g. Prozac) immediately preceding cessation can reduce depression in smokers who are not already depressed. Recent evidence has also shown that fluoxetine improves post-quit positive and negative mood states. This suggests that antidepressant medication may play a role in smoking cessation interventions but more evidence is needed.

Your doctor will determine what pharmacotherapy, if any, is suitable for you.

Lifestyle

Studies have shown that both sleep and physical activity have a positive effect on mood and smoking cessation.

Sleep deprivation has been shown to:

• Disturb normal attention;
• Decrease arousal;
• Promote fatigue; and
• Decreases inhibitory control.

The combination of these psychological effects not only leads to a negative mood but also increases the likelihood of relapse. It is therefore very important to make sure you have sufficient rest and sleep when you are attempting to quit smoking.

Exercise during smoking cessation has an encouraging effect on mood by promoting positive:

• Sleeping patterns;
• Self-esteem;
• Perceived coping ability;
• Weight control; and
• Ability to cope with stress and anxiety.

People who exercise during quit attempts report less depressive symptoms and withdrawal symptoms. Accordingly cigarette craving is reduced and the likelihood of a successful quit attempt is increased.

More Information

For more information on smoking, its health effects and how to quit smoking, as well as some useful tools, videos and animations, see Smoking.

References

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