Contingency management (CM) is a powerful behavioral intervention that has been shown to reduce the use of a wide variety of substances including tobacco. Use of CM techniques for smoking cessation has been restricted by the use of multiple daily measurements of breath CO as the objective indicator to reinforce abstinence. Cotinine, with its longer half-life, may be a better marker. We evaluated the use of urine cotinine (determined using once-daily semiquantitative Immunoassay Test Strips and verified using quantitative GC/HPLC techniques) as an abstinence indicator in treatment seeking adult and adolescent smokers participating in a CM-based intervention program. The results indicate that both techniques of determining urine cotinine were highly sensitive and moderately specific at detecting abstinence, and were highly concordant. However, specificity was somewhat lower during the first few days of a quit attempt and improved over time. The results were similar in adults and adolescent smokers and suggest that during the first few days of a quit attempt it would be advisable to continue to use daily multiple CO measurements to verify abstinence. However, once abstinence is achieved, once daily immunoassay test strips could be used for continued monitoring of urine cotinine levels. Immunoassay testing can identify individuals who relapse to smoking, though this study cannot evaluate whether the strips can identify resumption of abstinence. These results suggest that the use of cotinine as an abstinence indicator, by reducing the number of daily appointments, could significantly enhance the feasibility and utility of CM-based interventions for smoking cessation.

Purpose-Abstinence effects such as nicotine withdrawal and mood changes contribute to the maintenance of cigarette smoking in adult smokers and emerging reports on adolescent smokers suggest they may experience similar subjective effects when deprived. This study aimed to prospectively document tobacco abstinence induced changes during the first 48 hours of abstinence in adolescent smokers compared with nonsmokers, to distinguish effects distinct from typical adolescent lability.Methods-57 adolescent smokers and 44 adolescent nonsmokers were assessed during a 48 hour inpatient session. Characteristic nicotine withdrawal symptoms, cravings for cigarettes, and mood symptoms were measured at 13 time points following initiation of abstinence.Results-The only abstinence related effects observed were changes in craving for tobacco and feelings of anger. Tobacco craving increased and peaked quickly following initiation of abstinence and displayed a slight decrease towards the end of the 48 hour abstinence period, while anger symptoms peaked after more prolonged abstinence. Overall, smokers' symptoms and cravings were positively associated with amount of daily smoking but not with reports of dependence or biological measures of extent of use.Conclusions-We observed that among adolescent smokers, the primary effects associated with abstinence from cigarettes are relatively minimal and include a heightened and persistent craving to smoke and increases in anger. Although smokers had greater negative mood symptoms compared with nonsmokers, the presence and severity of most of these symptoms appear to be minimally altered by abstinence and not associated with dependency or biological indicators of amount of tobacco use.Research in adult smokers has shown that experiencing such abstinence effects as nicotine withdrawal and mood changes are important in the maintenance of cigarette smoking [1], and recent evidence indicates that the pattern, duration, and severity of withdrawal symptoms including negative affect, are particularly significant predictors of relapse in adult smokers [2,3,4]. However, the experience of tobacco withdrawal has not been as thoroughly evaluated in adolescent smokers.Retrospective evaluations from adolescent smokers indicate withdrawal experiences similar to those of adults when not smoking; including reported increases in cravings, nervousness, Please address correspondence to Suchitra Krishnan-Sarin, Ph.D., Yale University School of Medicine, Department of Psychiatry, CHMC, S 208, 34 Park Street, New Haven, CT 06519. Address e-mail correspondence to suchitra.krishnan-sarin@yale.edu. . Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could...