Predictors of nicotine withdrawal symptoms: findings from the first randomized smoking cessation trial in a low-income country setting

Int J Public Health. 2016 Jul;61(6):701-708. doi: 10.1007/s00038-016-0818-8. Epub 2016 Apr 15.


Objectives: To identify predictors of nicotine withdrawal symptoms among smokers who participated in a randomized cessation trial in a low-income country.

Methods: We analyzed data from 269 smokers who participated in a randomized, placebo-controlled smoking cessation trial conducted in primary healthcare in Aleppo, Syria. All participants received behavioral counseling and were randomized to receive either 6 weeks of nicotine or placebo patch and were followed for one year.

Results: Throughout the study, lower total withdrawal score was associated with greater education (p = 0.044), older age of smoking initiation (p = 0.017), lower nicotine dependence (p = 0.024), higher confidence in ability to quit (p = 0.020), lower reported depression (p < 0.001), higher adherence to patch (p = 0.026), belief of receiving nicotine patches rather than placebo (p = 0.011), and waterpipe use (p = 0.047).

Conclusions: Lower nicotine dependence, greater educational attainment, higher confidence in ability to quit and waterpipe use predict lower withdrawal severity. Waterpipe smoking may serve as a barrier to smoking cessation efforts in countries where its use is highly prevalent. Further, expectancies about the effects of pharmacotherapy appear to mediate the experience of nicotine withdrawal.

Keywords: Cessation; Low-income countries; Nicotine; Smoking; Withdrawal.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Behavior Therapy / methods
  • Behavior Therapy / statistics & numerical data
  • Counseling / methods
  • Developing Countries*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Nicotine*
  • Poverty
  • Smoking Cessation / methods*
  • Smoking Cessation / psychology
  • Substance Withdrawal Syndrome / epidemiology*
  • Substance Withdrawal Syndrome / psychology
  • Syria
  • Tobacco Use Cessation Devices / statistics & numerical data
  • Tobacco Use Disorder / prevention & control


  • Nicotine