, 2007). Similarly, PTSD is marked by elevations in negative affect (Marshall-Berenz, Morrison, Schumacher, & Coffey, 2011) that are likely related to the inability of many smokers with PTSD to achieve sustained smoking abstinence (Cook, McFall, Calhoun, & Beckham, 2007). Finally, the relationship any other enquiries between cravings and lapse in the PTSD group is consistent with research finding worse smoking withdrawal symptoms, including stronger cravings, in the early stage of abstinence among smokers with PTSD (Dedert et al., 2012). Analyses of the influence of the difference between baseline and quit date DHEA(S) levels revealed that a larger decrease between baseline and quit date DHEA(S) levels was related to shorter time to lapse. There was, however, no corresponding effect in DHEA.

Results suggest that the decrease in DHEA(S) levels on the quit date could be a marker of higher risk for early lapse, though the small sample size means that caution is warranted in evaluating results. Future research could include more measures of DHEA/DHEA(S) and other indicators of HPA axis function throughout the early period of abstinence. Additional research is needed to evaluate DHEA/DHEA(S) as a biomarker for smoking relapse and the utility of DHEA/DHEA(S) supplementation to facilitate smoking cessation. Study results were limited by the low rate of DHEA/DHEA(S) collection (55% agreed to donate a blood sample at both assessments). Due to the multiple types of readings participants were asked to record, future designs might focus data collection more closely around lapse occasions to reduce participant burden and increase adherence to this critical event.

This study was limited by the time to follow-up, as a longer time would allow assessment of relapse (i.e., a return to sustained smoking at baseline levels). Study results are also limited by the lack of a comparison group with non-PTSD psychiatric disorders. As a result, it is unclear whether differences were due to the presence of psychopathology generally, or the effects of PTSD in particular. Despite its limitations, this study provides important insights into the presence and process of early smoking lapse in individuals with PTSD. The short time to lapse (M = 1 day) and the influences of psychiatric symptoms and craving on early lapse suggest the utility of further research into intensive intervention for managing PTSD and withdrawal symptoms in the first week(s) of smoking abstinence.

Elevated smoking abstinence self-efficacy emerged as a significant predictor of longer time to lapse in both groups, supporting its importance in quit attempts. Because theory supports the responsiveness of self-efficacy to successful experiences (Bandura, 1977), smokers might experience a boost in self-efficacy from successfully Brefeldin_A abstaining from smoking for the first week, suggesting an added benefit of intensive early intervention in the first week of a quit attempt in smokers with PTSD.