Alcohol Hangover Symptoms Are More Common Among Smokers

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Research Article Open Access Alcohol Hangover Symptoms are More Common among Smokers Ygal Plakht1,2*, Yair Zlotnik3, Anna Aven3, Yael Engel3, Neta Bar Am3 and Gal Ifergane3 1Nursing Research Unit, Soroka University Medical Center, Beer Sheva, Israel 2The Leon and Matilda Recanati School, Ben-Gurion University of the Negev, Beer Sheva, Israel 3Headache Clinic, Department of Neurology, Soroka University Medical Center, Beer Sheva, Israel

Abstract Background: The popular concept which claims avoiding smoking contributes to meliorate hangover symptoms is currently not supported by the medical literature. In order to evaluate whether this concept is valid, we conducted a study which compares the tendency to develop hangover symptoms between smokers and non-smokers. Methods: The observational, cross-sectional study has included University students. The participants filled out anonymous questionnaire that included information regarding the habits of cigarette smokers and alcohol consumers. The tendency to develop hangover symptoms was evaluated using the Hangover Symptom Scale (HSS) compared to the past year. The data was assimilating between cigarette smokers and non-smokers. Results: Out of 487 participants, 99 (20.3%) has reported on usual cigarettes consumption during the previous year. The smoker participants have reported, on average, more hangover symptoms, compared with the non-smokers group: 5.66 (Standard Deviation [SD]=3.36) vs. 3.52 (SD=3.2) respectively; p<0.001. Additionally, the higher percent of smokers than non-smokers reported on at least one hangover symptom: 376/388 (97%) vs. 75/99 (75.8%) respectively; p<0.001. The mean HSS score was higher among smokers than non-smokers: 10.23 (SD=8.44) vs. 5.53 (SD=6.25) respectively; p<0.001. Furthermore, among smokers, a higher score of HSS was assigned for females, compared to males: 12.43 (SD=9.63) vs. 8.56 (SD=7.28) respectively; p=0.032. After adjustments for alcohol consumption amounts, gender, age and marital status, smoking was still ascribed with a higher HSS score (B=3.94; 95%CI: 2.4-5.47; p<0.001). Conclusion: Smokers have tended to report on more hangover symptoms and had a higher HSS scores compared to non-smokers, regardless of the amounts of alcohol consumed. These findings provide an additional support to the recommendation of smoking cessation.

Keywords: Tobacco smoking; Alcohol; Hangover; Students a hangover after a night of excessive drinking (lowering alcohol consumption, eating before drinking or avoid dehydration) recommend Introduction avoiding smoking, including passive exposure to cigarette smoke during a drinking night in order to reduce hangover symptoms. (http://www. Alcohol hangover is a common phenomenon, experienced by wikihow.com/Prevent-a-Hangover; http://kennywordsmith.hubpages. numerous people amongst alcohol consuming societies. Recent com/hub/How-To-Get-Over-A-Hang-Over---Best-Hangover- research has demonstrated the impact of this phenomenon on various Remedies; http://www.howtoprevent.com/physical-health/how-to- aspects such as quality of life, cognitive functioning and affect, work prevent-a-hangover/). effectiveness and economy [1]. Nevertheless, so far, no measure was found to be effective in reducing the burden of hangover, besides alcohol This popular concept, that avoiding smoking can ameliorate abstinence. While several strategies and products were systematically hangover symptoms is currently not supported by the medical literature. evaluated, none of them was found efficient [2]. In order to evaluate whether this concept is valid, we conducted a study which compares the tendency to develop hangover symptoms between Two of the most purchasable drugs, alcohol and tobacco, are often smokers and non-smokers. co-abused. In fact, about 7% of the U.S. population is co-dependent [3,4]. Additionally, alcoholism is estimated to be 10 times more Materials and Methods common amongst smokers than nonsmokers [5]. Concurrent use of Participants these drugs poses significant public health concern and a large financial burden upon society. 739 University students were recruited in this observational, cross- sectional study, during September and October of 2009. 252 subjects Results from animal and human studies have demonstrated have met the exclusion criteria, 47 due to chronic headache or head multiple mechanisms for alcohol and nicotine co-use. Smokers trauma, 124 due to alcohol abstinence and 81 participants who have not reported that they felt less intoxicated compared with nonsmokers after the administration of an identical dose of alcohol [6]. These findings suggest that smokers are more tolerant to alcohol’s effects. In rodents, *Corresponding author: Ygal Plakht, RN, PhD, Soroka University Medical Center, co-treatment may be influenced by each drug more effectively than the P.O.B. 151, Beer-Sheva 84101, Israel, Tel: +972-8-640-0029; Fax: +972-8-640- adverse effects of the both [7]. Supporting this concept, neuroimaging 3547; E-mail: [email protected] studies, which had been conducted on people during alcohol withdrawal Received July 05, 2012; Accepted August 28, 2012; Published August 31, 2012 period with continuity of cigarette smoking, found decreased severity of Citation: Plakht Y, Zlotnik Y, Aven A, Engel Y, Am NB, et al. (2012) Alcohol the withdrawal-related changes in gamma-aminobutyric acid (GABA) Hangover Symptoms are More Common among Smokers. J Addict Res Ther neurotransmitter activity [8]. S7:003. doi:10.4172/2155-6105.S7-003 Considering these interactions found, it is surprising that Copyright: © 2012 Plakht Y, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted several nonscientific internet sites such as, WikiHow, HubPages and use, distribution, and reproduction in any medium, provided the original author and HowToPrevent.com, which are full of good advice on preventing source are credited.

J Addict Res Ther Alcoholism ISSN:2155-6105 JART, an open access journal Citation: Plakht Y, Zlotnik Y, Aven A, Engel Y, Am NB, et al. (2012) Alcohol Hangover Symptoms are More Common among Smokers. J Addict Res Ther S7:003. doi:10.4172/2155-6105.S7-003

Page 2 of 4 reported their status regarding the important parameters (smoking or Chi-square test and Student’s t-test. Comparison of prevalence of measure of hangover symptoms). Finally, 487 students were included in specific HSS syndromes was performed with non-parametric Mann- this study. The study was approved by the local Internal Review Board. Whitney U test. Since 13 secondary outcomes were defined, we used Bonferroni method for correction for the multiple comparisons, and Study instrument significance level was set at p=0.0038. Participating subjects filled out questionnaires without the presence Independent predictors for HSS score were tested through of an interviewer, and did not include any recognizable data to assure multivariate analysis (linear regression). The sub-group analyses anonymity. The questionnaires included demographics information included multivariate analysis of variance (MANOVA), multivariate regarding cigarette and alcohol consumption and the tendency to analysis of covariance (MANCOVA) and analysis of variance (ANOVA) develop hangover symptoms. for linear trend. P-values less than 0.05 were considered as statistically The demographics had included age, gender and marital status. significant unless stated otherwise. Cigarette smoking status was assessed as daily number of cigarettes consumed during the last year. Alcohol consumption was reported as Results the standard-size (pub measure) amount of alcohol “drinks” consumed Out of the 487 participants, 99 (20.3%) reported usual cigarette in a typical drinking during day or night; 1/3 litre of beer, glasses of smoking during the last year. Among these, the daily consumption wine, and “shots” of spirit (liquor, vodka, arak, whiskey etc.), and the of cigarettes ranged 0.3-30 with the mean of 9.38 (SD=7.33). Twenty- number of drinking days in a typical week. seven participants (27.3% of all smokers) smoked less than 4 cigarettes The tendency to develop hangover symptoms was assessed using the a day and were categorized as “mild smokers”; 37 (37.4% of all smokers) Hangover Symptom Scale (HSS), which was developed and validated consumed less than 12 cigarettes daily, and 32 (32.3%) consumed 12 or by Slutske et al. [9]. For the study purposes, we translated the scale to more cigarettes per day (“moderate” and “heavy” smokers respectively). the local language, validated by re-translation to English and compared The baseline characteristics of the study population and comparison with the original tool. This tool contained 13 symptoms. For each between non-smokers and smokers are presented in table 1. Compared symptom, the participants reported the frequency of its appearance to the non-smokers, the smokers were older and consumed a larger during the last year, expressed as percentage of drinking occasions after amount of various kinds of alcohol (except wine). In addition, the which the symptom occurred, on a 5-point scale, ranging from never total amount of alcohol consumed was significantly greater amongst (0% of the time) to every time (100% of the time), that were followed the smokers. next morning by the symptom (one of the symptoms, vomiting could have occurred either during the night or the next morning). Assessing All the hangover symptoms (except anxiety) were reported by the percentage of drinking occasions after which hangover symptoms smokers to occur in a higher frequency, than by non-smokers (Table occur partially controls the differences in the frequency of drinking and allows the HSS item scores to be interpreted as hangover vulnerability Parameter Total sample Non-smokers Smokers p (n=487) (n=388) (n=99) or proneness [9]. Demographics Study variables Age–mean (SD) 24.2(2.6) 24.3(2.7) 23.7(2.3) 0.046 Sex, female–n (%) 233(48.3) 191(49.5) 42(43.8) 0.315 Based on a self-reported smoking status, the participants were Family status, married–n (%) 40(8.3) 34(8.8) 6(6.1) 0.388 defined as non-smokers and smokers. The last group was categorized in Measured alcohol consumption* – mean (SD) 3 equal-sized sub-groups in accordance to a daily number of cigarettes. Wine 1.35(1.46) 1.31(1.45) 1.48(1.53) 0.476 These categories were: “mild”, “moderate” and “heavy” smokers. Total Beer 1.05(1.57) 0.9(1.46) 1.67(1.82) <0.001 measured alcohol consumption in a typical week was calculated as daily Spirits 1.25(2.39) 1.02(2.01) 2.14(3.38) <0.001 number of alcohol “drinks” multiplied by number of drinking days in a Total 3.65(3.84) 3.23(3.55) 5.3(4.49) <0.001 week (frequency) [9,10]. HSS** parameters- mean (SD) The primary outcome of the study was the value of HSS score Headache on the morning after 0.7(0.94) 0.64(0.9) 0.97(1.01) 0.001 related to the last year. HSS scores for each participant were calculated Woke up tired 1.07(1.13) 0.96(1.1) 1.48(1.15) <0.001 as a number of experienced symptoms with a possible range of 0-13 Difficulties falling 0.4(1.13) 0.31(0.68) 0.78(1.16) <0.001 asleep (so called “dichotomous approach”), or as sum of ranks with a possible Nausea on the morning after 0.6(0.92) 0.53(0.88) 0.88(1.03) <0.001 range of 0-52 (“polytomous approach”), as postulated by Slutske at al. Thirst 1.32(1.24) 1.16(1.18) 1.92(1.31) <0.001 [9] . According to the authors, the internal consistencies (Cronbach’s Vomited on the morning after 0.37(0.74) 0.3(0.66) 0.62(0.93) <0.001 alpha coefficients) for the “dichotomous” and “polytomous” scales were Tremor/chills on the morning after 0.16(0.58) 0.11(0.51) 0.32(0.81) 0.001 0.84 and 0.86 respectively. In our sample, Cronbach’s alfa coefficients Difficulties 0.59(0.89) 0.48(0.79) 0.98(1.12) <0.001 were 0.86 and 0.89 for the “dichotomous” and “polytomous” scales concentrating respectively. Anxious on the morning after 0.1(0.45) 0.08(0.35) 0.21(0.7) 0.144 Weakness on the morning after 0.57(0.9) 0.49(0.83) 0.87(1.09) 0.001 Statistical analyses Felt depressed 0.16(0.49) 0.12(0.42) 0.31(0.68) 0.001 Data was analyzed using PASW Statistics 18 software. The data was Diaphoresis 0.12(0.48) 0.07(0.35) 0.31(0.79) <0.001 presented as a number of participants (n) and percent (%) of categories Sensitivity to light and sound 0.34(0.73) 0.28(0.66) 0.58(0.92) <0.001 for nominal data and mean with standard deviation (SD) for count * Alcohol consumption measured as number of “drinks” (1/3 liter of beer, glasses of data. The primary outcome of the study was presented as a cumulative wine, single measure of spirit) per week percent of participants. ** HSS - Hangover Symptom Scale Table 1: Baseline characteristics and Hangover Symptom Scale (HSS) parameters The comparison between the study groups was performed using of study population and in the groups in accordance of smoking status.

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(SD=9.86), and 9.5 (SD=8.44) respectively (p for trend=0.809). 100 90 Discussion 80 Non smokers 70 Smokers In the presented study, we have attempted to compare the tendency 60 50 to develop alcohol hangover between smokers and non-smokers, 40 in order to evaluate a popular belief that smoking may increase the 30 likelihood to suffer from hangover. 20 Cumulative percent 10 As reported in the literature, cigarette smoking and alcohol 0 0 5 10 15 20 25 30 35 40 45 consuming are highly co-morbid phenomenons. In our cohort, one- HSS Score fifth of all students have reported usual cigarette smoking and around one-third of those consumed more than half a cigarette pack daily. Figure 1: Percentage (cumulative percent) of Hangover Symptom Scale (HSS) score among the non-smokers and smokers. These findings are comparable with the results of other studies, in which 17-25% of students were current smokers [11,12]. Expectedly, alcohol consumption was higher amongst smokers. Parameter B 95%CI* for B Beta p Smoking (yes vs. no) 3.935 2.404-5.465 0.224 <0.001 Our findings seem to support the belief that smokers suffer more Measured alcohol consumption from hangover. More than 20% of the non-smokers did not experience (1 unit increase)** 0.364 0.202-0.526 0.200 <0.001 hangover at all during the previous year, compared to 3% of the Gender (female vs. male) 1.469 0.225-2.713 0.105 0.021 smokers. Smokers tended to report more hangover symptoms and had Marital status (single vs. married) 2.337 0.006-4.448 0.092 0.049 higher HSS scores compared with the non-smokers, regardless of the Age (1 year increase) -0.035 -0.286-(0.216) -0.013 0.783 amounts of alcohol consumed. This tendency was remarkably stronger among women. * CI=Confidence interval ** Alcohol consumption measured as number of “drinks” (1/3 litre of beer, glasses Nevertheless, this tendency to develop hangover was not correlated of wine, single measure of spirit) per week to the reported daily cigarette consumption of the smokers. It is possible Table 2: Relationship between smoking status and Hangover Symptom Scale (HSS) score (multivariable analysis). that regular smoking habits do not represent the amounts of cigarettes smoked during drinking nights. 1). These differences remained statistically significant after applying a The influence of cigarette smoking on the alcohol hangover was Bonferroni correction. Using the “dichotomous approach” to the HSS previously hypothesized, but it was never heavily supported by data scale, the smoker participants reported, in average, more symptoms: [13-15]. In one study of college students, smokers tended more to 3.52 (SD=3.2), compared with the non-smokers: 5.66 (SD=3.36) report hangover like experiences, but there was no evidence that (p<0.001). Furthermore, the percent of participants reporting at least smoking status was associated with increased hangover susceptibility one hangover symptom was significantly higher amongst smokers than [16]. In another work, a correlation between smoking and hangover non-smokers: 376/388 (97%) vs. 75/99 (75.8%) respectively; p<0.001. in a small sample of 18-19 years olds was reported (Jackson et al. Using the “polytomous approach”, the mean HSS score was significantly unpublished observations. Available at: http://digitalcommons.wustl. higher midst smokers than non-smokers: 10.23 (SD=8.44) vs. 5.53 edu/guzeposter2006/11). (SD=6.25); p<0.001. The cumulative percentage of the score midst smokers than non-smokers is depicted in figure 1. The pathophysiology of hangover is not fully understood; neither is it the causal relationship between the latter and cigarette In a multivariate analysis, smoking was found to be independently smoking. Since hangover is essentially a phenomenon occurring associated with higher HSS grade (Table 2). The weekly consumption after alcohol levels had dropped to zero, several authors have of alcohol, female gender and “non-married” marital status were postulated that its major metabolite, acetaldehyde could contribute also independently associated with higher HSS score. No significant to hangover development [15]. Alcohol is metabolized by alcohol relationship between age and HSS score grade was found. The percent dehydrogenase to acetaldehyde which has some of its effects similar of shared variance (adjusted R square) for this model was 11.3%. to hangover symptoms. Acetaldehyde is also a major component of tobacco smoke, being primarily produced by the combustion of The sub-group analysesshows no significant difference in mean HSS score between the genders among non-smokers: 5.57 (SD=6.54) and 5.5 (SD=5.97) and for females and males respectively (p=1). However, 100 90 amongst smokers, significantly higher mean score of HSS was assigned 80 for females, compared to males: 12.43 (SD=9.63) vs. 8.56 (SD=7.28); 70 Non smokers 60 p=0.032, as presented in figure 2. The results of MANOVA shows the Female smokers 50 independent significant relationship of HSS grade with smoking and Male smokers 40 gender (p<0.001 and p=0.011 respectively), and with interaction of 30 20 these two factors (p=0.014). After adding the parameters of age, amount percent Cumulative of alcohol and maternal status as the co-variables (MANCOVA) only a 10 minimal change was demonstrated regarding relationship between the 0 0 5 10 15 20 25 30 35 40 45 gender-smoking interaction and the primary outcome (p=0.019). HSS score

No significant trend reflecting the HSS score in accordance to the Figure 2: Percentage (cumulative percent) of Hangover Symptom Scale (HSS) level of smoking was found. The mean values of HSS score in the groups score among non-smokers (both male and female), female smokers and male smokers. of mild, moderate and heavy smokers were: 8.96 (SD=6.07), 11.59

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This article was originally published in a special issue, Alcoholism handled by Editor(s). Dr. Huiping Zhang, Yale University, USA.

J Addict Res Ther Alcoholism ISSN:2155-6105 JART, an open access journal