Anxiety and Smoking

Anxiety disorders are significantly more prevalent among smokers than in the general population [10,49]. Reported rates of smoking were highest among individuals with panic-related disorders (i.e., panic attacks, panic disorder, and agoraphobia) and other anxiety disorders in which panic attacks often occur (e.g., social anxiety disorder, posttraumatic stress disorder [PTSD], generalized anxiety disorder; [10]). There is also mounting evidence to suggest that the presence of anxiety disorders can interfere with one’s ability to reap the benefit of smoking cessation programs and reduce the odds successful quitting [50]. In addition to diagnosable anxiety disorders, Anxiety Sensitivity, a cognitive risk factor for anxiety, has been associated with worse cessation outcomes [51]. These findings suggest that integrated treatment programs capable of addressing smoking cessation in the presence of cooccurring anxiety disorders or high levels of anxiety sensitivity may allow for improved cessation outcomes and a recent case report provides some preliminary evidence supporting this approach [52].

Mindfulness and Mind-Body Approaches

Mindfulness involves the self-regulation of attention toward, and nonjudgmental awareness of, present moment experiences [53]. It is most commonly defined as “paying attention in a particular way: on purpose, in the present moment, and non- judgmentally” [54]. Mindfulness involves several related but distinct skills, including the ability to (1) observe internal and external events as they occur in the present moment; (2) describe or label these events objectively; (3) act with awareness of the present moment; (4) accept present moment events without judgment; and (5) refrain from reacting impulsively to events. Mindfulness-based interventions help patients cultivate these skills through regular practice in formal (e.g., mindful sitting meditation, body scan meditation) and informal (e.g., mindful walking, mindful eating) mindfulness exercises.

One primary goal of mindfulness-based treatments for nicotine dependence is to increase awareness and acceptance of smoking cues as they occur in the moment. This awareness helps smokers tolerate smoking triggers and choose goal-directed behaviors (e.g., going for a walk vs. automatically smoking a cigarette when upset). Initially, the goal of mindfulness training is simply to become more aware of internal and external events. After bringing these events into conscious awareness, the goal becomes learning to relate to these experiences with openness, non-judgment, and curiosity. Treatment ultimately aims to teach patients to then “de-center” from these experiences by learning to view them as transient aspects of their awareness that may or may not need to be acted upon. For tobacco treatment, this de-centering process means learning to experience smoking triggers without automatically responding to them by smoking.

Mindfulness-based interventions generally take a cognitive-behavioral approach. However, they differ from standard cognitive-behavioral therapies in a few key ways. For example, mindfulness-based interventions aim to change the process of responding to smoking cues, rather than the content of the cues themselves. Additionally, mindfulness-based approaches incorporate a heavy focus on experiential learning in which a clinician helps the patient internalize important lessons from mindfulness or exposure exercises by reflecting key observations back to them (e.g., that a craving naturally subsided on its own during the meditation).

The structure of different mindfulness interventions can vary, though the content remains largely the same. Across interventions, the focus is generally on the role of negative affect and automatic thoughts in smoking, and how to use mindfulness skills to manage these experiences. Treatment typically begins by providing psychoeducation about the nature of addiction, the concept of mindfulness, and how mindful attention can interrupt addiction cycles. Formal meditations are often included in the first session. Over time, mindfulness exercises expand to include a focus on thoughts and emotions, and how they perpetuate smoking behavior. Techniques for applying mindfulness skills to smoking triggers are then highlighted throughout the treatment. For example, the Mindfulness Training for Smoking Cessation program utilizes the acronym RAIN (Recognize, Accept, Investigate, and Note cravings) to help smokers refrain from smoking in response to cravings [55].

Research Evidence Base for Mind-Body Interventions

Research supports the use of mind-body interventions. Previous studies have involved the application of standard mindfulness-based interventions for nicotine dependence (e.g., Mindfulness-Based Stress Reduction; [54]) and the development of smoking-specific mindfulness treatments (e.g., [55, 56]). Two studies comparing mindfulness training to the American Lung Association’s (ALA) Freedom from Smoking (FFS) program [57 ] found similar abstinence rates immediately posttreatment but significantly higher abstinence rates in the mindfulness group at longer-term follow-ups [58]. A study comparing nicotine replacement therapy (NRT) to combination NRT and Acceptance and Commitment Therapy (ACT)-a behavioral intervention incorporating elements of mindfulness and acceptance— found no significant differences post-intervention, but significantly higher abstinence rates at 1-year follow-up in the NRT/ACT group [59]. Mindfulness training might provide unique benefits for relapse prevention.

Improvements in emotional outcomes may serve as mechanisms by which mindfulness training improves smoking outcomes. One study found that levels of acceptance post-treatment significantly mediated the effect of mindfulness training on smoking status at 1-year follow-up [60 ] . Several other studies have found that mindfulness training weakens or eliminates the relationship between negative affect and smoking urges [61,62], as well as the relationship between cravings and smok?ing behavior [63]. These findings suggest that mindfulness training helps smokers break associations between aversive internal experiences and smoking, which likely contributes to decreased smoking behavior.

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