Past between SAD, AS, smoking cessation outcomes

Past studies have established
relationships between smoking processes, anxiety sensitivity, and some anxiety
disorders such as post-traumatic stress disorder. Despite countless evidence of
the social nature of smoking, less attention has been paid to social anxiety’s
relationship with smoking, specifically poor cessation outcomes and social
anxiety disorder (SAD). This is an important aspect missing in the literature
given previous estimates that approximately 14–32% of individuals with SAD are
tobacco smokers (Morissette et al., 2007). Social learning theory is the essential
to fully understanding the relationship between SAD, smoking behaviors and poor
cessation outcomes (Marlatt and Gordon, 1985). Social learning theory explains
that relapse to smoking occurs in response to high-risk situations, including perceived
stressful emotional situations and perceived stressful social situations.
Existing experiments found strong reinforcement of the value of nicotine and
declining self-capability, which correlated with poor cessation outcomes. (Tong
et al., 2007). Comparing this to an undergraduate sample of 38 regular smokers,
SAD predicted smoking to cope behaviors and number of cigarettes that
participants estimated they would need to smoke to feel comfortable in social
situations (Watson et al., 2012).

American Psychiatric Association states SAD as a constant fear of social or
performance based situations in which a person feels exposed to unfamiliar
people or to possible judgement by others based on their performance or
behavior (American Psychiatric Association, 2013). An individual who has a fear
that he or she will act in a way or show anxiety symptoms that will be
embarrassing and humiliating in a social setting are examples of symptoms of
SAD. SAD is an important individual factor relevant to smoking processes,
perceived barriers of cessation and poor cessation outcomes. Although many
existing experiments have focused on the role of anxiety sensitivity (AS) in
predicting future panic attacks and other related forms of psychopathology,
other studies suggest persons with SAD, compared with those without a history
of SAD, are more likely to report elevated levels of AS. (Taylor, Koch, &
McNally, 1992). This is suggesting a possible relationship between SAD, AS,
smoking cessation outcomes and smoking behaviors (Schmidt, Lerew, & Joiner,
2000). This relationship is important to understanding how SAD plays a role in
AS which is an established cognitive risk factor for all other anxiety disorders.

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plays a specific and relevant role in psychological-based smoking processes and
their relation to AS and smoking cessation. The present studies suggest that
SAD may be more relevant to understanding AS and cessation-related
difficulties. This investigation seeks to examine specifically smoking
cessation difficulties, in the context of SAD, for perceptions of
cessation-related difficulties among adult treatment-seeking daily smokers. SAD
and AS were associated with lifetime heavy smoking behaviors, perceived
barriers to quitting, and failed quit attempts (Cougle et al., 2010). The
present study focuses on SAD perceptions, beliefs, and their relationship to
poor cessation outcomes. SAD is relevant to the fact that smoking will reduce
negative effects in social situations, which in turn reduces cessation rates in
smokers with SAD.

proposed study seeks to examine SAD’s relationship to perceived barriers to
quitting and to establish a significant correlation of increased cessation
difficulties for those with SAD. Those with higher levels of SAD have higher
perceived barriers to cessation thus leading to cessation difficulties.
Understanding how SAD rates correlate with perceived barrier rates is important
to understanding poor cessation outcomes. SAD’s relationship with perceived
barriers is a significant gap in the literature that needs to be thoroughly examined
to fully understand anxiety related cessation difficulties.




Two hundred heavy smokers with social
anxiety disorder are recruited through advertisements in local newspapers,
websites and community postings. To even consider participants had to be 18
years or older and smoke a minimum of 20 or more cigarettes daily for at least
2 years. Participants must provide an air carbon monoxide breath sample of 12
ppm or higher on the first baseline sessions to assure that all participants
are heavy smokers. Upon second arrival participants will also be administered a
carbon monoxide breath sample to assure participants are not smoking upon
second arrival unless failed cessation attempts are marked down. In addition,
participants had to meet full diagnostic criteria for SAD. Participants taking
psychotropic medications were also required to be on a stable dose for at least
four months that way reported symptoms were unreflective of starting or
stopping medications. Those left eligible completed baseline self-report
questionnaires and scheduled two experimental sessions, each session being 30
minutes long and scheduled eight weeks apart. Participants are recruited to
participate in examining the effects of an eight-week session of smoking
cessation analysis that focuses on vulnerability to SAD.


For both sessions all participants will be
administered The Liebowitz social anxiety scale (LSAS); which is used to
measure participants levels of SAD (Liebowitz, 1987). In comparison, The
Barriers to Cessation Scale was used to assess struggles, stress
related/associated with smoking cessation and later to be compared to SAD
measure scores (Macnee & Talsma, 1995). People who scored the highest on
the LSAS and Barriers to Cessation Scale initially should report more failed
cessation attempts, and a greater anxiety levels upon the second session
examination. Smoking cessation elevates levels of SAD symptoms, which
corresponds with increased perceived barriers to smoking cessation. The
Liebowitz Social Anxiety Scale is composed of 24 items divided into 2 subscales
each concerning SAD. The subscales are broken down into two categories of
questions, first being 13 items concerning performance anxieties and second 11
items pertaining to social situations. The 24 items are first rated on a scale
from (0=None to 4=Severe) on fearfulness felt during each of the situations,
and then the same items are rated regarding avoidance of each situation
(0=never to 4=usually) fear and avoidance are both significant symptoms of SAD
(Liebowitz, 1987). LSAS scale measures the amount to which participants are
concerned about possible negative consequences of SAD symptoms and scenarios.
LSAS was shown to have reliable psychometrics, the most important finding was
that people who showed one negative perception of a social scenario also fell
into other negative association categories. LSAS shows sound psychometrics by a
significant positive correlation observed between the results of Beck Scale
(Beck et al., 1961) and Liebowitz’s Scale. Software was used for statistical
analysis in the diagnosis of social anxiety and the scales’ relationship to one
another (Tyrala et al., 2015). The Barriers to Cessation Scale is a 19-item
measure to which participants indicate, on a Likert-type scale (0 = not a
current barrier or not applicable to 3 = large barrier), the amount to which
participants identified with each of the listed barriers to cessation such as a
fear of failing to quit or fear of never smoking again. Reliable psychometrics were
shown through the BCS scale, and the Daily Hassles Scale. This was demonstrated
by significant correlations and similar findings between the scores of the BSC
and scores of the Daily Hassles Scale (DeLongis, Folkman, & Lazarus, 1988).
An important finding was that the way people process barriers to smoking
heavily influences the process of quitting.


Participants will
be given a detailed description of the study over the phone and scheduled for
an appointment after responding to various community advertisements. Upon
arrival to the laboratory, each participant will be greeted by a research
assistant and provided verbal and written consent to participate in the
research study. After the initial sign up process, session
participants will be administered nicotine replacement therapy and be asked to
stop smoking. Participants will then be scheduled for a second session for
eight weeks later, participants will be asked to report failed cession attempts
in this period and be administered both tests upon the second arrival. The
participants will be paid fifty dollars, and the two sessions will be held in a
quiet office space. For ethical standards participants will be given nicotine
replacement therapy and will be asked to call the office if any concerns or
reactions arise. Two groups are assigned to participants, one group will be
high anxiety scores, and the other low anxiety scores. All scores obtained will
be from the initial test scores from first session participation and this will
determine their assigned group. High anxiety group participants, will have to score
12 or above on severe scores and low anxiety level participants will have to score
11 or less on severe scores on both scales. Instructions will be given to
participants upon the first session to stop smoking and keep a journal of how
many failed attempts they have in the next eight weeks if any. The sequence of
what will happen to participants is upon first session they will be
administered the LSAS scale, and the BCS scale. As the participants are keeping
track of their smoking behaviors groups will be assigned to each participant
with relation to their scores on both scales. When placed into groups the participants
will be administered the scales again for those who scored the highest on both
scales should report poor cessation outcomes. Only one form of manipulation
will be used which is nicotine replacement therapy. Intervention will only
happen if a participant has sudden side effects from nicotine replacement
therapy or significant emotional distress from cessation attempts.


primary goal of the present research is to examine smoking behaviors amongst
those with SAD and the impact of SAD on perceived barriers to cessation. The
findings support the present hypothesis that those with higher SAD levels not
only showed lower cessation rates but also showed greater perceived barriers to
cessation. The present research indicates that smokers with SAD may benefit
from treatment for SAD while attempting smoking cessation. Pearson’s r and a
paired t-test was used to test for possible group differences in smoking
behaviors, nicotine reinforcement and SAD. Pearson’s r correlation was used to
assess the extent to which the LSAS scale and the BCS scale correlated with
cessation outcomes. T-test significance was found in high SAD participants with
high perceived barriers of cessation and poor cessation outcomes. Participants
without SAD showed better results for smoking cessation attempts and showed
less perceived barriers of smoking cessation. Possible reasons for inconsistencies
in this experiment could be that although SAD does play a role in smoking
processing and cessation outcomes, sampling could be a potential issue in this
experiment. The sample this experiment chose from was primarily a group of adult smokers who volunteered to
participate for financial compensation. To rule out potential selection bias among participants with
these characteristics and increase the generalizability of these findings, it
will be important for researchers to draw from other populations and apply
recruitment tactics other than those used in the present study.

            Overall, the present study offers notable insight into
the relationship of SAD, cessation outcomes, and perceived barriers to
cessation. Results suggest SAD is significantly related to cessation outcomes
and perceived barriers. Although the current investigation found a relationship
between SAD and perceived smoking cessation barriers, future research needs to
be applied to fully understanding why there is a relationship between SAD and
smoking cessation. Future research can be used to assess which social
situations trigger tendencies to smoke more than others. Understanding that SAD
does play a specific and relevant role in smoking cessation attempts, these
findings need to be used as a stepping stone to understanding why SAD plays a
role in cessation outcomes. Numerous questions can be asked now that SAD is brought
to light as a factor in smoking cessation. Some questions that could be asked
after this investigation are, what social scenarios trigger SAD symptoms thus
leading to increased smoking urges? How relevant is SAD in cessation outcomes
and increased perceived barriers to smoking cessation? This investigation was a
frame work study used to open doors for numerous future investigations as to
why SAD plays a significant role in smoking processes. Overall, SAD and smoking
cessation difficulties influence one another and to improve cessation rates SAD
needs to be treated to help achieve cessation.