Interoceptive Exposure-Based Cessation Intervention for Smokers High in Anxiety Sensitivity: A Case Series

The current report presents the underlying rationale and components of an interoceptive exposure-based smoking cessation treatment for anxiety-sensitive smokers. The intervention was pilot-tested on three (female) daily smokers with moderate to high levels of nicotine dependence and high levels of anxiety sensitivity. Results indicated meaningful therapeutic gains in smoking outcome and theoretically expected changes in anxiety sensitivity, distress tolerance, and negative as well as positive affective states. Overall, the present case series highlights a potentially promising way to integrate interoceptive exposure-based treatment with standard smoking cessation treatment for smokers high in anxiety sensitivity. From a treatment development perspective, these case-series data suggest that future study of this intervention in a large-scale (controlled) clinical trial is indicated. Keywords: smoking; anxiety; anxiety sensitivity; distress tolerance; nicotine withdrawal; interoceptive exposure Cigarette smoking is the leading cause of preventable death, disease, and excess health cost globally (Centers for Disease Control and Prevention [CDC], 2008). There are currently about 1 billion cigarette smokers worldwide (Wald & Hackshaw, 1996). The selection hypothesis of smoking prevalence posits that smokers who are able to quit successfully are not "burdened" by specific individual difference characteristics that make it more challenging to quit (Hughes, 1993). Thus, the population of continuing smokers increasingly consists of individuals unable to quit (Pomerleau, 1997). The presence of emotional vulnerabilities or disorders may be one set of factors that interferes with successful smoking cessation (Irvin & Brandon, 2000). Indeed, those with psychiatric disorders are nearly twice as likely to be current smokers as those without psychiatric problems (41% vs. 22.5%), and smoking prevalence rates increase as the number of lifetime psychiatric disorders increases (Lasser et al., 2000). These disproportionately high smoking rates place those with psychiatric disorders at increased risk for tobacco-related illnesses and contribute substantially to the high rates of morbidity and mortality observed in psychiatric disorders (Hughes, 1993). Historically, anxiety disorders received little scholarly attention in regard to smoking (Zvolensky & Bernstein, 2005). Yet more recent research has found that tobacco use frequently co-occurs with anxiety and its disorders and that anxiety disorders may play a key role in the maintenance of tobacco use and dependence (Feldner, Babson, & Zvolensky, 2007; Kalman, Morissette, & George, 2005; Morissette, Tull, Gulliver, Kamholz, & Zimering, 2007). One emerging and promising line of inquiry examining the anxiety-smoking link has focused on the relations between anxiety sensitivity (AS) and smoking. AS is a well-established cognitive factor implicated in the development and maintenance of panic and related anxiety disorders (e.g., posttraumatic stress disorder; McNally, 2002; Taylor, 2003). The global AS construct encompasses lower-order fears of physical, mental, and publicly observable anxiety experiences (Zinbarg, Barlow, & Brown, 1997). This construct has been conceptualized as an individual-difference factor related to sensitivity to aversive internal states of anxiety, such as anxiety-related bodily sensations (Reiss, Peterson, Gursky, & McNally, 1986). Theoretically, people high in AS are more likely to be frightened of harmless heart palpitations because they believe these sensations will lead to cardiac arrest or other feared outcomes, whereas people low in AS do not fear these sensations because they believe them to be harmless. Empirically, AS is distinguishable from anxiety symptoms and other negative affect states (Rapee & Medoro, 1994; Zvolensky, Kotov, Antipova, & Schmidt, 2003). Various lines of research indicate that AS increases the risk for the future development of anxiety symptoms, panic attacks, and certain anxiety disorders (Hayward, Killen, Kraemer, & Taylor, 2000; Maller & Reiss, 1992; Schmidt, Lerew, & Jackson, 1999; Schmidt, Zvolensky, & Maner, 2006). …