SocialAnxiety Disorder and Smoking CessationPast studies have establishedrelationships between smoking, and some anxiety disorders such aspost-traumatic stress disorder and panic disorder. Despite countless evidenceof the social nature of smoking, less attention has been paid to socialanxiety’s relationship with smoking, specifically poor cessation outcomes andsocial anxiety disorder (SAD). This is an important aspect missing in theliterature given previous estimates that approximately 14–32% of individualswith SAD are tobacco smokers (Morissette et al., 2007).

Social learning theoryis the foundation to fully understanding the relationship between SAD, smokingbehaviors and poor cessation outcomes (Marlatt and Gordon, 1985). Sociallearning theory explains that relapse to smoking occurs in response tohigh-risk situations, including stressful emotional situations and socialsituations that are perceived as stressful. Existing experiments found strongreinforcement of the value of the drug, declining self-capability correlatedwith poor cessation outcomes. (Tong et al., 2007). Comparing this to an undergraduatesample of 38 regular smokers, SAD predicted smoking to cope with behaviors andnumber of cigarettes that participants estimated they would need to smoke tofeel comfortable in social situations (Watson et al., 2012). TheAmerican Psychiatric Association states SAD as a constant fear of social orperformance based situations in which a person feels exposed to unfamiliarpeople or to possible judgement by others based on their performance orbehavior (American Psychiatric Association, 2013).

An individual who has a fearthat he or she will act in a way or show anxiety symptoms that will beembarrassing and humiliating in a social setting are symptoms of SAD. Animportant individual factor relevant to psychological-based smoking processesand poor cessation outcomes is SAD. Although many existing experiments havefocused on the role of anxiety sensitivity (AS) in predicting future panicattacks and other related forms of psychopathology, other studies suggestpersons with SAD, compared with those without a history of SAD, are more likelyto report elevated levels of AS. (Taylor, Koch, & McNally, 1992).

This issuggesting a possible relationship between SAD, AS, how both affect smokingcessation outcomes and smoking behaviors (Schmidt, Lerew, & Joiner, 2000).This relationship is important to understanding how SAD plays a role in ASwhich is an established cognitive risk factor for all other anxiety disorders.SADplays a specific and relevant role in psychological-based smoking processes andtheir relation to AS and smoking cessation. The present studies suggest thatSAD may be more relevant to understanding AS and cessation-relateddifficulties. This investigation seeks to examine specifically smokingcessation difficulties, in the context of SAD, for perceptions ofcessation-related difficulties among adult treatment-seeking daily smokers. SADand AS are associated with lifetime heavy smoking behaviors, nicotinedependence, and failed quit attempts (Cougle et al.

, 2010). Our study focuseson SAD perceptions, beliefs, and their relationship in poor cessation outcomes.SAD is relevant to the fact that smoking will reduce negative affect in socialsituations, which in turn reduces cessation rates in smokers with SAD.Theproposed study seeks to examine SAD relationship to perceived barriers ofquitting and establishing a significant correlation of increased cessationdifficulties for those with SAD. Those with higher SAD have higher perceivedbarriers to cessation leading to cessation difficulties.

Understanding how SADrates correlate with perceived barrier rates is important to understanding poorcessation outcomes. SAD relationship with perceived barriers is a gap in theliterature that needs to be examined to fully understand anxiety relatedcessation difficulties. MethodsParticipantsOne hundred heavy smokers with socialanxiety disorder and one hundred smokers without SAD are recruited throughadvertisements in local newspapers, websites and community postings. To evenconsider participants had to be 18 years or older and smoke a minimum of 20 ormore cigarettes daily for at least 2 years. Participants must provide an air carbonmonoxide breath sample of 12 ppm or higher on the first baseline sessions toassure that all participants are heavy smokers. Upon second arrivalparticipants will also be administered a carbon monoxide breath sample toassure participants are not smoking in the end unless failed cessation attemptsare marked down. In addition, participants had to meet full diagnostic criteriafor SAD. Participants taking psychotropic medications were also required to beon a stable dose for at least four months that way reported symptoms wereunreflective of starting or stopping medications.

Those left eligible completedbaseline self-report questionnaires and scheduled two experimental sessions,each session being 30 minutes long and scheduled eight weeks apart. Participantsare recruited to participate in examining the effects of an eight-week sessionof smoking cessation analysis that focuses on vulnerability to SAD.MeasuresFor both sessions all participants will beadministered The Liebowitz social anxiety scale (LSAS); which is used tomeasure participants levels of SAD (Liebowitz, 1987). In comparison, TheBarriers to Cessation Scale was used to assess struggles, stressrelated/associated with smoking cessation and later to be compared to SADmeasure scores (Macnee & Talsma, 1995). People who scored the highest onthe LSAS and Barriers to Cessation Scale initially should report more failedcessation attempts and a greater anxiety level upon the second sessionexamination. Smoking cessation elevates levels of SAD symptoms, whichcorresponds with increased perceived barriers to smoking cessation. TheLiebowitz Social Anxiety Scale is composed of 24 items divided into 2subscales, 13 concerning performance anxieties and 11 pertaining to socialsituations.

The 24 items are first rated on a Likert Scale from (0=None to4=Severe) on fear felt during the situations, and then the same items are ratedregarding avoidance of the situation (0=never to 4=usually) which are bothsymptoms of SAD (Liebowitz, 1987). This scale measures the amount to whichparticipants are concerned about possible negative consequences of SAD symptomsand scenarios. LSAS was shown to have reliable psychometrics, the mostimportant finding was that people who showed one negative perception of asocial scenario also fell into other negative association categories. LSASshows sound psychometrics by a significant positive correlation observedbetween the results of Beck Scale (Beck et. al, 1961) and Liebowitz Scale.Software was used for statistical analysis in the diagnosis of social anxietyand the scales’ relationship to one another.

(Tyrala et. al, 2015). TheBarriers to Cessation Scale is a 19-item measure on which participantsindicate, on a Likert-type scale (0 = not a current barrier or not applicableto 3 = large barrier), the amount to which participants identified with each ofthe listed barriers to cessation such as a fear of failing to quit or fear ofnever smoking again. Reliable psychometrics were shown through the BCS scaleand the Daily Hassles Scale. This was demonstrated by significant correlationsand similar findings between the scores of the BSC and scores of the DailyHassles Scale (DeLongis, Folkman, & Lazarus, 1988).

An important findingwas that the way people process barriers to smoking heavily influences theprocess of quitting.Procedures:Participants willbe given detailed description of the study over the phone and scheduled for anappointment after responding to various community advertisements. Upon arrivalto the laboratory, each participant will be greeted by a research assistant andprovided verbal and written consent to participate in the research study. Afterthe initial sign up process, session participants will be administered nicotinereplacement therapy and be asked to stop smoking. Participants will then be scheduledfor a second session for eight weeks later, participants will be asked toreport failed cession attempts in this period and be administered both testsupon second arrival.

The participants will be paid fifty dollars and the two sessionswill be held in a quiet office space. For ethical standards participants willbe give nicotine replacement therapy and will be asked to call the office ifany concerns or reactions arise. Two groups are assigned to participants, onegroup will be high anxiety scores and the other low anxiety scores. All scoresobtained will be from the initial test scores from first session participationand this will determine their assignment. High anxiety group participants, willhave 12 or above severe scores and low anxiety level participants scored 11 orless severe scores on both scales.

Instructions will be given to participantsupon first session to stop smoking and keep a journal of how many failedattempts they have in the next eight weeks if any. The sequence of what willhappen to participants is upon first session they will be administered the LSASscale and the BCS scale. As the participants are keeping track of their smokingbehaviors groups will be assigned to each participant with relation to theirscores on both scales.

When placed into groups the participants will be administeredthe scales and those who scored highest on both scales should report poorcessation outcomes. Only one form of manipulation will be used which isnicotine replacement therapy. Intervention will only happen if a participanthas sudden side effects from nicotine replacement therapy or emotional distressfrom cessation attempts.Results/DiscussionTheprimary goal of the present research is to examine smoking behaviors amongstthose with SAD and the impact of SAD on perceived barriers to cessation.

Thefindings support the present hypothesis that those with higher SAD levels notonly showed lower cessation rates but also showed greater perceived barriers tocessation. The present research indicates that smokers with SAD may benefitfrom treatment for SAD while attempting smoking cessation. Pearson’s r and ttests were used to test for possible group differences on smokingbehaviors, nicotine reinforcement and SAD. Pearson’s r correlations were usedto assess the extent to which the LSAS scale and the BCS scale correlated withcessation outcomes. T test significance was found in high SAD participants withhigh perceived barriers of cessation and poor cessation outcomes. Participantswithout SAD showed better results for smoking cessation attempts and showedless perceived barriers of smoking cessation. Possible reasons for inconsistenciesin this experiment could be that although SAD does play a role in smokingprocessing and cessation outcomes, sampling could be a potential issue in thisexperiment. The sample this experiment chose from was primarily a group of adult smokers who volunteered toparticipate for financial compensation.

To rule out potential selection bias among participants withthese characteristics and increase the generalizability of these findings, itwill be important for researchers to draw from other populations and applyrecruitment tactics other than those used in the present study.             Overall, the present study offers notable insight intothe relationship of SAD, cessation outcomes, and perceived barriers tocessation. Results suggest SAD is significantly related to cessation outcomesand perceived barriers. Although current investigation found a relationshipbetween SAD and perceived smoking cessation barriers, future research needs to beapplied to fully understanding why there is a relationship between SAD andsmoking cessation. Future research can be used to assess which social situationsthat trigger tendencies to smoke more than others. Understanding that SAD doesplay a specific and relevant role in smoking cessation attempts, these findingsneed to be used as a stepping stone to understand why SAD plays a role incessation outcomes.

Numerous questions can be asked now that SAD is brought tolight as a factor in smoking cessation. Some questions that could be askedafter this investigation are, what social scenarios trigger SAD symptoms thusleading to increased smoking urges? How relevant is SAD in cessation outcomes andincreased perceived barriers to smoking cessation? Understanding thisinvestigation was a frame work study which open doors for numerous futureinvestigation as to why SAD plays a key role in smoking processes.