Butting out for good

Psychologist Sherry Stewart is interested inthe overlap of mental health and addictions issues. (DannyAbriel Photo)

A pack of smokes costs more than $14. Health Canada plastersdire warnings across every pack. Employers ban smoking on theirpremises outright. Peer pressure can be unrelenting.

And still, smokers huddle outside, braced against the worstweather, getting in a quick puff.

Psychologist Sherry Stewart noticed the barely-dressed patientssmoking at hospital entrances. Taking note of the chronic smokers,she wanted to better understand their addiction. How could thatlittle four by three inch package be so insidious for some smokersbut not for others?

"For a long time, I've been interested in the overlap of mentalhealth and addictions issues as an overarching theme throughout myresearch, whether the focus is alcohol abuse, problem gambling orsmoking cessation," says Dr. Stewart.

She knew that public health campaigns and tobacco interventionprograms have been quite successful in motivating many to quitsmoking—to the point that non-smokers now make up 80 per centof the Canadian population. At the same time, she was aware that acore group of smokers are unable to quit either on their own orthrough existing tobacco intervention programs. And while theliterature has established a linkage between smoking and anxiety,what's been missing is an explanation of how a predisposition toanxiety leads to smoking and how smoking in turn produces anxiousarousal.

Reasons to smoke

"In both cases, we're looking at reasons for smoking," sheexplains. Some people enjoy the tactile experience of handlingcigarettes, while others crave the stimulant effect and greaterconcentration. A final group uses smoking to reduce negativeaffect, such as feeling pessimistic, stressed out or nervous insocial situations.

Research participants were recruited in cooperation with theCapital District Health Authority's Addictions Prevention andTreatment Services. The group consisted of heavy smokers who weremotivated to stop smoking. Most of them had made three previousattempts to quit smoking. Many first lit up at a young age, someeven as early as their mid-teens. The average time the participantshad been smoking was 28 years. And, to be considered a heavysmoker, they had a pack a day habit.

The intention was to see if which of the coping motives might bethe variable that helps explain how the other factors are related.She began to focus her research on understanding which motivationwas most germane for the group of chronic heavy smokers. Theoutcome was a demonstration that people with more anxiousarousal— nervousness, social anxiety, negative moods—dosmoke at higher rates, as predicted.

"They are more focused on their symptoms so that reason putsthem at risk for smoking behaviour. It's for that coping reason, toself-medicate anxiety, that we see smoking at greater rates inanxious people," she says. "What this tells us is that we need totarget the motivations of people who are in this group of chronicheavy smokers. We have to help them cope differently, in healthierways. We need to educate them that in the longer term smoking isgoing to make them more anxious instead of lessening this pressure.At the moment, this doesn't happen much in currentinterventions."

One possibility is to develop a targeted intervention foranxious smokers and colleague Michael Zvolensky, of the Universityof Vermont, is exploring ways to deal with both these problems: theregular difficulties inherent in withdrawal along with treatment tobecome less sensitive to anxiety. This could mean a plannedwithdrawal program that includes cognitive therapy. The firstplanned withdrawal might be for 12 hours. The smoker documents thesymptoms and the therapist discusses the experiences. The coachingis key to being able to interpret sensations differently and todevelop more positive self-talk so that relapsing is not seen as afailure. The next planned withdrawal would be for 24 hours.

Symptoms come back stronger

"Anxiety sensitive people relapse more quickly, so the earlydays—and even hours—are particularly tough on them,"she says. "Anxiety sensitive people are more motivated to quit andyet they have a harder time."

The study, funded by the former Canadian Tobacco ControlResearch Initiative, also learned that coping motives explain howsmoking increases a person's anxious symptoms over time spentsmoking. Symptoms keep coming back stronger, so the smoking'coping' mechanism is maladaptive over time.

"We've done environmental interventions to get smoking ratesdown, but those who are still smoking have psychological challengesthat make it more of a challenge," she says.

"Evaluating the mediating role of coping-basedsmoking motives among treatment-seeking adult smokers," wasrecently published in Nicotine andTobacco Research (Nov. 2009). While Dr. Stewart believesthis is a promising avenue for further study, she notes that Canadano longer has a national research funding agency directed towardsmoking cessation.