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ScienceDirectCognitive and Behavioral Practice 21 (2014) 350-363

An Anxiety Sensitivity Reduction Smoking-Cessation Program forSpanish-Speaking Smokers (Argentina)

Michael J. Zvolensky, University of Houston and University of Texas MD Anderson Cancer CenterDaniel Bogiaizian and Patricio López Salazar, Asociación Ayuda, Anxiety Disorders Clinic, Buenos Aires

Samantha G. Farris and Jafar Bakhshaie, University of Houston

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The present study evaluated a Spanish-language version of an Anxiety Sensitivity Reduction Program for Smoking Cessation among asample of daily adult smokers from Argentina (n = 6; Mage = 49.4, SD = 15.43) in an open trial methodological design. To be eligible,each participant expressed a current desire to quit smoking and previous difficulties with anxiety/mood symptoms during past quitattempts (e.g., anxiety, stress, depression, irritability). Participants completed a baseline assessment and received eight 90-minute weeklygroup sessions. The study involved one doctoral-level and two graduate-level therapists. Follow-up visits were scheduled at 1, 2, 4, 8,and 12 weeks post-quit day. Smoking status was confirmed biochemically and via self-report at quit day and each follow-up assessment.The treatment yielded positive results in terms of attendance, positive smoking cessation outcome (5 out of 6 were abstinent at 12-weekfollow-up), and significant reductions in anxiety sensitivity. The results suggest potential clinical utility among Spanish-speakingsmokers for an anxiety-sensitivity smoking cessation program in regard to cessation outcome.

S MOKERS prone to psychiatric symptoms and conditionsare a high-risk smoking subpopulation (Ziedonis et al.,

2008). Among the various psychiatric symptoms andpsychopathologies, depressive and anxiety symptoms andsyndromes are highly prevalent in the general populationand are comorbid with smoking (Leventhal, Ramsey,Brown, LaChance, & Kahler, 2008; Piper, Cook, Schlam,Jorenby, & Baker, 2011; Piper et al., 2010; Zvolensky,Bernstein, Yartz, McLeish, & Feldner, 2008). Amongcurrent smokers, negative emotional symptoms and disor-ders significantly increase risk of smoking cessation failure(Hall,Muñoz, &Reus, 1994;Hitsman, Borrelli, McChargue,Spring, & Niaura, 2003), heighten severity of tobaccowithdrawal (Langdon et al., 2013; Leventhal et al., 2008),and contribute to maladaptive cognitive beliefs andcognitive-affective reactions to tobacco (Brandon, 1994;Peasley-Miklus, McLeish, Schmidt, & Zvolensky, 2012). Forthis reason, there is good reason to better understand andclinically target depression/anxiety symptoms and disor-ders in order to improve cessation outcome.

ords: South America (Argentina); smoking cessation; negativet; anxiety sensitivity; treatment development

-7229/13/350-363$1.00/0013 Association for Behavioral and Cognitive Therapies.ished by Elsevier Ltd. All rights reserved.

Although still limited in overall scope (see Richards,Cohen, Morrell, Watson, & Low, 2013, for a review),specialized treatments targeting depression/anxiety symp-toms and disorders for smoking cessation have beendeveloped (e.g., Feldner, Smith, Monson, & Zvolensky,2013; Hertzberg, Moore, Feldman, & Beckham, 2001;MacPherson et al., 2010; McFall et al., 2010; McFall et al.,2005; Zvolensky, Lejuez, Kahler, & Brown, 2003). Yet, theresults of these studies generally suggest rather modestimprovements or even mixed results (e.g., Brown et al.,2007; Hitsman et al., 2003). Rather than focus primarily ondepression/anxiety symptoms, others have suggested thatthere may be merit to identify and target transdiagnosticfactors that are related to both anxiety anddepression aswellas other negative mood problems (e.g., anger) amongsmokers to facilitate cessation success (Zvolensky &Bernstein, 2005; Zvolensky, Schmidt, & Stewart, 2003).One promising line of inquiry in this domain has focusedon the relations between anxiety sensitivity and smoking.

Anxiety sensitivity is a transdiagnostic factor implicatedin the development and maintenance of panic andother emotional disorders (e.g., posttraumatic stress disor-der; McNally, 2002; Taylor, 2003). This construct has beenmost commonly conceptualized as an individual differencefactor related to sensitivity to aversive internal states ofanxiety (Reiss, Peterson, Gursky, & McNally, 1986). Anxietysensitivity is distinguishable empirically and theoreticallyfrom anxiety symptoms and other negative affect states(Rapee & Medoro, 1994; Zvolensky, Kotov, Antipova, &

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Schmidt, 2003). For example, anxiety sensitivity demon-strates incremental predictive validity relative to negativeaffectivity or trait anxiety in the prediction of anxietysymptoms (Zvolensky, Kotov, et al., 2003; Zvolensky, Lejuez,et al., 2003; Zvolensky, Schmidt et al., 2003). Moreover,numerous lines of research indicate that anxiety sensitivitysignificantly increases the risk for the future development ofanxiety and depressive symptoms, panic attacks, and anxietyas well as other mood disorders (Hayward, Killen, Kraemer,& Taylor, 2000; Maller & Reiss, 1992; Marshall, Miles, &Stewart, 2010; Schmidt, Lerew, & Jackson, 1999; Schmidt,Zvolensky, & Maner, 2006).

Research also indicates anxiety sensitivity is related tosmoking behavior. For example, anxiety sensitivity ispositively correlated with smoking motives to reducenegative affect (Battista et al., 2008; Comeau, Stewart, &Loba, 2001; Leyro, Zvolensky, Vujanovic, & Bernstein, 2008;Novak, Burgess, Clark, Zvolensky, & Brown, 2003; Stewart,Karp, Pihl, & Peterson, 1997; Zvolensky, Bonn-Miller,Bernstein, & Marshall, 2006) and negative affect reductionexpectancies (beliefs that smoking will reduce negativeaffect; Brown, Kahler, Zvolensky, Lejuez, & Ramsey, 2001;Gregor, Zvolensky, McLeish, Bernstein, & Morissette, 2008;Johnson, Farris, Schmidt, Smits, & Zvolensky, 2013). Recentresearch also suggests that anxiety sensitivity is predictive ofgreater increases in positive affect pre- to post-cigarette use(Wong et al., 2013) and that among high anxiety-sensitivesmokers (relative to low anxiety-sensitive smokers), cigarettesmoking after exposure to stressful situations reducessubjective anxiety (Evatt & Kassel, 2010; Perkins, Karelitz,Giedgowd, Conklin, & Sayette, 2010). From a cessationperspective, smokers higher relative to lower in anxietysensitivity perceive quitting as more difficult (Zvolensky,Vujanovic, et al., 2007). Other work has identified thatanxiety sensitivity may be related to more intense nicotinewithdrawal during early phases in quitting (i.e., 1 weekpost-quit; Johnson, Stewart, Rosenfield, Steeves, &Zvolensky,2012; Langdon et al., 2013; Marshall, Johnson, Bergman,Gibson, & Zvolensky, 2009; Vujanovic & Zvolensky, 2009;Zvolensky, Lejuez, et al., 2004), but not necessarilywithdrawal in later phases of quitting (Mullane et al.,2008). Higher levels of anxiety sensitivity are also related togreater odds of early lapse (Brown et al., 2001) and relapseduring quit attempts (Assayag, Bernstein, Zvolensky, Steeves,& Stewart, 2012; Zvolensky et al., 2006; Zvolensky, Bernstein,et al., 2007; Zvolensky, Stewart, Vujanovic, Gavric, & Steeves,2009). Importantly, the observed anxiety sensitivity-smokingeffects do not appear to be explained by smoking rate,nicotine dependence, gender, other concurrent substanceuse (e.g., alcohol, cannabis), panic attacks, or traitlikenegative mood propensity (Johnson et al., 2013; Wonget al., 2013).

Efforts have been made to target reductions in anxietysensitivity to improve cessation outcomes. These efforts

are guided by non-tobacco-oriented intervention pro-grams for the prevention of anxiety/mood psychopathol-ogy; such programs have targeted anxiety sensitivityvia psychoeducation, cognitive restructuring, andinteroceptive exposure (Broman-Fulks & Storey, 2008;Gardenswartz & Craske, 2001; Schmidt et al., 2007;Vujanovic, Bernstein, Berenz, & Zvolensky, 2012).These anxiety-sensitivity-reduction techniques have sub-sequently integrated into smoking cessation programs foranxiety-prone smokers motivated to quit. For example, inthe earliest study in this area, a 16-session integratedanxiety-sensitivity smoking-cessation treatment was foundto successfully reduce anxiety sensitivity and was improvedquit success (Zvolensky, Lejuez, et al., 2003). Controlledsmoking cessation work found that a single-session inter-vention program can reduce anxiety sensitivity andfacilitate reductions in smoking rate at 1-month follow-up(Feldner, Zvolensky, Babson, Leen-Feldner, & Schmidt,2008). Based upon such work, an 8-session program forsmokers high in anxiety sensitivity was developed, entitledthe Anxiety Sensitivity Reduction Program for SmokingCessation (Zvolensky, Yartz, Gregor, Gonzalez,&Bernstein,2008). In general, the treatment applied cognitive restruc-turing and acceptance-oriented behavioral strategies as wellas interoceptive exposure with a specific focus on reducinganxiety sensitivity, combined with evidenced-based behav-ioral counseling for smoking cessation (see Zvolensky,Yartz, et al., 2008; Zvolensky & Farris, 2012, for compre-hensive session-by-session descriptions of the treatment). Ina case series evaluation (n = 3), this program yieldedsignificant reductions in anxiety sensitivity and facilitatedsmoking cessation success at 1-month follow-up (Zvolensky,Yartz, et al.).

In the present study, we evaluated an adapted versionof Anxiety Sensitivity Reduction Program for SmokingCessation to replicate and uniquely extend past work infour significant ways. First, we sought to complete anuncontrolled evaluation of the program with a 3-monthfollow-up. With consistent findings relative to past work(Zvolensky, Yartz, et al., 2008), this current test wouldfurther strengthen existing findings and set the stage for alarger, controlled clinical trial. Second, we sought totranslate the treatment to the Spanish language andprovide a cross-national test of the acceptability and clinicalutility of the treatment program in South America(Argentina); no other cultural adaptations were made.This extension to the Spanish language from Englishis important because smoking rates are exceedinglyhigh in South America generally and Argentina specifically(e.g., 29% prevalence in Argentina; World HealthOrganization [WHO], 2008). Moreover, a Spanish-language version of the treatment, with further culturaladaptation, could potentially be disseminated to otherSpanish-speaking populations in other parts of the world

352 Zvolensky et al.

(e.g., Mexican Americans; Reitzel et al., 2009). Third, theintervention was further refined from the previous evalu-ation by expanding it to more comprehensively focus onreactivity to, and tolerance of, negative emotional andbodily symptoms during quitting and the regulation of suchstates by smoking (cf. addressing clinical anxiety). Thischange was important as negative affect states, broadly,often are related to poorer cessation outcome (Piasecki,Kenford, Smith, Fiore, & Baker, 1997) and qualitativepatient feedback from the initial trial suggested such abroader focus would be clinically useful (i.e., patientsreported they struggle withmany varieties of negative affectwhen quitting; Zvolensky, Yartz, et al., 2008). Thus, wetested the treatment on smokers who were interested inquitting and also experienced significant emotional distressobstacles in past quit attempts. Finally, we added atelephone support component to treatment in whichevery 48 hours post-quit the therapist would contact thepatient to provide direction/support in smoking cessationand alternative emotion regulation tactics. This decisionwas guided by clinical observation in the initial case seriesthat additional social support and individually tailoredfeedback would be useful (Zvolensky, Yartz, et al.) andempirical findings suggesting telephone support canenhance cessation success (Free et al., 2011).

It was expected that the Anxiety Sensitivity ReductionProgram for Smoking Cessation would facilitate abstinencedue to decreased emotional vulnerability, as indexed bydecreased (a) anxiety sensitivity; (b) negative emotionalityas indexed by negative affectivity (generalized tendencyto experience negative affect states; Watson, 2000); as wellas (c) nicotine withdrawal severity (Hughes, Higgins, &Hatsukami, 1990). Formal comparisons were plannedacross three clinically and conceptually distinct time points:(a) from baseline to quit day (treatment phase change);(b) from1 to 12 weeks follow-up (change over the course offollow-up); and (c) from baseline to 12-week follow-up(baseline to end of follow-up change). We expected thegreatest clinically and statistically significant change to beevident from baseline to quit day and from baseline tofollow-up assessments (a and c time points mentionedabove). We did not expect meaningful change (stable)across follow-up assessments (time point b mentionedabove), as the “active therapeutic element” would haveoccurred earlier in treatment with the present model andbe maintained thereafter (Zvolensky, Yartz, et al., 2008).

MethodParticipants

Participants were six adult smokers (Mage = 50.7, SD =14.15, range 28 – 67 years; 5 female) living in Buenos Aires,Argentina. Participants were self-referred to an anxietydisorder treatment (outpatient) clinic in Buenos Aires whoresponded to an advertisement to quit smoking. All

participants expressed current motivation to quit smokingand indicated previous difficulties with anxiety/moodsymptoms during past quit attempts (e.g., anxiety, stress,depression, irritability). No other recruitment or screeningtactics were involved, nor were there any other inclusion/exclusion criteria. No participants had a current Axis Idisorder (as determined through structured clinicalinterview). Half of the participants completed 4 years ofcollege; one completed part of college and two completedprimary schooling. Below, we provide (a) a detaileddescription of each participant and their smoking-basedclinical presentation and then (b) a group-based summaryof the cohort.

Participant 1 was a 41-year-old divorced female whoreported smoking an average of 20 cigarettes per day andhad been smoking regularly for the past 20 years(Fagerström Test for Nicotine Dependence [FTND]score = 7.0; moderate to high level of nicotine depen-dence). He reported two previous quit attempts (mostrecently 2 years ago), and endorsed significant withdraw-al symptoms including weight gain, digestive problems,irritability, restlessness, anxiety, and cravings.

Participant 2 was a 51-year-old married male whoreported smoking an average of 20 cigarettes per day andhad been smoking regularly for the past 35 years (FTNDscore = 1.0; low nicotine dependence). He reported threeprevious quit attempts, with his most recent attempt about1 year ago, which lasted approximately 9 months. Duringthe attempt, he endorsed minimal withdrawal symptoms(only mild increased appetite).

Participant 3 was a 28-year-old single female whoreported smoking an average of 7 cigarettes per day andhad been smoking regularly for the past 14 years (FTNDscore = 0; no dependence). She reported four previousserious quit attempts, which lasted at most 10 days.During her most recent quit attempt (2 years ago), sheendorsed experiencing moderate withdrawal symptomsincluding increased appetite and weight gain, restlessness,anxiety, and cravings.

Participant 4 was a 67-year-old married female whoreported smoking an average of 15 cigarettes per day andhad been smoking regularly for the past 45 years (FTNDscore = 2.0; low level of nicotine dependence). Shereported seven serious previous attempts where she quit“cold-turkey,” with hermost recent cessation attempt in thepast year in which she was quit for 3 months. She endorsedsignificant withdrawal symptoms including digestive prob-lems, depression/low mood, irritability, restlessness, anxi-ety, and cravings.

Participant 5 was a 60-year-old married female whoreported smoking an average of 20 cigarettes per day andhad been smoking regularly for the past 30 years (FTNDscore = 4.0; moderate level of nicotine dependence). Shereported three previous quit attempts and has utilized

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several quit strategies including “cold-turkey,” a smokingcessation program, acupuncture, and nicotine gum;however, she was quit for only 1 day during her mostrecent cessation attempt (approximately 1 year ago). Sheendorsed withdrawal symptoms including severe digestiveproblems, increase appetite, and weight gain.

Participant 6 was a 57-year-old widowed female whoreported smoking an average of 15 cigarettes per day andhad been smoking regularly for the past 21 years (FTNDscore = 5.0; moderate level of nicotine dependence). Shereported two previous quit attempts, with her most recentattempt being 4 years ago and lasting 5 months. Sheendorsed significant withdrawal symptoms includingincreased appetite and weight gain, irritability, restless-ness, and cravings.

Collectively, participants reported smoking an averageof 14.5 cigarettes per day (SD = 4.64) and reported beinga regular smoker for 27.5 years (SD = 5.11). The averageage of first cigarette use was 14.5 years (SD = 1.22). Theaverage FTND score was 3.2 (SD = 2.64), indicating low tomoderate levels of nicotine dependence. Participantsreported an average of 3.5 previous serious quit attempts(SD = 1.87) (i.e., a quit lasting over 24 hours) and indicatedthey utilized an averageof 3.2 (SD = 1.47) different strategiesto aid in the quit attempt (e.g., nicotine replacementtherapy, behavior modification, gradual reduction,Bupropion). All participants endorsed the experience ofwithdrawal symptoms during their most recent quit attempt,and most frequently included digestive problems, increaseappetite, irritability, restlessness, anxiety, and cravings.

Measures

The assessment battery was selected to assess threeprincipal areas, including (a) demographics, tobaccouse, and nicotine withdrawal; (b) sensitivity/tolerance foranxiety/bodily stress; and (c) negative affect. Spanishtranslations of all self-report assessments were utilized.

Demographics, Tobacco Use, and Nicotine WithdrawalA Demographics Questionnaire was used that included

items regarding participants’ education and treatmenthistory for psychiatric and medical illnesses. The question-naire was administered at baseline.

The Smoking History Questionnaire (SHQ; Brown,Lejuez, Kahler, & Strong, 2002) is a self-report question-naire used to assess smoking history and pattern. The SHQincludes items pertaining to smoking rate, age of onset ofsmoking initiation, years of being a daily smoker, andnumberof past quit attempts. TheSHQhasbeen successfullyused in previous studies as a measure of smoking history,pattern, and symptom-based problems during quitting(Zvolensky, Lezjuez, et al., 2004; Zvolensky, Leen-Feldner,et al., 2004). The SHQ was administered at baseline.

The Fagerström Tolerance Questionnaire (FTQ;Fagerström, 1978) was used as a continuous self-reportmeasure of nicotine dependence at baseline, andassesses gradations in tobacco dependence (Heatherton,Kozlowski, Frecker, & Fagerström, 1991). Specifically, theFTQ (8-item measure) was administered and was scoredas the FTND (6-item total score), which includes twoitems rated on a 4-point Likert-style scale (0–3) and fouritems rated dichotomously (yes/no). The FTND hasshown good internal consistency, positive relations withkey smoking variables (e.g., saliva cotinine; Heathertonet al., 1991; Payne, Smith, McCracken, McSherry, &Antony, 1994), and high degrees of test-retest reliability(Pomerleau, Carton, Lutzke, Flessland, & Pomerleau,1994). The Bedfont Micro III Smokerlyzer CO Monitor(Model EC50; Bedfont Scientific USA, Medford, NJ) wasused as a biochemical verification of smoking status viaanalysis of expired carbon monoxide (CO) in breathsamples. Research indicates that 8–10 ppm is an optimalcutoff score for reliably discriminating status as a dailysmoker (Jarvis, Tunstall-Pedoe, Feyerabend, Vesey, &Saloojee, 1987; Morabia, Bernstein, Curtin, & Berode,2001). The CO test was administered at baseline and eachpost-quit assessment.

A Timeline Followback (Sobell & Sobell, 1992)procedure was employed at the quit day appointmentand at each of the follow-up appointments. Specifically,participants were asked about their daily smokingbehavior following the cessation date, including whetheror not they smoked each day. If they smoked, participantswere asked to specify the number of cigarettes smokedper day. This method of tracking smoking has been usedsuccessfully in past work (McLeish, Zvolensky, & Bucossi,2007).

The Minnesota Nicotine Withdrawal Scale (MNWS;Hughes & Hatsukami, 1986, 1998; Hughes et al., 1984)assesses the experienceof nicotinewithdrawal symptoms. Foreach of the eight common nicotine withdrawal symptoms(frustration or anger/irritability, anxiety/nervousness,difficulty concentrating, restlessness/impatience, hunger,awakening at night, depressed or sad mood, and desireto smoke), respondents rate on a 5-point Likert-type scale(0 = none to 4 = severe) thedegree towhich the symptoms arecurrently experienced. The MNWS has demonstrated goodvalidity and reliability in regard to examining withdrawalsymptoms from cigarettes (Allen, Hatsukami, Christianson,& Nelson, 1996; Hughes, Gust, Skoog, Kennan, & Fenwick,1991). The MNWS was used in this study to index changein nicotine withdrawal symptoms at baseline and over thepost-quit assessment.

Sensitivity of Anxiety and Bodily StressThe Anxiety Sensitivity Index-III (ASI-3; Taylor et al.,

2007) was employed to assess anxiety sensitivity. The ASI-3

354 Zvolensky et al.

is an 18-item self-report measure of the sensitivity to, andfear of, anxiety-related sensations. Respondents are askedto indicate, on a 5-point Likert-type scale (0 = not at all to4 = very much) the degree to which they are concernedabout possible negative consequences of anxiety-relatedsensations (e.g., “It scares me when I blush in front ofpeople”). The ASI-3 has demonstrated sound internalconsistency, test-retest reliability, and convergent validityas well as discriminant and criterion validity (Tayloret al.). The ASI-III was administered at baseline and eachpost-quit assessment to index change in anxiety sensitivity.

Negative MoodThe Positive Affect Negative Affect Scale (PANAS;

Watson, Clark, & Tellegen, 1988) assesses two globaldimensions of affect: negative (PANAS-NA) and positive(PANAS-PA). For each of 20 adjectives (e.g., “irritable”),participants indicate on a 5-point Likert-type scale (1 = veryslightly to 5 = extremely) the degree to which the descriptortypifies how they generally feel. Both the PANAS-NA andPANAS-PA have demonstrated good convergent anddiscriminant validity, as well as high levels of internalconsistency (rangeof alpha coefficients: .83 to .90 and .85 to.93, respectively). A large body of literature supports thepsychometric properties of the PANAS (see Watson, 2000).The PANAS-NA was used in this study to index thepropensity to experience negative affect symptoms atbaseline and each post-quit assessment.

Treatment Overview

The treatment program employs elements of cognitive--behavioral treatment of anxiety and elements of smokingcessation treatment tailored for daily smokers who have ahistory of emotional problems while quitting. We provide adetailed description of the core elements of the program;however, themanual itself can be attained by contacting thelead author.

Element 1: Therapeutic RationaleParticipants are provided with a comprehensive psy-

choeducational rationale for linkages between negativemood, emotional reactivity, and smoking. This task isconducted during Session 1. It is emphasized that dueto the negative associations with one another, it is importantto target these problems simultaneously in order to break“stubborn” smoking-negative mood relations. It is ex-plained that in addition to “typical” smoking cessationtreatment (e.g., monitoring cigarettes, use of the nicotinereplacement therapies), the current treatment focuses onlearning and practicing emotion regulation strategies thatwill help them to better manage, interpret, tolerate, andcope with emergent nicotine withdrawal and anxiety/bodily symptoms. Specifically, anxiety sensitivity is defined

and illustrative smoking examples of interplaywith smokingare offered.

It is then clarified how smoking can often be employedto regulate mood/bodily tension or stress in the shortterm (perceived or objectively or both). The process ofthe forward-feeding cycle is explained, whereby fears ofanxiety/bodily sensations and perceived distress intoler-ance can lead to both subjective threat evaluations andheightened attention to threatening stimuli. It is ex-plained that such experiences may “sensitize” a person tothreat cues (i.e., makes them reactive). In this way,smoking can often be reinforced as an emotion regula-tion tactic for the management of anxiety/bodily tensionand other negative mood states. For these reasons,(a) targeting the fear of anxiety, (b) improving tolerancefor emotional/bodily distress, and (c) modifying suchprocesses via acceptance-oriented emotion regulationexercises can be important in addressing smoking. In thiscontext, the importance of practicing exposure exercisesboth in and out of session is emphasized. Specifically, ananalogy to exercise is drawnwhereby patients are remindedthat to learn to run a marathon a person needs to practicerunning in smaller amounts first on a consistent basis. As inexercise, achieving success in smoking cessation can oftenbe benefited by recurrent, consistent practice prior to a quitattempt.

Element 2: Decreasing Emotional Sensitivity to Anxiety/BodilyStress and Increasing Tolerance for Such States

The second element in the treatment program involvesusing evidenced-based strategies originally developed foranxiety treatment programs to decrease emotionalsensitivity and increase tolerance for aversive internalsensations (i.e., graduated exposure). This aspect oftreatment is designed to gradually decrease emotionalresponsivity to threat-provoking cues that are directlyrelevant to their personal cessation effort, as is done infear extinction paradigms (Bouton & Nelson, 1998). Forexample, a smoking-relevant exposure may include gradu-ated smoking abstinence (to model exposure to nicotinewithdrawal) and exposure to uncomfortable bodily sensa-tions (e.g., straw breathing to elicit physiological arousalsensations). These graduated exposure exercises are done ina systematic and controlled manner, wherein emotionallycorrective outcomes can be facilitated (e.g., by remindingparticipants that the sensations are not harmful, andcorrecting other maladaptive thoughts that may emergeduring the exercises). The therapist coaches the patientthrough the exercise, prompting her/him to observe thesensations and their cognitive-affective reactions in anonjudgmental manner (e.g., without reacting to them ina reflexive catastrophic fashion); presumably, this type oflearning process offers patients a greater degree of

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emotional tolerance and facilitates self-efficacy for absti-nence.

Therapists combine cognitive restructuring strategieswithmindfulness and cognitive distancing strategies to facilitatetherapeutic exposure exercises and facilitate awareness ofthoughts and cognitive distortions. Acceptance-based strate-gies are employed to foster increased cognitive diffusion(similar to cognitive distancing; Hayes, Strosahl, & Wilson,1999) and willingness to experience unwanted quit-relatedthoughts, feelings, and bodily sensations without efforts toexcessively control them; and thereby, increase tolerance foranxiety, withdrawal, and related sensations (Brown et al.,2008). Patients are explicitly taught that the goal of suchtherapeutic work is to learn that these internal cues can besuccessfully experienced without resorting to coping-oriented smoking behavior to control or reduce thesesensations and unwanted (frightening) feelings/thoughts.Exposure to somatic and other interoceptive symptomsin advance of cessation ensures that participants have practiceand experience with an alternative model of symptommanagement before the symptoms of smoking discontin-uation are actually encountered during their quit attempt.

Beginning in Session 3, exposure exercises are de-scribed, demonstrated, and practiced in session. Moreover,individuals are instructed to practice the exercises outsideof session. Specific exercises used are hyperventilation,chair spinning, stair climbing, head rolling, and strawbreathing. However, if these exercises are not relevant forthe person, different exposure tactics are employed that arepersonally relevant. Overall, patients are encouraged topractice those exercises that create the symptoms mostrelevant to their smoking experiences. The importance ofvarying practice contexts to facilitate the “unlearning” ofemotional responsivity across settings is emphasized as arationale for frequently practicing exercises out of session.The therapist pays particular attention to drawing a clearconnection between aversive anxiety-related states andsomatic changes, and discusses such experiences as theyrelate to changing smoking behavior (e.g., observing andbeing aware of thoughts/feelings during a cessationattempt and their role in motivating a smoking response).Once patients can identify and isolate bodily sensations,they are coached to change their cognitive reactions tothese sensations by reframing them in more adaptiveways and accepting themas “normal and acceptable” ratherthan “dysfunctional” reactions. As described earlier,exposure intensity and relevance to cessation is driven byincorporating increasingly longer periods of smokingdeprivation into the exposure exercises. For example,patients increase the time periods of smoking deprivationin order to get exposed to the aversive sensations(increasing the time between cigarettes up to 6 or morehours). In such a deprived state, the patient then completesinteroceptive exposure exercises in session. The therapist

frames this exposure to the patient as a “double dose” ofstress exposure that may better prepare them for their quitattempt by mimicking the feeling of a powerful stressfulevent coupled with nicotine withdrawal.

Element 3: Specialized Smoking-Oriented Psychoeducation andEmotion Regulation Training in Session and With WeeklyBetween-Session Telephone Support

The final element of the treatment program providesevidence-based techniques for altering smoking behaviorthat is specifically adapted to a smoking population that hasself-identified that emotional symptoms often impede theirquit success. This component of the proposed treatmentincludes a variety of interrelated therapeutic tactics andprocedures based in evidence-based smoking cessationtreatment. In Session 1, a formal self-monitoring programfor smoking in which participants track each cigarettethey smoke through their quit day, noting situational andemotional cues for smoking urges, is presented. Also, pastquit attempts are discussed as learning experiences andfunctionally analyzed to identify factors contributing tosuccess and failure during previous attempts. Then,therapists work with the patient to identify idiographichigh-risk situations for smoking urges, with a specific focuson anticipating both internal and external situationsthat make them want to smoke. We then help patientscreate and practice specific coping plans for such situations(e.g., drive to work without smoking) to gain positivesuccess with them prior to quitting and address anyunexpected issues prior to quit day. In Session 6, nicotinereplacement therapy (NRT; using the transdermal nicotinepatch) is introduced via psychoeducation and tailoringthe NRT dose based on the participants’ smoking level.Participants can also choose to reduce their cigaretteconsumption prior to this time point. Quit day is set forSession 7, which occurs after the patient has demonstratedprogress in exposure exercises, and presumably, increasedresilience to anxiety and withdrawal sensations acrossvarying contexts. During this sessions and beyond patientsare using the transdermal nicotine patch.

Throughout the program, the therapist provides positivereinforcement and social support for quitting by congratu-lating participants for deciding to quit smoking, elicitingprimary personal reasons for wanting to quit, providingwritten materials outlining the main points from eachsession, and reviewing thepositive health benefits of quitting.Prior to quit day, they are instructed to remove tobaccoproducts and stimuli (e.g., cigarettes, ashtrays, lighters) fromtheir primary environments (e.g., home, workplace, car),and, where applicable, participants are encouraged to asksmokers in these environments to avoid offering themcigarettes. This activity removes unnecessary risks for lapse/relapse to tobacco use. Prior to quit day, participants preparea written Abstinence Plan worksheet. This plan consists of

356 Zvolensky et al.

an individualized list of behaviors the person will do prior tosmoking (e.g., call a specific support person, go for a walk).Patients are asked to plan at least eight specific andreasonable items for the list, which they share with theirtherapist. They also write their top reasons for personallydeciding to quit as an additional abstinence-reinforcingreminder during smoking urges, and they are instructed tokeep a copy of this plan with them until the end of theprogram.

On quit day, therapists encourage participants toobserve and monitor their quitting experiences, includ-ing degree of withdrawal symptoms, emotional distress,and the specific strategies used to avoid smoking. It isemphasized that anxiety/negative mood and withdrawalsymptoms are opportunities to practice skill developmentrather than reasons to consider smoking to escape suchfeelings/sensations. Throughout the program, partici-pants are encouraged to behave differently by acceptingunpleasant experiences rather than inflexibly attempt-ing to escape or avoid them. Starting on quit day,participants receive a phone call every 48 hours fromthe therapist to provide additional social support andindividual guidance vis-à-vis emotional stress-smoking.These calls last about 10 to 15 minutes in length and arecarried out from quit day through each of the follow-upassessments. Moreover, the patients are encouraged toprovide daily updates to their therapists via daily phonecheck-ins to help keep them on track between weeklymeetings as they desire from quit day through each ofthe follow-ups.

Treatment Standardization

Each therapist had native Spanish fluency and wastrained in the therapy during a 1-week time period.Treatment integrity was carried out through in-persontraining by the first author and weekly supervision by thesecond author. Across training and employment of theintervention, there was an explicit effort to maintaintreatment standardization.

Procedure

Upon arrival at the clinic, participants completed awritten consent form and then a comprehensive baselineassessment (described in detail below). After completionof the baseline assessment (15 days before the start oftreatment), participants were scheduled for group treat-ment. The treatment was conducted in eight 90-minuteweekly group sessions, with quit day occurring on Session7. Follow-up visits were scheduled at 1, 2, 4, 8, and12 weeks post-quit day. At all time-points, smoking statuswas confirmed with a CO sample of expired air and theTLFB, and self-report assessments tapping the relevantemotion-tobacco constructs were collected. In the present

study, abstinence was determined by the combination ofself-reported abstinence via the TLFB and a CO expiredbreath sample of ≤3 ppm on quit day and each follow-upassessment. Participants were not reimbursed for theirparticipation.

Analytic Approach

Due to the methodological design, descriptive data arereported individually and as a group as well as graphedfor visual inspection. Due to the nonnormal distributionof the data and the small sample size, NonparametricWilcoxon Signed-rank test with exact probability statisticswas utilized to examine within-subject changes betweentime points (Mundry & Fischer, 1998; Siegel & Castellan,1988); one-tailed Wilcoxon tests were employed due tothe directional hypotheses. Monte Carlo simulation(10,000 samples) was used to estimate the 99% confi-dence intervals (p b .05 of the “null hypotheses”; Manly,1991; Mooney, 1997). Formal comparisons were madeacross three clinically and conceptually relevant timepoints: (a) from baseline to quit day (treatment phasechange); (b) from 1 to 12 weeks follow-up (change overthe course of follow-up); and (c) from baseline to 12-weekfollow-up (pretreatment to end of follow-up change). Dueto the small sample size, clinical significance was evaluatedgraphically and in the larger context of the Monte Carlosimulations.

ResultsAttendance

Eight sessions were completed over 8 weeks, whichresulted in 100% of completed sessions (attendance). Incase some participant missed a weekly session, she/he wasimmediately assigned an individual session that sameweek to ensure that all patients were moving forward atthe same pace; a missed session occurred three timesduring the course of the study and all were rescheduled,as described above.

Smoking Outcome and Nicotine Withdrawal

All participants utilized NRT intervention and gradu-ally reduced cigarette use prior to quit day. With regard tosmoking cessation, all participants remained abstinent forthe entire follow-up period (quit day to Week 12), withthe exception of one participant. One participant (Case6) reported a lapse to smoking at Week 1 post-quit day.Per the TLFB, a lapse occurred on days 8 and 9 post-quitday and which was biochemically confirmed (CO read-ing = 8 ppm). However, after these 2 days of smoking,the participant reported complete abstinence during theremaining follow-up period.

Nicotine withdrawal symptoms reduced after treat-ment and before quit day (see Figure 1). Nicotine

Figure 1. Changes in nicotine withdrawal, anxiety sensitivity, and negative affectivity during course of study.

357Argentina

Smoking

Trial

358 Zvolensky et al.

withdrawal increased slightly at Week 1 follow-up. Duringfollow-up, there was a significant gradual decline innicotine withdrawal between Weeks 2 and 4 (Z = −2.03,Exact p = .031, 99% CI = .027, .036) and Weeks 4 and 8(Z = −2.2, Exact p = .016, 99% CI = .012, .019). A slightrise in withdrawal symptoms was observed at Week 12follow-up (see Tables 1 and 2). There was no noteworthyindividual-level variability observed across follow-up as-sessments. There was a significant change from baselineto Week 12 follow-up for nicotine withdrawal symptoms(Z = −1.992, Exact p = .031, 99% CI = .026, .034).

Anxiety Sensitivity

There was a significant change from pre- to postinter-vention in anxiety sensitivity (i.e., from baseline to quitday; Z = −2.20, Exact p = .016, 99% CI = .011, .017).There was no individual-level exception to this pattern(see Table 2). After a slight increase in anxiety sensitivity1-week follow-up, there was no statistically significantchange observed; however, there was a slight (visuallydetected) rise in anxiety sensitivity at Week 8 follow-up(see Figure 1). At individual level, the unexpectednonsignificant group-level increase of anxiety sensitivityat Week 8 appeared to be due to the large rise in anxietysensitivity for Participant 5 (see Table 2). There was asignificant change from baseline to Week 12 follow-up forchange in anxiety sensitivity (Z = −2.032, Exact p = .031,99% CI = .028, .037).

Negative Affect

As measured via the PANAS-NA, no statistically signifi-cant change from pre- to postintervention was detected(see Tables 1 and 2). Thereafter, there was a visuallydetected group-level increase in negative affect observed atWeek 1 and 2 follow-up, followed by a gradual decline untilWeek 8 (see Figure 1). There also was a small increase innegative affect at 12 weeks follow-up. Time point compar-isons during the follow-up phase demonstrated a significantreduction in negative affect from Week 4 to 8 (Z = −1.992,

Table 1Means and Standard Deviations for Assessments

Baseline Quit Day Week 1 W

Measure M SD M SD M SD M

MNWS-Total 12.7 4.50 12.0 4.73 13.3 4.13 1ASI-3-Total 15.8 7.68 6.8 6.08 8.5 5.75PANAS-NA 25.5 5.39 19.5 5.36 21.7 9.95 2

Note. MNWS-Total = Minnesota Nicotine Withdrawal Scale – Total score (Hbaseline = 7–18); Anxiety Sensitivity Index-III – Total score (Taylor et al., 200and Negative Affect Scale – Negative Affect subscale (Watson et al., 1988;

Exact p = .031, 99% CI = .027, .036). There were nostatistically significant differences between other timepoint comparisons and no noteworthy individual-levelvariability (see Tables 1 and 2). There was a significantchange from baseline to Week 12 follow-up for negativeaffect (Z = −1.782, Exact p = .047, 99% CI = .041, .052).

Discussion

In the present study, we evaluated a translated version ofan 8-session Anxiety Sensitivity Reduction Program forSmoking Cessation among Spanish-speaking smokers fromArgentina who had previous difficulties with anxiety/moodsymptoms during past quit attempts using an open trialmethodological design (Carroll & Nuro, 2002). Thetreatment yielded positive results in terms of attendance, aspatients regularly attended appointments and activelyengaged with the treatment material (i.e., completed eachsession).Moreover, positive outcomeswere evident in regardto smoking cessation outcome. Specifically, all but oneparticipant reported abstinence, as indexed by self-reportand biochemical verification, at the 12-week follow-upassessment. Only one participant reported a smokinglapse. Also as expected, severity of nicotine withdrawalsymptoms reduced after treatment and before quit day andfrom baseline to 12-week follow-up (see Figure 1). Thechange of symptoms from baseline to Week 12 and thereduction of symptoms at two of the time point comparisonsacross follow-up assessments were significant. These datareplicate past positive smoking outcome findings observed ata 1-month follow-up for an earlier version of the treatment(Zvolensky, Yartz, et al., 2008) and uniquely extend suchresults to 3-month follow-up assessment among Spanish--speaking smokers.

Consistent with the focus and design of the treatment,results indicated significant reductions in anxiety sensitiv-ity. Specifically, there was a significant reduction in anxietysensitivity from baseline to postintervention and asignificant change from baseline to Week 12 follow-up.Although there was a slight increase in anxiety sensitivity at1-week follow-up (see Figure 1), as found in earlier work

eek 2 Week 4 Week 8 Week 12

SD M SD M SD M SD

1.5 3.15 9.5 2.66 6.0 2.97 6.7 4.188.2 6.15 6.8 7.13 8.2 8.42 8.0 6.893.5 6.53 20.2 3.31 16.0 4.86 19.0 7.68

ughes & Hatsukami, 1986; possible range 0–27; observed range at7; possible range 0–72; observed range at baseline = 9–29); Positivepossible range 10–50; observed range at baseline = 16–32).

Table 2Individual Change From Baseline Through 12-Week Follow-up

Case 1

Baseline Quit Day Week 1 Week 2 Week 4 Week 8 Week 12

Measure Raw Z Raw Z Raw Z Raw Z Raw Z Raw Z Raw Z

MNWS-Total 13.0 0.07 15.0 0.63 14.0 0.16 16.0 1.43 12.0 0.94 6.0 0.00 14.0 1.75ASI-3-Total 29.0 1.71 6.0 −0.14 4.0 −0.78 8.0 −0.03 4.0 −0.40 7.0 −0.14 7.0 −0.15PANAS-NA 25.0 −0.09 18.0 −0.28 14.0 −0.77 26.0 0.38 23.0 0.86 24.0 1.65 31.0 1.65

Case 2

Baseline Quit Day Week 1 Week 2 Week 4 Week 8 Week 12

Measure Raw Z Raw Z Raw Z Raw Z Raw Z Raw Z Raw Z

MNWS-Total 18.0 1.18 7.0 −1.06 8.0 −1.29 7.0 −1.43 6.0 −1.31 5.0 −0.34 9.0 0.56ASI-3-Total 11.0 −0.63 3.0 −0.63 4.0 −0.78 3.0 −0.84 2.0 −0.68 1.0 −0.85PANAS-NA 32.0 1.20 20.0 0.09 19.0 −0.27 15.0 −1.30 19.0 −0.35 17.0 0.21 24.0 0.69

Case 3

Baseline Quit Day Week 1 Week 2 Week 4 Week 8 Week 12

Measure Raw Z Raw Z Raw Z Raw Z Raw Z Raw Z Raw Z

MNWS-Total 17.0 0.96 16.0 0.85 19.0 1.37 13.0 0.48 13.0 1.31 10.0 1.35 4.0 −0.64ASI-3-Total 10.0 −0.76 1.0 −0.96 7.0 −0.26 3.0 −0.84 1.0 −0.82 0.0 −0.97 0.0 −1.16PANAS-NA 29.0 0.65 25.0 1.03 39.0 1.74 32.0 1.30 24.0 1.16 14.0 −0.41 18.0 −0.14

Case 4

Baseline Quit Day Week 1 Week 2 Week 4 Week 8 Week 12

Measure Raw Z Raw Z Raw Z Raw Z Raw Z Raw Z Raw Z

MNWS-Total 13.0 0.07 14.0 0.42 15.0 0.40 10.0 −0.48 8.0 −0.56 7.0 0.34 6.0 −0.16ASI-3-Total 20.0 0.54 17.0 1.67 19.0 1.83 19.0 1.76 19.0 1.70 17.0 1.05 18.0 1.45PANAS-NA 26.0 0.09 20.0 0.09 19.0 −0.27 17.0 −0.99 17.0 −0.96 13.0 −0.62 16.0 −0.41

Case 5

Baseline Quit Day Week 1 Week 2 Week 4 Week 8 Week 12

Measure Raw Z Raw Z Raw Z Raw Z Raw Z Raw Z Raw Z

MNWS-Total 7.0 −1.26 15.0 0.63 15.0 0.40 13.0 0.48 10.0 0.19 7.0 0.34 4.0 −0.64ASI-3-Total 16.0 0.02 11.0 0.69 11.0 0.43 11.0 0.46 12.0 0.72 20.0 1.40 11.0 0.44PANAS-NA 16.0 −1.76 24.0 0.84 27.0 0.54 28.0 0.69 22.0 0.55 18.0 0.41 13.0 −0.83

Case 6

Baseline Quit Day Week 1 Week 2 Week 4 Week 8 Week 12

Measure Raw Z Raw Z Raw Z Raw Z Raw Z Raw Z Raw Z

MNWS-Total 8.0 −1.04 5.0 −1.48 9.0 −1.05 10.0 −0.48 8.0 −0.56 1.0 −1.69 3.0 −0.88ASI-3-Total 9.0 −0.89 3.0 −0.63 6.0 −0.43 5.0 −0.52 3.0 −0.54 4.0 −0.49 4.0 −0.58PANAS-NA 25.0 −0.09 10.0 −1.77 12.0 −0.97 23.0 −0.08 16.0 −1.26 10.0 −1.24 12.0 −0.96

Note. MNWS-Total = Minnesota Nicotine Withdrawal Scale – Total score (Hughes & Hatsukami, 1986); Anxiety Sensitivity Index-III – Totalscore (Taylor et al., 2007); Positive and Negative Affect Scale – Negative Affect subscale (Watson et al., 1988).

359Argentina Smoking Trial

(Zvolensky, Yartz, et al., 2008), no statistically significantchange across follow-up was observed. This slight increase inanxiety sensitivity at 1-week follow-up may be due to high

degrees of interoceptive perturbation common to that phaseof the quit experience (Hughes et al., 1990). Overall, thepresent data suggest change in anxiety sensitivity was

360 Zvolensky et al.

“produced” prior to quitting and maintained thereafter.These data add to a growing corpus of work that suggestsclinically relevant change in anxiety sensitivity is associatedwith quit success (Assayag et al., 2012) and anxiety sensitivityreduction methods can be successfully integrated in thatcontext (Feldner et al., 2013; Zvolensky, Lejuez, et al., 2003).

For negative affect, significant reductions in symptomswere detected from baseline to 12-week follow-up andfrom Week 4 to Week 8 post-quit. These findings,considered in context of the changes observed for anxietysensitivity and design of the intervention, suggest somedesynchrony between affect-relevant transdiagnosticprocesses such as anxiety sensitivity and negative emo-tional symptoms. For example, change was observed inanxiety sensitivity, but not negative affect, from baseline topostintervention. Such results are consistent with theo-retical models of anxiety (Barlow, 2002; Chorpita &Barlow, 1998), clinical anxiety research (e.g., Bentleyet al., 2013), and experimental psychopathology anxietywork (e.g., Schmidt & Lerew, 2002; Zvolensky, Eifert, &Lejuez, 2001) that suggest how one responds to distres-sing symptoms is not perfectly coupled with negativeemotional symptom expression. Moreover, based onprevious empirical evidence (Kahler et al., 2002; Mathewet al., 2013), the significant reduction in negative affectfrom Week 4 to Week 8 post-quit could be possibly beattributed to the successful cessation outcomes amongparticipants rather than to the therapeutic effects of theanxiety sensitivity reduction program per se.

The current study has a number of limitations. First, itis an open trial, and therefore, it is, by definition, at anearly stage of treatment development (Rounsaville,Carroll, & Onken, 2001). Consistent with Carroll andNuro's (2002) model for sequential treatment develop-ment, at the next stage, a randomized clinical trial iswarranted. With a randomized trial, we would be able toisolate comparability of the treatment to standard careand explicate mechanisms of change. These studies arenow ongoing in North America. Second, the sample size issmall. Therefore, it is possible that there is limitedgeneralizability of the results. Future work should utilizelarger sample sizes to address this limitation. Third, due tothe methodological design and sample size, we cannotexplore time sequential effects. Thus, it is not possible toidentify mechanisms of action. In future work, it would behelpful to identify temporal relations of theoreticallyrelevant mechanisms of action. Fourth, we did notformally assess homework compliance, adherence, oracceptability of treatment via standardized instruments.Past work has indicated that greater homework compli-ance can increase smoking cessation success (Funk,Zvolensky, & Schmidt, 2011; Glasgow, Schafer, & O’Neill,1981; Kamarck & Lichtenstein, 1988). Future research onthis treatment program could, therefore, benefit by

documenting the degree of homework compliance andhow such behavior relates to smoking and emotionaloutcomes. Likewise, formally documenting adherence tothe protocol and acceptability of the treatment would beuseful next steps in refining the intervention. Fifth, thereis a high-level of quit day and post-quit day telephonesupport. It is presently unclear how such support plays arole in the observed findings relative to other treatmentelements. It will be important for future work to addressthe active elements in treatment using a randomizedcontrol design. Finally, although the present treatmentwas translated to Spanish, it does not necessarily meanthat it would be equally applicable to all Spanish-speakingpopulations (e.g., Latino smokers). In fact, there was nomajor cultural adaptation of the present treatmentoutside of the language translation (English to Spanish).Future work could evaluate the present treatment inother Spanish-speaking populations in South, Central,and North America. In this context, qualitative data onthe treatment experience would be useful to ascertain ifgreater cultural adaptability would be a useful addition interms of acceptability/adherence (e.g., increasing familysupport). In this same context, we translated to thetreatment, but did not engage in further individualizationof the program. In clinical practice, it may be useful tofurther tailor the intervention so as to match it to thepersonalized needs of specific clients.

Overall, the present study provides novel empiricaldata on the Anxiety Sensitivity Reduction Program forSmoking Cessation among Spanish-speaking smokers whohad previous difficulties with anxiety/mood symptomsduring past quit attempts. The results suggest potentialclinical utility of the anxiety sensitivity smoking cessationprogram in regard to cessation outcome.

Conflict of Interest Statement

The authors declare that there are no conflicts of interest.

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Ms. Farris is supported by a cancer prevention fellowship through theUniversity of Texas MD Anderson Cancer Center, funded by theNational Cancer Institute grant (R25T-CA057730). The content doesnot necessarily represent the official views of the National CancerInstitute or the National Institutes of Health.Funding. There are no sources of funding to report for the currentstudy.

Address correspondence to Michael J. Zvolensky, Ph.D., TheUniversity of Houston, 126 Heyne Building, Suite 104, Houston, TX77204–5502; e-mail: mjzvolen@central.uh.edu.

Received: July 10, 2013Accepted: October 28, 2013Available online 15 November 2013