1. Project ECHO Managing Anxiety Associated with Withdrawal
Patricia Figueroa, M.Ed., LPC
Cho Lam, Ph.D.

2. Smoking and Anxiety Disorders
Current smoking rate among adults in the U.S. is 16.8%
Significantly higher smoking rates among individuals with anxiety disorders
Panic disorder: 19%-47%
Post-traumatic stress disorder: 44%-66%
Social anxiety disorder: 14%-32%
Generalized anxiety disorder: 17%-55%

3. Smoking and Nonclinical Anxiety
Empirical findings suggest that smoking reduces anxiety
The anxiolytic, or anxiety-alleviating, effect of nicotine varies by
Route of administration
Inhaled (e.g., smoking) vs. transdermal (e.g., nicotine patch)
Timing of administration

4. Anxiety: A Common Withdrawal Symptom
Anxiety is one of the most common symptoms of nicotine withdrawal
If smoking is anxiolytic, then smoking abstinence would likely increase anxiety
Previous findings suggest that, on average, anxiety increases in the first 1-3 days postcessation (the increase can be as long as 2 weeks).
Smokers who quit often reported anxiety as the risk factor for relapse

5. “If I don’t smoke, I can’t
manage my anxiety”

6. Integrating Motivational Interviewing
Avoid immediately jumping into offering strategies and techniques
Clients as experts on themselves
Elicit – Provide – Elicit
Always ask for permission
Provide information as options rather than directives
Ask for feedback

7. Strategies for Reducing Anxiety
Remind patient that anxiety will pass with time
Often builds for the first 3 days
May last 2 weeks, and begin to later subside
Engaging in physical activity can help
Reducing caffeine by limiting or avoiding coffee, soda, tea
Using NRT
Relaxation techniques

8. Diaphragmatic Breathing
Technique to help to slow down breathing when anxious or stressed
Our breathing changes when we are anxious
We take short, quick, shallow breaths
6-8 breathing cycles per minute are recommended to help reduce anxiety
5 minutes, twice per day OR as needed
Suggest that patients start by using this technique when in a calm or relaxed state.

9. Diaphragmatic Breathing
Breathe from the diaphragm or abdomen
Shoulders and chest area should be relaxed and still
If difficult to keep upper body still while expanding abdomen:
Advise patient to try laying down with one hand on abdomen and the other on the chest
Ask the patient to watch the hand on the abdomen rise as they inhale. Hand on the chest should barely move.

10. Diaphragmatic Breathing
Patient Instructions:
Gently close your eyes
Take a slow breath in through your nose, filling your abdomen with air
Hold your breath for a couple of seconds
Exhale slowly through your mouth
Wait a couple of seconds before taking another breath
LET’S TRY IT!
See Patient Handout

11. Progressive Muscle Relaxation
When we are anxious, we often experience muscle tension
PMR teaches the patient to monitor and control muscle tension
Through practice patients can learn to distinguish between the feeling of a tensed muscle and a relaxed muscle.
Eventually patients can begin to “cue” this relaxed state at the first sign of muscle tension that is experienced when anxious.

12. Progressive Muscle Relaxation
2 step process
STEP 1: Systematically tensing particular muscle groups.
STEP 2: Release the tension and pay attention to how the muscles feel when relaxed.
TIPS:
Patients should start by practicing when in a relaxed state.
Walk the patient through this exercise when being done for the first time.
See Patient Handout

13. Thank you!