Exploring the Mechanisms, Popularity & Health Implications of Vaping

How Does Vaping Work?

Vaping imitates the act of smoking by utilizing battery-powered devices that produce an aerosol resembling water vapor. However, this aerosol contains not only nicotine but also flavorings and over 30 additional chemicals. When inhaled, the aerosol enters the lungs, allowing the nicotine and chemicals to enter the bloodstream. A single vape pod contains the same amount of addictive nicotine as 20 cigarettes. Vaping conditions the brain to anticipate higher nicotine levels, leading to a stronger desire to vape.[1]

Initially, vape devices resembled traditional cigarettes, but more recent models have taken on different forms, such as resembling a USB flash drive or a compact pod. Vaping devices vary in their appearances, yet they share fundamental components, including a battery, sensor and atomizer/flavor cartridge.[2]

Targeted Age Group

As numbers for cigarette smoking have been on the decline for the past year, the popularity of vapes, a type of e-cigarette, has exploded in the United States, especially in younger generations. Johns Hopkins Medicine conveyed that over two million middle and high school students admitted to the use of vapes in 2022, with 80% of them using flavored e-cigarettes.[3] The Texas Health and Human Services notes that the teenage brain is particularly vulnerable to the impact of nicotine, making it more challenging to quit vaping and raising the likelihood of teens transitioning to smoking tobacco cigarettes due to nicotine addiction.[4]

Vaping devices have gained immense popularity among teenagers, becoming the most prevalent form of nicotine used among youth in the United States. A 2020 report from the National Institute on Drug Abuse indicates that many teens are unaware that vaping cartridges contain nicotine and mistakenly believe they only contain flavoring.[5] The widespread availability of these devices, captivating advertisements, a wide range of e-liquid flavors, and the perception that they are safer than traditional cigarettes contribute to their appeal among this age group. Moreover, their concealable nature, lacking the distinct odor of tobacco cigarettes, and their ability to be disguised as flash drives make them easier for teens to hide from teachers and parents.[6]

Why do People Vape?

The idea that vaping is less harmful than smoking has made it especially popular to young audiences, who do not see negative repercussions from the devices and often do not even know they contain nicotine.[7] According to the CDC, some vaping devices advertise themselves as not even containing any nicotine despite being found to have it.[8] The popularity of vaping makes it extremely accessible to young people, and teenagers are especially susceptible to the idea of doing something because those around them choose to participate. The CDC adds that one of the most common reasons provided for beginning to vape by middle and high school students in the United States was that they had a friend who used vapes. Further, most participants added they continued to vape due to feelings of stress, depression and anxiety.[9]

Negative Health Effects

While there is a belief that vaping is significantly better for health than smoking cigarettes, this is not necessarily true. Vaping can be linked to a number of lung injuries and even deaths as a large number of harmful chemicals have been identified in these devices. Nicotine, found in both traditional cigarettes and e-cigarettes, serves as the main active component and possesses a strong addictive nature. It generates a desire for smoking and can lead to withdrawal symptoms if the craving is ignored. Johns Hopkins Medicine notes that nicotine is considered a toxic substance, capable of elevating blood pressure, triggering a surge in adrenaline levels, accelerating heart rate, and augmenting the risk of experiencing a heart attack.[10]

effects on the brain

Additionally, the use of nicotine during adolescence can pose risks to the developing brain, which continues to mature until approximately the age of 25. Nicotine consumption during this stage can potentially harm the regions of the brain responsible for attention, learning, mood regulation and impulse control.[11] In the process of forming memories or acquiring new skills, the brain establishes stronger connections (synapses) between its cells, and the adolescent brain constructs synapses at a faster rate compared to adult brains. However, nicotine alters the normal formation of these synapses. Furthermore, the use of nicotine during adolescence may also heighten the likelihood of future addiction to other substances.[12]

easing Anxiety?

The CDC found that when asked why they vape, one of the most common responses youth will provide is that it, “helps ease their feelings of stress, anxiety or depression”. However, continuous use of an e-cigarette can actually exacerbate these feelings.[13] Nicotine-containing e-cigarettes exert an impact on various major systems within the body. For instance, vaping stimulates increased dopamine activity in the brain's reward pathway, elevates heart rate and blood pressure, and potentially disrupts the functioning of the hypothalamic-pituitary-adrenal (HPA) axis. These physiological changes, in turn, have psychological implications for addiction, cognition, mood and anxiety.[14]

The use of nicotine salts in e-cigarettes enhances the efficiency of nicotine delivery, potentially increasing their addictive nature. Vaping may also result in short-term enhancements in cognitive performance, as nicotine has the ability to improve memory and attention. Users of e-cigarettes often report mood-enhancing and anxiety-reducing effects, although Tattan-Birch & Shahab (2020) note these may be actually attributed to the relief of withdrawal symptoms.[15] Symptoms of nicotine withdrawal encompass irritability, restlessness, feelings of anxiety or depression, sleep difficulties, impaired concentration, and intense cravings for nicotine. In an attempt to alleviate these symptoms, individuals may continue using tobacco products and associate their feelings of relief with the act of vaping rather than withdrawal. Teenagers may resort to vaping as a means to cope with stress or anxiety, inadvertently perpetuating a cycle of nicotine dependency.[16]

If you or someone you know is struggling with anxiety and/or nicotine addiction, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support. Click here to see our interview on the role of social anxiety in addiction as well as how Cognitive Behavioral Therapy (CBT) and Exposure and Response Prevention (ERP) can be effective methods at overcoming substance abuse.

Contributed by: Ananya Kumar

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Texas Health and Human Services. (2023). What is Vaping? Texas Department of State Health Services. https://www.dshs.texas.gov/vaping/what-is-vaping#:~:text=Vaping%20simulates%20smoking.,cross%20over%20into%20the%20bloodstream.

2 Ibid.

3 Blaha, M. J. (2022). 5 Vaping Facts You Need to Know. Johns Hopkins Medicine.  https://www.hopkinsmedicine.org/health/wellness-and-prevention/5-truths-you-need-to-know-about-vaping

4 Texas Health and Human Services

5 NIDA. 2020, January 8. Vaping Devices (Electronic Cigarettes) DrugFacts. Retrieved from https://nida.nih.gov/publications/drugfacts/vaping-devices-electronic-cigarettes

6 Ibid.

7 Johns Hopkins Medicine

8 Centers for Disease Control and Prevention. (2022). Quick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults. CDC. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults.html

9 Ibid.

10 Johns Hopkins Medicine

11 CDC

12 Ibid.

13 Ibid.

14 Tattan-Birch, H., & Shahab, L. (2020). The Psychobiology of Nicotine Vaping. In Psychobiological Issues in Substance Use and Misuse (1st Edition). Routledge. 

15 Ibid.

16 CDC

Chronic Stress & Memory Erosion

The Bright Side of Stress?

Stress is a necessary human experience that keeps us alive.[1] It can be defined by the physical and mental responses we use to combat stressors experienced in our lives, such as threatening situations, insecurity, a tumultuous relationship or academic and work responsibilities.[2] We learn from previous stressors (e.g., avoiding sketchy alleyways we know of, or the signs of “red flags” in a relationship.) These adaptations are how short-term stress can beneficially inform our memory and subsequent learning. Stress-induced fears, anxieties and physiological signals cause us to react to danger or threats so that we know how to avoid a stressor again.

When the brain processes an imminent stressor, the sympathetic nervous system and hypothalamic-pituitary-adrenocortical (HPA) axis react to release adrenaline and glucocorticoids.[3] The sympathetic nervous system activates physiological responses for a fight or flight response. For example, pupils dilate and heart rate increases. The HPA axis regulates the stress response through structures such as the hypothalamus and hippocampus, an important structure for memory, via steroid hormones like cortisol.[4] By a negative feedback loop, the hippocampus’ cortical receptors are activated for the memory and biological learning of a stressful event.[5] As a result, memory is improved following an acute stress response so that our learning is improved for future similar stressful situations.[6,7] 

When Stress Becomes Problematic

While research indicates that short-term or acute stress can promote behavioral adaptations and improve spatial memory, in the same study by Lin et al. (2022), prolonged durations of stress led to behavioral and cognitive impairment in animal models.[8] Relatedly, in humans, long periods of stressful life events lead to cognitive and memory declines in older adults.[9] Additionally, prolonged (i.e., chronic) stress can increase risk of disease and mortality.[10,11] 

Chronic stress causes the body to be constantly out of balance (i.e., allostasis) in response to trying to restore balance (i.e., homeostasis) through energy expenditure.[12] The cumulatively created effect of chronic stress is referred to as allostatic load (when allostasis is repeatedly activated with a lack of adaptation or conclusion of the stress response.)[13] These chronic and repeated stress responses increase cortisol, which negatively affect components of memory (like navigation and long-term memory retention), and structurally damages neurons necessary for memory.[14,15] This leads the human body to be in a constant state of neurological disruption that is not restored, resulting in negative impacts on one’s memory.[16-22]  

Despite these negative health impacts, chronic stress remains an extremely common experience. According to the American Institute of Stress (2022), 94% of American workers say they are stressed at work while 55% of Americans report that they are stressed during any given day.[23] While some degree of stress in life is vital, an allostatic load can decrease well-being and cognition, and should be reduced to promote one’s health and overall life.

What Chronic Stress Looks Like

Chronic stress has particularly negative effects on the hippocampus (related to forming and sustaining memory), amygdala (related to emotional regulation) and neurons in the prefrontal cortex (related to problem-solving and planning).[24] Duman (2004) notes that by using physical restraints on rats, chronic stress was found to decrease neuron length and branching in the hippocampus.[25] Furthermore, increased glucocorticoid circulation leads to decreased neural plasticity (i.e., when neurons adapt and connect to process or establish information), and decreased growth of neurons in the hippocampus.[26] Brain-derived neurotrophic factor (BDNF) signaling, a marker of neural plasticity, is also reduced in the prefrontal cortex and hippocampus following chronic stress.[27] 

Chronic stress essentially impairs memory consolidation and retrieval, making reactivating and forming new information more difficult and less frequent.[28] Memory for spatial and navigating information was found to be impaired due to chronic stress, as well.[29] The body’s homeostatic regulation in response to a prolonged stressor additionally causes chronic neuroinflammation.[30] For these reasons, allostatic load leads to an increased risk of developing certain disorders such as post-traumatic stress disorder (PTSD), depression and neurodegeneration; these risks increase with age and cortisol levels.[31] 

Signs of chronic stress include:[32-34]

• Emotional dysregulation

• Decreased memory for events, general knowledge and navigation

• Social withdrawal

• Depressive symptoms

• Increased anxiety and constant worrying

• Fatigue or low energy

• Immune system dysregulation and impaired disease resistance

• High blood pressure

• Digestive problems

 When chronic stress becomes persistently life-impairing, it can be a significant factor in several disorders, such as those involving anxiety, emotional disruption and cognitive problems. Stress-related cognitive impairment is found in several conditions and disorders:

• PTSD symptom severity is associated with cognitive decline.[35] 

• Chronic stress is a risk factor for dementia.[36]

• In middle age, those with depression and high allostatic load have a higher risk of cognitive decline.[37] 

• Childhood psychological stress (i.e., childhood poverty) is associated with a greater risk for anxiety-related symptoms and allostatic load in adolescence and adulthood with intensity relating to the duration of the allostatic load.[38] 

• Impaired memory in depressed individuals is often attributed to chronic stress and its duration.[39]

Those with anxiety and mood disorders tend to experience psychological stress for lengthy periods. This is why high allostatic load is a factor for memory problems as the brain’s hippocampal neurons atrophy or degenerate and plasticity is disrupted by exhausted homeostatic energy expenditure. 

Perceptive Differences 

While individuals with mood or anxiety disorders are more vulnerable to chronic stress and memory impairment, stress responses can still vary by person and are not exclusive to those who experience such disorders. Chronic stress itself is also not a disorder, but a comorbid risk factor for memory impairment that can look different for everyone.

Internal beliefs vary per individual and are subjective, causing certain situations to be stressful to some and not to others, and leading to varied effects on memory. For example, students’ perceived high stress is found to be partially reliant on low self-efficacy (i.e., belief in self-success) and high emotional attention.[40] Additionally, high stress and cortisol levels lead to worsened memory performance such as declarative memory (i.e., memory for general knowledge and events), and cortisol is found to be in higher levels in females than males.[41,42] This is because cortisol levels are impacted by ovarian hormones such as estrogen.[43] Therefore, higher baseline cortisol levels may lead to high cortisol release when responding to stress.[44] For such reasons, cortisol administration is a way of inducing depression in animal models in addition to physical and social stressors due to chronic exposure. Other individual differences (such as age) may impact perceived stress as in older adults; egocentric stressors (e.g., self-health and financial stressors) were found to be detrimental to cognitive functioning as opposed to non-egocentric stressors.[45] 

Societal stressors may also impact the rate and intensity of the stressors that different groups face. For example, individuals of a sexual minority often experience increased impairment in psychosocial adaptation and overall quality of life likely due to negative stereotyping or stigma consciousness.[46] Menhinick & Sanders (2023) note that fear of violence is also an imminent physical stressor that many LGBTQ+ individuals and racial minorities experience, which can induce chronic stress, depression and PTSD.[47] 

Solutions to Mitigate and Overcome Chronic Stress

Several methods can be employed to tackle chronic stress. A social-psychological approach may look at the stressors that arise from social norms. From such a perspective, effortful social change can alleviate minority stress and threats, which removes the fault from the individual experiencing the neurological effects of stressors and targets the creation of the stressors themselves, such as violence and microaggressions arising from biases.[48] 

In terms of regenerating neurological functioning, Hernandez & Brinton (2022) found that allopregnanolone (a neurosteroid) may activate the GABA-chloride complex and can help to promote neurogenesis or the formation of neurons in the brain.[49] Relating to diet, Szala-Rycaj et al. (2023) found that chicory root insulin and topinambur powder, when supplemented long-term, can alleviate anxiety and cognitive disorder-like symptoms that were induced through chronic stress in animal models.[50] Additionally, Duman (2004) notes that antidepressants such as selective serotonin reuptake inhibitors (SSRIs) have been shown to reflect a reversal of neuron atrophy in the hippocampus and promote neural plasticity as well.[51] Note: it is important not to start or stop taking any medications or supplements without first discussing them with your physician and/or pharmacist.

Several evidence-based psychotherapies are effective at preventing and overcoming the effects of chronic stress. Acceptance and Commitment Therapy (ACT) is an approach that focuses on the awareness of mental states and thoughts with particular effectiveness for mood and anxiety disorders.[52] Mindfulness-Based Therapy (MBT) additionally reduces stress through attention to physical experiences and meditation.[53] This modality directly targets psychological stress reduction by promoting relaxation and building mindfulness skills. Cognitive Behavioral Therapy (CBT) is effective in treating stress-related disorders such as PTSD, anxiety, and depression by utilizing cognitive-restructuring of negatively-formed or maladaptive thoughts and behaviors that cause stress.[54] 

Due to the variety of potential stressors that one can experience and the individuality of perceived stress responses, it is possible that a combination of stressor-targeting and personal psychological support is necessary for both avoiding chronic stress and memory impairment, in addition to recovering from chronic stress. In everyday life, acute stress is beneficial for memory and the body, but chronic stress that takes both physical and psychological forms should be avoided as much as possible. Lowering chronic stress may further be promoted through prioritizing safety, relaxation, nutrition, time in nature, engaging in therapy to find ways to cope with stressors, and decreasing time on social media.[55] 

Moreover, this responsibility to avoid chronic stress is not always carried solely by the individual but is also held by a network of people that socially impact each other’s lives every day. In order to reduce the negative memory and health effects of chronic stress, both the individual and the environment by which they interact should be addressed. Stress and memory research continues to rapidly evolve, and may eventually be able to determine how to quantify, possibly by time and neural information, dangerous amounts of allostatic load on the brain and the processes of memory.  

If one is experiencing prolonged or chronic stress that is impacting daily life and overall well-being, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Phoebe Elliott

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Hadany, L., Beker, T., Eshel, I., & Feldman, M. W. (2006). Why is stress so deadly? An evolutionary perspective. Proceedings. Biological sciences, 273(1588), 881–885. https://doi.org/10.1098/rspb.2005.3384

2 American Psychological Association. (2023). Stress. In APA Dictionary of Psychology. https://dictionary.apa.org/stress?amp=1 

3 Lenart-Bugla, M., Szcześniak, D., Bugla, B., Kowalski, K., Niwa, S., Rymaszewska, J., & Misiak, B. (2022). The association between allostatic load and brain: A systematic review. Psychoneuroendocrinology, 145, 105917. https://doi.org/10.1016/j.psyneuen.2022.105917

4 Peavy, G. M., Salmon, D. P., Jacobson, M. W., Hervey, A., Gamst, A. C., Wolfson, T., Patterson, T. L., Goldman, S., Mills, P. J., Khandrika, S., & Galasko, D. (2009). Effects of chronic stress on memory decline in cognitively normal and mildly impaired older adults. The American journal of psychiatry, 166(12), 1384–1391. https://doi.org/10.1176/appi.ajp.2009.09040461

5 Ibid.

6 Lenart-Bugla et al. (2022)

7 Peavy et al. (2009)

8 Lin, L., Zhang, J., Dai, X., Xiao, N., Ye, Q., & Chen, X. (2022). A moderate duration of stress promotes behavioral adaptation and spatial memory in young C57BL/6J mice. Brain Sciences, 12(8) doi:10.3390/brainsci12081081

9 Peavy et al. (2009)

10 Bobba-Alves, N., Juster, R. -., & Picard, M. (2022). The energetic cost of allostasis and allostatic load. Psychoneuroendocrinology, 146 doi:10.1016/j.psyneuen.2022.105951

11 Selye, H. (1950). Stress and the general adaptation syndrome. British medical journal, 1(4667), 1383–1392. https://doi.org/10.1136/bmj.1.4667.1383

12 Bobba-Alves et al. (2022)

13 Lenart-Bugla et al. (2022)

14 Akan, O., Bierbrauer, A., Kunz, L., Gajewski, P. D., Getzmann, S., Hengstler, J. G., Wascher, E., Axmacher, N., & Wolf, O. T. (2023). Chronic stress is associated with specific path integration deficits. Behavioural brain research, 442, 114305. https://doi.org/10.1016/j.bbr.2023.114305

15 Kirschbaum, C., Wolf, O. T., May, M., Wippich, W., & Hellhammer, D. H. (1996). Stress- and treatment-induced elevations of cortisol levels associated with impaired declarative memory in healthy adults. Life sciences, 58(17), 1475–1483. https://doi.org/10.1016/0024-3205(96)00118-x

16 Peavy et al. (2009)

17  Bobba-Alves et al. (2022)

18 Lenart-Bugla et al. (2022)

19 Prieto, S., Nolan, K. E., Moody, J. N., Hayes, S. M., Hayes, J. P., & Department of Defense Alzheimer’s Disease Neuroimaging Initiative (2023). Posttraumatic stress symptom severity predicts cognitive decline beyond the effect of Alzheimer's disease biomarkers in Veterans. Translational psychiatry, 13(1), 102. https://doi.org/10.1038/s41398-023-02354-0

20 Perlman, G., Cogo-Moreira, H., Wu, C. -., Herrmann, N., & Swardfager, W. (2022). Depression interacts with allostatic load to predict cognitive decline in middle age. Psychoneuroendocrinology, 146 doi:10.1016/j.psyneuen.2022.105922

21 Duman R. S. (2004). Neural plasticity: consequences of stress and actions of antidepressant treatment. Dialogues in clinical neuroscience, 6(2), 157–169. https://doi.org/10.31887/DCNS.2004.6.2/rduman

22 Kirschbaum et al. (1996)

23 The American Institute of Stress. (2022). What is Stress? https://www.stress.org/daily-life 

24 Lenart-Bugla et al. (2022)

25 Duman (2004)

26 Ibid.

27 Ibid. 

28 Lenart-Bugla et al. (2022)

29 Akan et al. (2023)

30 Craddock, T. J. A., Michalovicz, L. T., Kelly, K. A., Rice, M. A., Jr., Miller, D. B., Klimas, N. G., . . . Broderick, G. (2018). A logic model of neuronal-glial interaction suggests altered homeostatic regulation in the perpetuation of neuroinflammation. Frontiers in Cellular Neuroscience, 12 doi:10.3389/fncel.2018.00336 

31 Palego, L., Giannaccini, G., & Betti, L. (2021). Neuroendocrine response to psychosocial stressors, inflammation mediators and brain-periphery pathways of adaptation. Central Nervous System Agents in Medicinal Chemistry, 21(1), 2-19. doi:10.2174/1871524920999201214231243 

32 National Institutes of Health. (2022). Stress. In The National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/stress 

33 Mariotti A. (2015). The effects of chronic stress on health: new insights into the molecular mechanisms of brain-body communication. Future science OA, 1(3), FSO23. https://doi.org/10.4155/fso.15.21

34 Yaribeygi, H., Panahi, Y., Sahraei, H., Johnston, T. P., & Sahebkar, A. (2017). The impact of stress on body function: A review. EXCLI journal, 16, 1057–1072. https://doi.org/10.17179/excli2017-480

35 Prieto et al. (2023)

36 Ibid.

37 Perlman et al. (2022)

38 De France, K., Evans, G. W., Brody, G. H., & Doan, S. N. (2022). Cost of resilience: Childhood poverty, mental health, and chronic physiological stress. Psychoneuroendocrinology, 144 doi:10.1016/j.psyneuen.2022.105872 

39 Dillon, D. G., & Pizzagalli, D. A. (2018). Mechanisms of Memory Disruption in Depression. Trends in neurosciences, 41(3), 137–149. https://doi.org/10.1016/j.tins.2017.12.006

40 Navarro-Mateu, D., Alonso-Larza, L., Gómez-Domínguez, M. T., Prado-Gascó, V., & Valero-Moreno, S. (2020). I’m not good for anything and That’s why I’m stressed: Analysis of the effect of self-efficacy and emotional intelligence on student stress using SEM and QCA. Frontiers in Psychology, 11 doi:10.3389/fpsyg.2020.00295

41 Kirschbaum et al. (1996)

42 Wolf, O. T., Schommer, N. C., Hellhammer, D. H., McEwen, B. S., & Kirschbaum, C. (2001). The relationship between stress induced cortisol levels and memory differs between men and women. Psychoneuroendocrinology, 26(7), 711–720. https://doi.org/10.1016/s0306-4530(01)00025-7

43 Edwards, K. M., & Mills, P. J. (2008). Effects of estrogen versus estrogen and progesterone on cortisol and interleukin-6. Maturitas, 61(4), 330–333. https://doi.org/10.1016/j.maturitas.2008.09.024

44 Wolf et al. (2001)

45 De France et al. (2022)

46 Dispenza, F. (2023). Chronic illness and disability among sexual minority persons: Exploring the roles of proximal minority stress, adaptation, and quality of life. Psychology of Sexual Orientation and Gender Diversity, doi:10.1037/sgd0000642

47 Menhinick, K. A., & Sanders, C. J. (2023). LGBTQ+ stress, trauma, time, and care. Pastoral Psychology, doi:10.1007/s11089-023-01073-z

48 Riggs, D. W., & Treharne, G. J. (2017). Decompensation: A novel approach to accounting for stress arising from the effects of ideology and social norms. Journal of Homosexuality, 64(5), 592-605. doi:10.1080/00918369.2016.1194116

49 Hernandez, G. D., & Brinton, R. D. (2022). Allopregnanolone: Regenerative therapeutic to restore neurological health. Neurobiology of Stress, 21 doi:10.1016/j.ynstr.2022.100502

50 Szala-Rycaj, J., Szewczyk, A., Zagaja, M., Kaczmarczyk-Ziemba, A., Maj, M., & Andres-Mach, M. (2023). The influence of topinambur and inulin preventive supplementation on microbiota, anxious behavior, cognitive functions and neurogenesis in mice exposed to the chronic unpredictable mild stress. Nutrients, 15(9) doi:10.3390/nu15092041

51  Duman (2004)

52 Wersebe, H., Lieb, R., Meyer, A. H., Hofer, P., & Gloster, A. T. (2018). The link between stress, well-being, and psychological flexibility during an Acceptance and Commitment Therapy self-help intervention. International journal of clinical and health psychology : IJCHP, 18(1), 60–68. https://doi.org/10.1016/j.ijchp.2017.09.002

53 Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Journal of consulting and clinical psychology, 78(2), 169–183. https://doi.org/10.1037/a0018555

54 Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive therapy and research, 36(5), 427–440. https://doi.org/10.1007/s10608-012-9476-1

55 National Institutes of Health. (2022). Stress. In The National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/stress