Addiction is broadly defined as physical and/or psychological dependency on a drug. People who are dependent on tobacco are classified by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as having tobacco use disorder, which is placed in the same class as other substance use disorders. Such disorders are diagnosed based on symptoms such as craving, withdrawal, impaired control over use of the substance, and continued use despite knowledge of health risks.1
The determinants of smoking are some mix of biological, psychological and social/cultural factors. Theories of smoking and smoking cessation differ in their conceptualisations of the relative importance of and inter-relationships between these factors. Interventions aiming to promote healthy behaviours that are based on theory or theoretical constructs are more effective than those not grounded in theory.2
7.3.1 Behavioural theories
Behavioural theories (or behaviourism) focus on how people learn to behave in particular ways. Behaviourism was born from two main schools of thought:
- Classical conditioning, whereby a person learns to associate two previously unrelated stimuli (e.g., Pavlov’s famous experiments in which dogs learned to associate the sound of a bell with food).3 In terms of smoking, a person can learn to associate smoking with other feelings and events (such as being in a stressful situation or having a coffee) and these situations then automatically induce cravings and ‘cue’ his or her smoking behaviour.4
- Operant conditioning, which posits that behaviour is shaped by its consequences (i.e., reward or punishment).5 When nicotine is inhaled, it causes a rapid release of dopamine, in turn causing feelings of pleasure that reward and reinforce the behaviour. This pleasure and reinforcement drive the process of addiction.4
Behavioural modification approaches to smoking cessation are underpinned by these principles. Behavioural approaches to cessation focus on changing habits and patterns that cue smoking, replacing smoking with a different, more desirable behaviour, rewarding abstinence, and emphasising the immediate and longer term benefits of quitting. A review of behavioural interventions for smoking cessation found that most report moderate success in quitting at six months.6 (See Section 7.13.)
7.3.2 Social cognitive theory
Social cognitive theory, an extension of social learning theory, posits that people learn from one another through observation, instruction, or modelling. It expands on behaviourism by explaining behaviour as a product of reciprocal interactions between cognitive, behavioural, and environmental influences.7, 8 An important tenet of social cognitive theory is self-efficacy, or the belief or expectation a person has that he or she can successfully perform a task. Social cognitive theory posits that self-efficacy is fundamental to any behaviour change.8 A number of studies have shown a positive relationship between self-efficacy and changes in smoking behaviours.9, 10
Social learning theory forms the basis of cognitive behavioural therapy, which considers that people’s thoughts, feelings, and behaviours can interact with and influence each other to maintain problem behaviours.11 Cognitive behavioural approaches to smoking cessation aim to break the situational and emotional connections that have been established with smoking.12 Behavioural strategies target the pleasurable associations and situational cues that reinforce and maintain smoking, while cognitive strategies target the cognitions and emotions that may also play a role in the person’s tobacco use (for example, the person may believe he or she does not have any control over smoking, or perceive that it helps with coping).
7.3.3 Theory of planned behaviour
The theory of planned behaviour (TPB) states that people’s behavioural intentions and behaviours are determined by their attitudes, social pressure (i.e., subjective norms), and the amount of control they perceive to have over the behaviour.13 A meta-analysis exploring the efficacy of the TPB found it to be useful in predicting intentions and behaviour across a range of health behaviours.14 One study has shown that the theory strongly predicts smoking intentions and behaviours, especially perceived behavioural control.15 Other studies exploring the TPB and cessation have highlighted the predictive value of attitudes and norms in intention to quit smoking,16 and the important role of behavioural intentions in subsequent quit attempts.9,17
7.3.4 Health belief model
The health belief model (HBM) is based on expectancy–value theory, which posits that a person’s values and expectations drive motivation. The HBM was developed to explain and predict health-related behaviours, and is one of the most commonly applied models in health behaviour research and practice. It suggests that engagement (or lack of engagement) in health-promoting behaviour can be predicted by people's perceived susceptibility (i.e., beliefs about their risk of contracting a health condition), perceived threat (feelings concerning the seriousness of contracting an illness or leaving it untreated), perceived benefits of taking health action and barriers to action, perceived self-efficacy (i.e., beliefs about their ability to perform the action), and cues/triggers to action.18, 19
In regards to smoking, the HBM would predict that tobacco use is determined by an individual’s perceptions regarding: susceptibility to tobacco-related diseases; costs, benefits, and barriers to engaging in smoking or quitting behaviours; and triggers to change the behaviour. A study of high school students in Iran found significant differences in knowledge, perceived susceptibility, benefits, self-efficacy, and cues to action between smokers and non-smokers, indicating that the HBM may be useful in predicting smoking behaviours.20 Among a sample of Chinese college students, greater perceived benefits of smoking and higher perceived costs of non-smoking were associated with being a past or a current smoker.21 In terms of quitting, high perceived susceptibility to illness and high self-efficacy have been shown to predict reductions in smoking.22
7.3.5 Social–ecological model
The social–ecological model emphasises the reciprocal relationship between behaviours and the social environment.2 Creating an environment that is conducive to change is important in promoting the adoption of healthy behaviours, and interventions based on this model are therefore complex, multi-level (emphasising individual, interpersonal, organisational, community, and public policy influences), and multi-sectoral.23
In the context of tobacco control, proponents of the social–ecological model have argued that traditional theories (such as the health belief model and theory of planned behaviour) place too much emphasis on individual-level, rational choice, and ignore the powerful ways in which the tobacco industry can shape the environment and influence smoking behaviours. They highlight the importance of public health experts using multi-level, multi-sectoral interventions in preventing tobacco use; interventions based on notions of individual decision-making are less effective, they argue, and may inadvertently support the tobacco industry's framing of tobacco-caused diseases as the result of “unfortunate but informed” individual choices.23
7.3.6 Transtheoretical model/Stages of change
The transtheoretical model (TTM) posits that successful behaviour change involves a sequence of steps: precontemplation (not even thinking about changing), contemplation (thinking about changing), preparation (planning for change), action (adopting new habits), and maintenance (ongoing practice of new, healthier behaviour).24 The TTM may be useful in explaining and predicting changes in a range of health behaviours, including smoking cessation.25
According to the theory, in order to successfully quit, smokers will move from not thinking about quitting (precontemplation), to seriously considering quitting at some point (contemplation), to aiming to quit in the immediate future and making plans to do so (preparation), to quitting (action), to staying quit (maintenance). People may not always move through the stages in a sequential manner; some may relapse and go back to an earlier stage, which can depend on their levels of motivation and self-efficacy.2
Opponents of the TTM claim that it does not satisfy the criteria required of a valid stage model, primarily because the stages are not qualitatively distinct categories.26 Some have argued that the definitions of the stages are arbitrary,27 based either on timeframes of intention or length of time quit. An Australian study of Quitline callers found only limited support for the TTM in cessation, with the exception of the importance of self-efficacy.28 A number of researchers have proposed alternatives to the stages.29, 30 For example, it may be more useful to re-categorise pre-quitting into: not interested, open to the possibility, and actively planning. Post-quitting, there is no consensus on which categories, if any, would be appropriate. However, there is some evidence that quitters’ experiences in the first month or so, when strong cravings to smoke occur at least daily, are different from the subsequent period when cravings are less common.31
7.3.7 Psychoanalytic theory
Developed by Sigmund Freud, psychoanalytic theory assumes that unconscious psychological processes and early childhood experiences determine a person’s personality and behaviour. Freud contended that children progress through a sequence of developmental stages—oral, anal, Oedipal, latency, and genital—and frustration or over-gratification during one of the stages leads to fixation at that stage, and to the development of an oral, anal, or Oedipal personality style.32
Freudian theorists view smoking as caused by fixation at the oral stage. The oral personality, according to the theory, regards the mouth as the greatest source of pleasure, leading to excessive consumption of food, alcohol, or drugs.32 A number of studies have tried to link orality and smoking, thus supporting the value of psychoanalytic theory in this context; however, results are mixed and studies are generally of poor quality.33 A review of empirical data found limited evidence for the efficacy of psychodynamic psychotherapy for substance-related disorders (though none of the studies looked at smoking), but concluded that further research is needed.34 (See Section 7.15.3 for further information on individual counselling.)
7.3.8 Physiological models of addiction
Physiological models attempt to explain the brain mechanisms that underlie addiction. Nicotine use causes the release of dopamine, leading to feelings of reward and pleasure. However, the effects of nicotine are short lasting, and often followed by withdrawal symptoms such as cravings and irritability. Over time and with continued use, the number of nicotine receptors in the brain can increase, compounding nicotine cravings. Frequently pairing smoking with another activity can also lead to neurochemical changes that affect how parts of the brain connect with each other, which creates the unconscious associations between certain activities (such as having a cup of coffee) and cravings. Further, a person’s genes play an important role in addiction, with certain genetic variants appearing to influence how heavily a person will smoke, how addicted to nicotine he or she becomes, and the likelihood of relapse after quitting.4 (See Chapter 6, Section 6.2 for further information on addiction.)
These findings have a number of implications for quitting. They highlight the important role of pharmacotherapies in cessation, which aim to reduce withdrawal symptoms and block the reinforcing effects of nicotine. Some researchers have also attempted to develop vaccines that create antibodies that bind to nicotine in the bloodstream and prevent it from entering the brain in the first place.35 Others are attempting to enhance treatments for nicotine addiction by individualising pharmacotherapy based on which genetic variant/s a person may have.36 For further information on pharmacotherapies, see Section 7.16 .
7.3.9 Smoking and quitting as products of social and environmental influences
A robust body of research has demonstrated a causal relationship between uptake and continuation of smoking in young people and a range of social and environmental factors, including the home environment, peer group influences, and exposure to tobacco industry advertising and promotion.37, 38 (See Chapter 5, sections 5.7 , 5.8 , 5.15 and 5.16 for further information.) Tobacco companies spend billions of dollars on tobacco advertising and promotion each year, which in turn increases overall tobacco consumption and encourages young people to start smoking. Environments where smoking is socially accepted and normalised, and where tobacco products are more widely accessible and visible, also serve to promote smoking.38
Social and environmental factors can also be powerful drivers in preventing uptake and encouraging quitting. Legislation that denormalises smoking by making it less visible and less socially acceptable (such as advertising and promotion bans, smokefree environments, and restricted sales to youth) has been crucial in reducing smoking rates over time.37, 38 (See Chapter 14 for further information.)
7.3.10 Religious views on smoking
Religious views on smoking vary widely, but many religious traditions instruct their members on what is permissible in respect to diet, exercise, and drug use. Religion and religious authorities can be important influences on smoking and quitting, particularly in places where they hold great importance to the population. Smoking has been described by Christian leaders as “contrary to the original form of man’s creation”,39 and the Vatican has forbidden smoking in closed public spaces, places frequented by the public, and workplaces.40 The Mormon Church (of Jesus Christ and the Latter Day Saints) and the Seventh Day Adventist Church have been active for many years in encouraging both members and the public more generally to give up smoking.41 Indeed the lower incidence of cancer and heart disease among Seventh Day Adventists, who generally do not smoke or drink, provided evidence that helped to consolidate the case that implicated smoking as a cause of lung cancer and cardiovascular disease.42 A study in the US found that religiously active people were less likely to smoke, and if they did, they smoked fewer cigarettes.43
Many other religions, including Islam and Buddhism, have religious principles that forbid or discourage the use of addictive substances.44 For example, some Islamic scholars have pronounced smoking as ‘haram’ (forbidden), while others see it as only ‘makruh’ (advised against).45 Among a sample of Malaysian Muslim university students, Islamic beliefs had positive influences on non-smokers; a significant proportion reported believing that Islam prohibits smoking because of its potential harm.46 Most learned monks in Thailand see tobacco use, because it is harmful and addictive, as antithetical to Buddhist concepts.44 A study of Thai Buddhists and Malaysian Muslims found that the majority of both groups believed that their religion discourages smoking, and more than half reported that their religious leaders had encouraged them to quit in the past.44 A growing body of research supports the effectiveness of mindfulness-based interventions—which are founded in Buddhist principles—for smoking cessation. See Section 7.8.4 for further information..
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References for Section 7.3
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