Theories tell how and why things work; how and why one variable is related to another. Research findings that are theory based can be placed in a framework that advances science further than findings that are unconnected to formal theory. However, much of the research in smoking cessation is atheoretical. This review of nursing research on smoking cessation published from 1989 through 2008 revealed that nearly half of the studies were based on explicit formal theories. The transtheoretical model and self-efficacy theory were the most frequently used explicit theories with most theories emanating from psychology. Five nursing theories were identified in this review. Studies that used implicit rather than explicit theories dealt with five major concepts: nicotine dependence, social support, high-risk situations, mood-affect, and the influence of clinical diagnosis. Largely missing from this set of studies were investigations based on biobehavioral models, including genetics and neuroscience. The relevance of the theories and concepts identified in this review to current clinical guidelines on smoking cessation is discussed. With their grounding in theory and their expert knowledge of clinical issues, nurses are in an excellent position to develop theories that will help researchers in every discipline make sense of smoking cessation

The theory of planned behavior and smoking cessation.Norman P1,Conner M,Bell R.Author informationAbstractA sample of 84 smokers attending health promotion clinics in a primary care setting completed questionnaires that assessed the main constructs of the theory of planned behavior, perceived susceptibility, and past cessation attempts. Regression analyses revealed that intention to quit smoking was primarily predicted by perceived behavioral control and perceived susceptibility. At 6-month follow-up, the making of a quit attempt was predicted by intention and the number of previous quit attempts, whereas the length of the quit attempt was predicted solely by the length of the longest recent quit attempt. The results suggest that interventions should focus on perceptions of susceptibility and control to increase smokers' motivation to quit. However, further work is required to identify the social cognitive variables that ensure that initial quit attempts are translated into longer term abstinence.

Social Cognitive TheoryHealth Behavior Models>Social Cognitive TheoryOverviewSocial Cognitive Theoryexplains how individuals initiate and maintain a given behavior (i.e., quitting smoking) by emphasizing the role ofinteractions among various cognitive, environmental, and behavioral factors (i.e., reciprocal determinism): Cognition: Various mental processes that occur within the individual, such as behavioral capability, outcome expectancies, emotional coping responses, and feelings of self-efficacy. Environment: Any factor physically external to the individual that can impact ones behavior. The environment is comprised of social factors (i.e., family, friends, observational learning), and physical factors (i.e., weather, availability of tobacco products, etc.). Behavior:The manner in which the individual reacts to various inputs from their social and/or physical environment (i.e., self-regulation).Key ConstructsConstructDefinition (for Tobacco Users)

Behavioral CapabilityKnowledge and skill to perform a given behavior; promote mastery learning through skills training

Reciprocal DeterminismThe interaction between the tobacco user, smoking, and the environment in which the behavior is performed. Environmental factors can have an effect on the tobacco user. The tobacco user can also have an effect on the environment.

Emotional Coping ResponsesStrategies or tactics that are used by a person to deal with emotional stimuli

Outcome ExpectationsA tobacco users beliefs about the likelihood and value of the consequences of their choices regarding smoking.

Self-EfficacyA tobacco users confidence and beliefs to perform behaviors to bring about cessation of tobacco use.

Collective EfficacyThe beliefs about a group of tobacco users ability to perform actions together to bring about the cessation of tobacco use.

Observational LearningBehavioral acquisition that occurs by watching the actions and outcomes of others behavior; Include credible role models of the targeted behavior

Incentive MotivationUse of rewards and punishments to modify tobacco use (i.e., increasing taxes on tobacco)

FacilitationProviding tools, resources, or environmental changes for a smooth tobacco cessation process.

Self-Regulation(Self-Control)Personal regulation of goal-directed behavior; The tobacco users ability to control themselves through several methods, including, self-monitoring, goal-setting, feedback, self-reward, self-instruction, and enlistment of social support.

Moral DisengagementWays of thinking about tobacco use and the individuals who are harmed by ones tobacco use (i.e., second-hand smoke) that make infliction of harm acceptable

Strategies to Use with Tobacco Users Help clients acquire the necessary skills for change Ask the client to self-monitor tobacco use via a behavior diary Discuss previous attempts to quit and the factors (cognitive & environmental) that contributed to relapse Emphasize behavior changes that the client has made and discuss how past success can generalize to quitting tobacco use Increase the positive outcome expectancies for quitting smoking Increase the client's feelings of self-efficacy for quitting tobacco use by utilizing the following methods:MethodInvolves

Mastery ExperienceEnabling the tobacco user to succeed in attainable but increasingly challenging performances of cessation behaviors (i.e., via role-plays about non-use). The experience of performance mastery is the strongest influence of self-efficacy belief.

Social ModelingShowing the tobacco user that others like themselves can quit. This may include modeling non-use of tobacco and use of various tasks involved in the process of smoking cessation, as well as introducing client to other who have quit.

Improving Physical & Emotional StatesMaking sure the tobacco user has addressed any physical or emotional concerns before attempting to quit. This may include efforts to reduce stress and depression.

Verbal PersuasionTelling the tobacco user that he or she can quit. Strong encouragement can boost confidence enough to initiate efforts toward quitting.

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Cessation ResearchReferencesTables Adapted from:Glanz, K., Rimer, B.K. & Lewis, F.M. (2002).Health Behavior and Health Education. Theory, Research and Practice.San Fransisco: Wiley & Sons. p169.McAlister, A. L., Perry, C. L., & Parcel, G. S. (2008). How individuals, environments, and health behaviors interact: Social cognitive theory. In Glanz K, Rimer BK, Viswanath K, Eds. (4thed). Health Behavior and Health Education: Theory, Research, and Practice. San Francisco: Jossey-Bass. pp167-188.

Theories about smoking and quittingShow / hide chapter menuThere is no definition of addiction that is universally accepted but in general addiction refers to physiological and psychological dependency on a drug. Many social, cultural and economic factors contribute to the development, maintenance and change of health behaviour patterns.1Some researchers have suggested that a broader conceptualisation of addiction is needed. This involves a model in which addiction is understood as a syndrome with multiple opportunistic expressions, such as smoking.2Interventions based on theory or theoretical constructs are more effective than those not using theory.1The 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 and interrelationships between these three aspects, with some variation in how they deal with the psychological factors.7.3.1Cognitivebehavioural theoriesThe most influential theories in tobacco control and public health are ones that can be broadly conceptualised as cognitivebehavioural. These theories often have separate sub-theories that theorise the relationships between cognitive aspects and factors influencing conditioned, reactive behaviours. One subset, expectancy value theories, focuses on rational appraisals of costs and benefits. These are purely or largely cognitive in focus and include such theories as the theory of planned behaviour,3the health beliefs model,4the rational addiction model5and the transtheoretical model.6A second set of theories, of which the social cognitive theory of Bandura7is best known, try to incorporate other factors, but focus on context.A third set of theories, broadly conceptualised as self-regulatory theories, focus on what volitional processes act to inhibit or constrain affective reactions and impulse to act on affective inputs. These include Leventhal's perceptual motor theory,8which has not been applied to smoking as much as it could have, and more recently the hugely influential PRIME theory of West9and temporal self-regulation theory.10These theories focus on ways in which people manage more basic conditioned and innate reactions, including emotional reactions, to substances.Overall, most of the evidence for the effectiveness of non-pharmacological approaches is that various cognitivebehavioural interventions are helpful. They are the basis of Quitline callback protocols and of most publicly available cessation courses.7.3.2Behavioural theoriesBehavioural theories focus on how people learn to behave in particular ways. Behaviourists believe people learn to behave through mechanisms such as conditioning and positive and negative reinforcement. They respond to stimuli in their environment and establish an association or linkage between two events. In the context of smoking, a person learns to associate smoking with other feelings and events (e.g. being in a stressful situation or having a coffee) and these continue to 'cue' their smoking behaviour. Behavioural modification approaches to smoking cessation are underpinned by these theories. In addition to highlighting the negative consequences of smoking, behavioural approaches to cessation focus on educating the individual smoker to extinguish learned responses, to reward themselves for abstinence and to draw greater attention to the immediate and benefits of quitting. Most studies of behavioural interventions for smoking cessation report moderate success in quitting at six months.11(SeeSection 7.13.)7.3.3Psychodynamic theoriesPsychodynamic theories assume that unconscious forces of which they are unaware determine a person's behaviour. The hidden motives for our behaviour reflect our instinctive biological drives and our early experiences, particularly the way in which our parents treated us. The theories focus on the psychosexual stages of development first described by Sigmund Freud and postulate that problems at any stage of development can result in the child becoming stuck at a stage. If this happens traces of that stage will remain in their behaviour as an adult. Smoking is viewed as a fixation at the oral stage. Criticisms of the psychodynamic approach include its qualitative methods, lack of objectivity in interpretation and the reliance on theoretical constructs that are difficult to prove. This theory underlies psychoanalytic individual counselling approaches to smoking cessation intervention. Reviews of psychological interventions for smoking cessation have found that therapists draw on a variety of psychological techniques rather than a distinctive theoretical model, and that there is therefore little evidence about the relative effectiveness of different approaches.12There is some evidence for the efficacy of psychodynamic psychotherapy for substance-related disorders, with outcome related to the competent delivery of therapeutic techniques and to the development of a therapeutic alliance.13(SeeSection 7.15.3for further information on individual counselling.)7.3.4Physiological models of addictionPhysiological models of addiction focus on the physical dependence on psychoactive substances that cross the bloodbrain barrier once ingested, temporarily altering the chemical patterns of the brain. Even taken in low quantities, nicotine is a potent chemical. It causes a range of physiological changes and creates dependency, which in turn is reinforced by unpleasant sensations upon withdrawal. (SeeChapter 6, Section 6.2for further information on addiction.)The implication for smoking cessation is that an individual smoker needs to break his/her addiction to nicotine, highlighting the role of pharmacotherapies in smoking cessation. (SeeSection 7.16for further information on pharmacotherapies.)7.3.5Sociological theoriesSociological theories relate to social learning that encourages patterns of use in the person's family, peer group or sub-culture. Cultural and social norms, variations in drug use patterns, and values and behaviours of parents, siblings, friends and role models affect drug use. A major implication for cessation within this model is the need to address a person's smoking within the context of his or her family, cultural and social environment.7.3.6Smoking and quitting as issues of communication and commercial and social marketingSmoking is very much a communication issue, related to the encouragement to smoke and normalisation of smoking in particular through commercial and social marketing. There is a causal relationship between uptake of smoking in children and exposure to smoking in the home environment, around peers and through tobacco advertising. (SeeChapter 5, sections5.7,5.8,5.15and5.16for further information.) Later in life, taking up smoking is also influenced by tobacco promotion in environments popular with young people. (SeeChapter 5, Section 5.17for further information.) Research shows that tobacco advertising, in its various guises, is associated with an increase in overall tobacco consumption and that it may remain in a community's collective memory for many years even after being banned. Regulating advertising and promotion can reduce both prevalence and initiation of smoking. (SeeChapter 11, Section 11.1for further information.)Quitting is also influenced by the communication of messages that raise awareness of smoking-related health risks and of the benefits of stopping smoking. Anti-smoking social marketing campaigns have played a significant role in changing attitudes towards smoking, increasing quitting attempts and leading to a downward trend in smoking prevalence. The ways in which campaign communication works include by highlighting smoking as an important community health issue, raising the importance of quitting on a person's agenda, changing the social norms regarding smoking and giving a focus and direction to the quitting activity that is naturally occurring among smokers. (SeeChapter 14for further information.)7.3.7Eclectic, ecological modelsEclectic models of behaviour maintain that no one theory can fully explain a person's behaviour; instead they borrow from many different theories. Psychosexual and psychosocial stages of development, love and acceptance and self-actualisation as well as behavioural and sociological concepts are all influential within this model. Changing an individual's smoking behaviour in this context may involve combining a psychodynamic perspective with more active interventions such as in cognitivebehavioural therapy. (SeeSection 7.15.3for further information on individual counselling.)Ecological models centre on the relationship between the developing individual and four expanding levels of the changing environment, from home and family to the broader cultural context. Within this model, health promotion interventions such as smoking cessation should not only be targeted at individuals but should also affect interpersonal, organisational and environmental factors influencing health behaviour. Further evaluation of this model is warranted.17.3.8Religious and Eastern philosophical views about smoking as a compulsive behaviourThe 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 smokingseehttp://en.wikipedia.org/wiki/Religious_views_on_smokingandhttp://adventist.org/beliefs/statements/main-stat23.htmlfor further details. 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.14Apart from these examples, the involvement of religious authorities in public health campaigns for tobacco control is a relatively recent phenomenon.15There is little evidence that religious belief or affiliation has a major impact except in the case of religions with very strong sanctions against tobacco use. However, in areas where religion plays a very prominent role in society, such as in Mormon-dominated Utah in the US, where the prevalence of current smoking (daily or less than daily) is only 9.1% seewww.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm, and in countries such as Malaysia and Thailand,15it can be important as part of an integrated set of programs and policies for tobacco control.Eastern philosophy includes the various belief systems of Asia, including Buddhism, Hinduism, Confucianism and Islam. The distinction between the religious and the secular tends to be less in Eastern philosophy than in Western religions and the same philosophical school often contains both religious and philosophical elements. The inner world of a human being and his or her ability to control and develop it is of the highest value. Spirituality, virtue, and meditation as a means of establishing control over emotions and life as a journey are key concepts.16Most religions, including Islam and Buddhism, have religious principles that forbid or discourage the use of addictive substances.15For example, some Islamic scholars have pronounced smoking as 'haram' (forbidden), while others see it as only 'makruh' (advised against) and most learned monks in Thailand see tobacco use, because it is harmful and addictive, as antithetical to Buddhist concepts.15As part of Eastern philosophical views a range of techniques, including an approach called mindfulness, is suggested to assist motivation, reduce mood disturbance and overcome cravings. (SeeSection 7.8.4for further information.)References1. Glanz K and Bishop DB. The role of behavioral science theory in development and implementation of public health interventions. Annual Review of Public Health 2010;31:399-418. Available from:http://www.ncbi.nlm.nih.gov/pubmed/200702072. Shaffer HJ, LaPlante DA, LaBrie RA, Kidman RC, Donato AN and Stanton MV. Toward a syndrome model of addiction: multiple expressions, common etiology. Harvard Review of Psychiatry 2004;12(6):367-74. Available from:http://www.ncbi.nlm.nih.gov/pubmed/157644713. Ajzen I and Fishbein M. Theory of Planned Behavior: predicting and changing behavior: the reasoned action approach. New York: Psychology Press, 2010. Available from:http://www.mendeley.com/research/predicting-changing-behavior-reasoned-action-approach/4. Rosenstock IM. Social Learning Theory and the Health Belief Model. Health Education and Behavior 1988;15(2) Available from:http://heb.sagepub.com/content/15/2/175.short5. Becker G and Murphy K. A theory of rational addiction. The Journal of Political Economy 1988;96(4):675700. Available from:http://www.drugtext.org/library/articles/becker02.htm6. Prochaska JO and DiClemente CC. Stages and processes of self-change in smoking cessation towards an integrative model of change. Journal of Consulting and Clinical Psychology 1983;51(3):3905. Available from:http://www.ncbi.nlm.nih.gov/pubmed/68636997. Bandura A. Social Learning Theory. Englewood Cliffs, New Jersey: Prentice Hall, 1977.8. Leventhal H and Cleary P. The smoking problem: a review of the research and theory in behavioral risk modification. Psychological Bulletin 1980;88(2):370405. Available from:http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=1980-31012-0019. West R. Current issues and new directions in Psychology and Health: the potential contribution of health psychology to developing effective interventions to reduce tobacco smoking. Psychology & Health 2010;25(8):88992. Available from:http://www.informaworld.com/smpp/section?content=a928167994&fulltext=71324092810. Hall P and Fong G. Temporal self-regulation theory: A model for individual health behaviours. Health Psychology Review 2007;1(1) Available from:http://www.tandfonline.com/doi/abs/10.1080/1743719070149243711. Murthy P and Subodh B. Current developments in behavioral interventions for tobacco cessation. Current Opinion in Psychiatry 2010;23(2):1516. Available from:http://journals.lww.com/co-psychiatry/pages/articleviewer.aspx?year=2010&issue=03000&article=00013&type=abstract12. Lancaster T, Stead L, Silagy C and Sowden A. Regular review: effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ (Clinical Research Ed.) 2000;321(7257):3557. Available from:http://www.bmj.com/cgi/content/full/321/7257/35513. Leichsenring F. Are psychodynamic and psychoanalytic therapies effective?: A review of empirical data. International Journal of Psychoanalysis 2005;86(Pt 3):841-68. Available from:http://www.ncbi.nlm.nih.gov/pubmed/1609607814. Wynder EL and Lemon R. Cancer, coronary artery disease and smoking: a preliminary report on differences in incidence between Seventh-day Adventists and others. California Medicine 1958;89(4):267-32. Available from:http://www.ncbi.nlm.nih.gov/pubmed/1358514515. Yong HH, Hamann SL, Borland R, Fong GT and Omar M. Adult smokers' perception of the role of religion and religious leadership on smoking and association with quitting: a comparison between Thai Buddhists and Malaysian Muslims. Social Science and Medicine 2009;69(7):1025-31. Available from:http://www.ncbi.nlm.nih.gov/pubmed/1969575816. Fishbein M and Ajzen I. Belief, Attitude, Intention and Behavior: An Introduction to Theory and Research. Reading, Massachusetts: Addison-Wesley, 1975.Recent referencesPromising interventionsCarim-Todd, L., S. Mitchell, and B. Oken, Mind-body practices: an alternative, drug-free treatment for smoking cessation? A systematic review of the literature. Drug and Alcohol Dependence, 2013. [Epub ahead of print].Available from:http://www.sciencedirect.com/science/article/pii/S0376871613001439http://www.ncbi.nlm.nih.gov/pubmed/23664122

Translating theory into action: A focus on smoking cessationShare This PageSeptember 01, 2012One to OneA young woman approaches the pharmacy to pick up a prescription and you notice a pack of cigarettes in her purse. You ask her if she is interested in trying to quit smoking. She replies that she has tried to quit smoking in the past, but she always goes back to smoking during periods of stress. She seems interested in hearing what you have to say, but has not given any recent thought to quitting in the near future.What is the best cessation message a pharmacist could convey to this patient? The answer lies in the details of three explanatory behavioral models researchers have spent years developing and refining. By understanding the constructs of such models, pharmacists can make targeted interventions that are appropriate for patients who need to make changes in their lifestyles, behavior patterns, or medication-taking habits.Actions are plannedConstructs from theoretical models are often used to guide health behaviors and interventions such as smoking cessation. An important model in public health is the theory of planned behavior, which is a part of the theory of reasoned action (see Figure 1). These theories assume that behavioral intention is influenced by a patients beliefs and attitudes toward performing a behavior and by the beliefs of what others think of the behavior.Figure 1. Theories of reasoned action and planned behavior

Source: National Cancer Institute. Theory at a glance: a guide for health promotion practice, 2nd ed. Bethesda, MD: National Institutes of Health; 2005:18. Accessed atwww.cancer.gov/cancertopics/cancerlibrary/theory.pdf, August 24, 2012.As the figure shows, the theories are closely related. Attitudes toward a target behavior, subjective norms, and perceived behavioral control all feed into behavioral intention, which will ultimately drive the target behavior. In the case presented above, the target behavior is smoking cessation.Attitudesrepresent a patients attitude toward a given behavior. A direct attitude about the target behavior of smoking cessation may be one in which a patient thinks quitting is good or bad. An indirect attitude is one in which a patient believes a peripheral outcome (such as weight gain) may or may not occur as a result of the target behavior.Subjective normsinvolve what others think of a given behavior and whether the patient thinks key people approve or disapprove of a given behavior. For example, a physician or other health care provider may have encouraged the patient to quit smoking, and this will positively influence the patients willingness to quit. The patient may also feel disapproval of smoking by others, further reinforcing the desire to quit.Perceived behavioral controlinvolves whether patients believe they can exercise control over performing the behavior. External factors may be involved.These three factors collectively determine a patientsbehavioral intention, and that leads to the behavior itself. The woman at the counter is most likely to succeed if she believes quitting is good, thinks others believe the same thing, and is confident she can quit.What stage is that?A model that provides specific actions for pharmacists is the transtheoretical model of change. It assumes that behavioral change is a process and not an event, and that as a patient attempts to change a behavior, he or she goes through various stages.The model includes five stages: precontemplation (no intention of taking action in next 6 mo), contemplation (intends to take action in next 6 mo), preparation (intends to take action in next 30 d), action (has changed behavior for 6 mo).Determining which stage patients are in is the key, as this will guide counseling. For example, in the case above, the woman is in the precontemplation stage and therefore should receive education on the need for change and the benefits associated with the change. This differs substantially from information that would be presented to patients in the maintenance stage, which may include counseling on coping mechanisms to prevent relapse.Maria G. Tanzi, PharmD

Smoking Cessation: Theory, Interventions and PreventionRetail Price:$225.00

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Editors:Jerome E. Landow

Book Description:Smoking is the most common risk factor for the development of lung cancer, which is the leading cause of cancer death. It is also associated with many other types of cancer, including cancers of the esophagus, larynx, kidney, pancreas, and cervix. Smoking also increases the risk of other health problems, such as chronic lung disease and heart disease. Smoking during pregnancy can have adverse effects on the unborn child, such as premature delivery and low birth weight.The health benefits of smoking cessation (quitting) are immediate and substantial.

Almost immediately, a person's circulation begins to improve and the level of carbon monoxide in the blood begins to decline. (Carbon monoxide, a colorless, odorless gas found in cigarette smoke, reduces the blood's ability to carry oxygen.) A person's pulse rate and blood pressure, which may be abnormally high while smoking, begin to return to normal. Within a few days of quitting, a person's sense of taste and smell return, and breathing becomes increasingly easier.

People who quit smoking live longer than those who continue to smoke. After 10 to 15 years, a previous tobacco user's risk of premature death approaches that of a person who has never smoked.Quitting smoking reduces the risk for developing cancer, and this benefit increases the longer a person remains "smoke free."

Quitting smoking may cause short-term after-effects, especially for those who have smoked a large number of cigarettes for a long period of time. People who quit smoking are likely to feel anxious, irritable, hungry, more tired, and have difficulty sleeping. They may also have difficulty concentrating. Many tobacco users gain weight when they quit, but usually less than 10 pounds. These changes do subside.

This new book presents new and important research in this bewildering field.