Literature Review Paper

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A B e h a v i o r a l T h e o r y A n a l y s i s o f T o b a c c o U s e
A m o n g A d o l e s c e n t s a n d A d u l t s
Abigail Gaines
Health 2400
Determinants of Health Behavior
Section 002

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INTRODUCTION
In today’s society, tobacco use is the number one preventable disease throughout the United
States (CDC, 2015). Tobacco contains many different chemicals that cause cancer such as
benzene and formaldehyde and other substances that are toxic to the body like certain metals
such as arsenic and cadmium (Smoking, 2016). However, the most addictive chemical in any
tobacco product is nicotine, which happens to be both a sedative and a stimulant (Relay Health,
2010). Nicotine is designed to increase the release of dopamine, which is a chemical
neurotransmitter in the brain. Dopamine is the main reason a person feels a sense of wellbeing or
happiness (Peterken, 2014). An individual becomes dependent upon nicotine because when
inhaled, nicotine travels to the brain where it produces these sensations of relaxation and will
most likely lead to future dependency (Peterken, 2014). Studies show that virtually all cigarette
smokers start smoking before 18 years of age (Health Consequences, 2014).
For reference, there are more than ten times as many individuals that have died prematurely from
cigarette smoking then have died in all wars fought by the United States up until today (CDC,
2015). Smoking causes almost 500,000 deaths per year throughout the United States, which
happens to be more than the deaths from addiction upon alcohol, motor vehicle accidents among
drivers of all ages, and weapon-related accidents (CDC, 2015). Not only are consequences of
smoking individualistic, smoking also impacts the environment and the health of others. Since
smoking involves the process of exhaling toxic substances, many individuals will breathe in the
chemicals that were not filtered out by the lungs, which can become extremely dangerous
(Boughnot & Davidson 2015). Individuals who do not engage in smoking or nicotine behaviors
are still susceptible to diseases such as lung cancer and are at a potential increased risk of lung
cancer by as much as 20-30%. And throughout the United States, secondhand smoke is
responsible for as many deaths as 38,000 (Boughnot & Davidson, 2015).
Cigarette smoking and nicotine dependence affects every race, age category, and social status
realm. Of these different categories, the most at risk are: non-Hispanic American
Indians/Alaskan natives, persons among the ages of 25 – 44 years, and those who are living
below the poverty line (CDC, 2015). The most alarming statistic shows that 19.5% of American

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high school students and 5.2% of middle school students are smoking cigarettes (Sternberg,
2015).
From an economic standpoint, cigarette smoking and nicotine behaviors are responsible for
dramatic revenue across all categories. Smoking behaviors are responsible for more than $300
billion directly related to smoking illnesses. This can be broken down into direct medical care
costing $170 billion and $156 billion in loss of productivity (CDC, 2015).
In order to combat the epidemic of tobacco use in the United States, there are numerous
government agencies such as the Substance Abuse and Mental Health Services Administration
(SAMHSA) and the World Health Organization (WHO) that develop and promote its
intervention programs to promote cessation of smoking. Along with these programs, Healthy
People 2020 aims to prevent and reduce the initiation of tobacco use among children,
adolescents, and adults.
Along with free government programs that promote smoking cessation, individuals can
personally seek out help from their medical doctor or counselor. A physician could recommend
certain alternatives such as nicotine gum, nasal spray, and transdermal patches along with drug
medications such as Chantix and Zyban. Other routes of treatment include the alternative
pathway, which could include anything from hypnosis, acupuncture, herbal supplements, and
special diets (Krapp, 2007).
THEORY
The literature regarding behavior response to programs of smoking cessation tends to focus on
theories related to perceived behavioral control along with the importance of an individual’s
attitudes and self-efficacy levels. Such models include the Theory of Planned Behavior and the
Transtheoretical/Stages of Change Model. Evaluating each model individually and determining
their positive and negative effects on smoking cessation within an individual is essential to
developing other programs and interventions that will continue to decrease the use of smoking.

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The Theory of Planned Behavior
Among numerous theories describing health behaviors, the Theory of Planned Behavior (TPB)
has become one of the leading cognitive models used to predict certain health behaviors due to
its ability to explain differences among behaviors when only few factors are present
(Hukkelberg, Hagtvet, Knvac, 2014). This model takes into account that a person’s attitudes
(positive or negative assessment of smoking cessation), subjective norms (an individual’s
thoughts of whether other individuals that are important to them believe they should engage in
certain behaviors or not) and perceived behavioral control (perceptions about how easy or
difficult it is to control a particular behavior) are all predictors as to whether or not a person has a
significant intention to either perform or not perform a certain health behavior (Hukkelberg et al.,
2014; Høie, Moan, & Rise, 2010).
A recent study implemented using the TPB model by examining individuals, which allowed the
researchers to predict the intentions of individuals to quit smoking. Surveys were used to gather
demographics such as gender, age, and ethnicity and TPB constructs such as attitudes towards
quitting smoking, subjective norms, and perceived behavioral control among the participants
(Høie et al., 2010). When measuring the constructs of this model, each construct was measured
using a specific scale. When measuring an individual’s attitudes towards quitting smoking, a
semantic differential scale with the stem: “My quitting smoking during the next three months
would be…” with six answer choices of paired adjectives to respond with, such as “bad-good”,
“wrong-right”, “unnecessary-necessary” (Høie et al., 2010). For measuring subjective norms, the
survey used a three item scale with the basic statement of “People who are important to me…”
with responses like “think I should quit smoking during the next three months,” or “wish I would
quit smoking during the next three months” (Høie et al., 2010). Perceived behavioral control, a
major component of the TPB, was measured using a five item scale by asking simple questions
based on how much control an individual perceives that they have over quitting smoking with
the answer choices ranging from 1 being no control versus 7 being complete control (Høie et al.,
2010). A hierarchical multiple regression analysis was performed on multiple variables and
results were concluded that the intention to quit smoking was highly correlated with an
individual’s attitudes, subjective norms, and perceived behavioral control. Those who had a more

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positive attitude and outlook, who were more influenced by people who were important to them,
and believed they had a greater control over quitting smoking were more likely to maintain
smoking cessation (Høie et al., 2010).
Høie, Moan, and Rise (2010) reviewed how the Theory of Planned Behavior could be improved
by including additional predictors that would betterment the prediction of an individual’s
intention to quit smoking. The models analyzing smoking cessation incorporated past behavior
of cessation attempts and also looked at self-identity and group identity. An individual
demonstrates past behavior of smoking cessation by the number of previous attempts they have
tried to quit. Past behavior history can be used not only in smoking cessation interventions, but
also in weight management and other diagnoses of diseases and prevention. In this study, past
behavior was the strongest determinate used to study an individual’s intention to quit smoking. It
was found that the more frequent attempts an individual has made to quit smoking, there would
be a greater likelihood that the individual would be motivated enough to eventually quit smoking
(Høie et al., 2010).
Transtheoretical Model/ Stages of Change Theory
The Transtheoretical Model (TTM), also known as the Stages of Change Theory (SCT) focuses
on different stages of behavioral change, more specifically five stages of change. These five
stages include precontemplation, contemplation, preparation, action, and maintenance of a
specific behavior (Atak, 2007). The TTM can be applied to a variety of behaviors, for example,
weight management, colorectal and mammography screenings, and even condom use, but the
greatest behavior that this model is used for is cessation of smoking (Atak, 2007). However, as it
may seem that an individual going through the stages of change goes from one stage directly to
the next in a linear fashion, this is not the case. The Transtheoretical Model is most useful in a
cyclical staged process rather than in liner form because it allows an individual to progress not
only forward but to relapse backwards to previous stages (Atak, 2007).
Precontemplation, the first stage of this model is a stage in which individuals are inactive and
have no intention of changing the specific behavior and this could be due to individuals being

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misinformed or not informed at all about how to partake in healthy behaviors or they do not fully
understand the consequences of their unhealthy behavior (Atak, 2007). For example, the
individual does not perceive that their smoking is a problem and has no intention to quit in the
future (Cahill & Lancaster, 2010). Contemplation is when the individual has started thinking
about changing a particular behavior, yet they still believe that the cons (negatives) and pros
(benefits) of change are equal so there is no reason to begin changing (Atak, 2007). For example,
the individual is aware that their smoking is a problem, and is thinking about quitting (Cahill &
Lancaster, 2010). Preparation is the stage in which individuals start to realize that the pros
outweigh the cons and therefore they need to take action. Although the behavior is being
performed inconsistently during this stage, individuals are at least trying to make change for the
better. Action is the stage when an individual has performed a behavior consistently for a time
period of six months. In this stage, individuals realize that the pros exceedingly outweigh the
cons. Although the behavior has been performed for six months, individuals in this stage are at
the greatest risk for relapse (Atak, 2007). Maintenance is the stage in which individuals have
performed a behavior consistently for a time period of more than six months. In this stage,
individuals have a high confidence level and enjoy the benefits brought about from changing a
behavior (Atak, 2007). Individuals who make it through the stages of change to the final result
will continue to work on the behavior to prevent relapse (Cahill & Lancaster, 2010).
Decisional balance is when an individual compares the benefits and negatives of partaking in a
certain health behavior. When comparing these two, if the benefits outweigh the cons then an
individual will be more likely to conform to a health behavior rather than if the cons outweigh
the benefits. In the TTM, decisional balance between pros and cons are different for each stage
that a person is in (Atak, 2007). For example, if an individual is in the contemplation stage then
they will put more emphasis on the benefits than they did in the precontemplation stage, which
shows an increase in the individual’s process of change (Atak, 2007). Since the cons outweigh
the pros in the precontemplation and contemplation stages, more information is needed to
increase an individual’s views of the benefits during these two stages (Dijkstra, Vries, & Bakker,
2008).

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Self-efficacy is an individual’s inner confidence to complete a particular behavior. If an
individual has a high level of self-efficacy, then they are more likely to participate in a healthy
behavior because they are more confident and feel as though they have more control over the
behavior. In this particular study, it was concluded that smokers in the preparation stage showed
a significant increase in self-efficacy when progressing to the next stage of action (Dijkstra et al.,
2008; Atak, 2007).
Another major component of the Transtheoretical Model includes the ten processes of change,
which include consciousness raising, dramatic relief, environmental-reevaluation, self-
reevaluation, self-liberation, helping relationships, counterconditioning, contingency
management, stimulus control, and social liberation (Atak, 2007). These processes of change
move the individual through the five stages of change by using different strategies that provide
certain guidelines and provide assistance to the individual (Atak, 2007). In response to every
individual being different, information needs to be altered and presented in a way that is
understandable to the person. This relates not only to the stages of change but also to the
processes of change. The processes of change need to be applied at different stages of change to
stimulate individuals and prevent as much relapse as possible (Atak, 2007). For example,
environmental-reevaluation is realizing the impacts that smoking has on the environment and
individuals around you. When coming to the realization of what smoking does to the
environment, an individual sees that the smoke pollutes the air, it can cause littering of cigarette
butts, and most importantly it can cause second-hand smoke to other individuals in the vicinity
around them. This process of change is most importantly used in the precontemplation and
contemplation stages to get the individual to start thinking about changing and eventually
wanting to change, in this case to stop smoking (Atak, 2007).
Intrapersonal Factors
Intrapersonal factors are one of the main reasons why an individual chooses to act a certain way
or to engage in a specific health behavior. These factors come from within an individual and
consist of beliefs, attitudes, knowledge, values, self-efficacy, and even demographics.

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According to the CDC (2010), almost 70% of current smokers stated that they wanted to stop
smoking entirely. Demographics of smokers were also examined and it was found that
individuals above the age of 25 with a low level of education, equal to a high school diploma,
exhibit the lowest ratios of quitting smoking. On the other hand, smokers that displayed an
educational level of an undergraduate or graduate degree showed quit ratios above 60% (CDC,
2010). This significant increase could potentially be due to individuals having more information
about the serious health effects and outcomes that smoking has on not only themselves, but also
the environment and other individuals around them.
By living in a smoke-free home and having a workplace that strictly enforces a no smoking
policy, individuals are more likely to refrain from smoking and participate in cessation programs
(Lee & Kahende, 2007). These two factors are been found to be most important in refraining
from smoking because most individuals do not want to break strict policies in the workplace and
they also want to protect their family from secondhand smoke within their household. When
examining whether gender plays a specific role in smoking cessation, studies are contradictory
with some saying that males are more likely to maintain cessation of smoking, while other
studies find no significant relationship among gender and cessation (Lee & Kahende, 2007).
Studies do in fact agree on five basic determinants that are most prevalent when examining
positive attempts of cessation and these include living in a smoke-free home, having a no
smoking policy in the workplace, having higher education levels, being married along with
living with a significant other, and being of older age (Lee & Kahende, 2007).
A positive attitude along with increased self-efficacy was shown to increase the likelihood of
participating in smoking cessation programs (Hoie et al., 2010). It was also determined that
individuals who have regularly attempted cessation of smoking and have exhibited past
behaviors of intentions to quit smoking are more prone to act and eventually quit smoking and
continue the maintenance of this healthy behavior (Hoie et al., 2010).
Interpersonal Factors

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Interpersonal factors are most closely related to the relationships that an individual has with
another person or actions that take place between or among a group of individuals, like peers or
family members. Since individuals can influence one another, it is important for smokers to
surround themselves with other smokers who also want to quit and this in turn will increase the
chances of their own personal quitting due to social pressures (Dohnke, Weiss-Gerlack, & Spies,
2011). Social influences are conceived by one’s own thoughts by whether or not individuals who
are important to the person want the individual to adopt a specific behavior or to change a
behavior, which can also be classified as perceived social norms. For example, “my family
members or friends want me to quit smoking” (Dohnke et al., 2011). If an individual perceives
that a specific relationship is more important then another, the perceived social norm that the
significant other has about the behavior (smoking), will be of a stronger influence than the
opinions of others that the individual does not deem as meaningful. This is also correlated with a
more positive attitude of smoking cessation (Dohnke et al., 2011).
Another social influence that could potentially promote an individual to engage in cessation of
smoking would be to see a loved one get diagnosed with a major disease from smoking, such as
lung cancer. This could be a major factor in assisting an individual in deciding that they need to
stop smoking immediately so that they are not affected by life altering news, such as receiving a
serious medical diagnosis, which in turn affects other individuals within their social network.
Organization, Community, Environment, and Policy Factors
Within communities and organizations, policies are implemented for numerous amounts of
reasons, for example to betterment workplaces and also to promote a healthy and clean
environment for individuals who reside in those particular areas.
When individuals smoke, they are exposing multiple populations to secondhand smoke such as,
parents, elderly adults, and young children. Secondhand smoke can potentially be dangerous in
the fact that it can cause disease and premature death in young children and it also affects healthy
individuals by infecting them with cigarette smoke even though they chose not to partake in the
non-healthy behavior of smoking (Koh, Alpert, Judge, Caughey, Elqura, Connolly, & Warren,

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2011). It was stated earlier that secondhand smoke is responsible for a 20-30% increased risk of
developing diseases from smoking such as lung cancer or asthma (Boughton & Davidson, 2015).
Policies regarding smoking have now been implemented in various states due to the continued
increase of exposure due to secondhand smoke in order to reduce the mortality rates that are
caused by the negligent actions of those who smoke. One particular studied stated that 80% of
smokers who were surveyed in Ireland actually supported the policy that implemented no
smoking in public places (Koh et al., 2011). Recently laws have been put into action among
different restaurant locations that state “smoking is not allowed,” which deters individuals from
smoking. Individuals could see this statement and begin to think that they need to change their
smoking behavior so that they could be more accepted in the community.
Another factor that targets organizations and communities are the promotion of cessation
advertisements through the use of social means such as the television, radio, and social media
applications. Ads are measured by examining the amount of perceived effectiveness that is
reported by individuals along with their emotions and thoughts about the ad (Davis,
Nonnemaker, Duke, & Farrelly, 2013). Advertisements are categorized into two different types,
each of which targets a specific population group. The first type of advertisement is the “why to
quit” ad and these messages are tailored to individuals who do not yet have enough information
to encourage them to engage in cessation (Davis et al., 2013). The other type of advertisement is
the “how to quit” ad, which targets individuals who want to quit smoking but feel as though they
need an extra boost in self confidence, encouragement, or both to start the process of cessation
(Davis et al., 2013). These advertisements promote individuals within a community or an
organization to band together to encourage each other that smoking cessation is a possible
reality, and once cessation is obtained, communities can support the maintenance of this healthy
behavior.
Enabling Factors
Enabling factors are those that motivate an individual to participate in the process of changing
from a negative health behavior to that of a positive health behavior – smoking to smoking
cessation. Morton, McLeroy, & Wendel (2012) define enabling factors as “conditions of the

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person or the environment that facilitate performance of an action and include availability,
accessibility, and the affordability of health care and other resources.”
In order to quit smoking, some individuals need the help of others, for example, a professional
counselor or a physician. In a recent study, it was examined that an individual’s request for help
to quit smoking, in combination with the personal commitment of the provider to provide
information and plan interventions were found to be the two most important motivations to
engage in cessation (Neil-Urban, LaSala, & Scott, 2001). By joining a support group for smokers
who are wanting and willing to quit, individuals will gain peer support and be more likely to
engage in cessation rather than if they are trying to quit on their own.
Reinforcing Factors
Reinforcing factors are those that impact the individual after they have stopped smoking and are
committed to the behavior of cessation as a long-term health behavior change. Reinforcement
can range from being negative to positive, however there are more positive outcomes associated
with smoking cessation rather than negative outcomes.
Those who had a more positive attitude and outlook, who were more influenced by people who
were important to them, and believed that they had a greater control over quitting smoking were
more likely to maintain smoking cessation (Høie et al., 2010). Emotional and appraisal support is
crucial to any health behavior change, however it is necessary when an individual wants to quit
smoking. If an individual has the support from family members, friends, and even a healthcare
provider or physician, they are more likely to have a greater sense of self-confidence and a
higher level of perceived behavioral control and will believe that they are able to successfully
engage in smoking cessation.
The health benefits of discontinuing smoking should be enough reinforcement for an individual
to engage in cessation. When an individual decides to smoke a cigarette, they are ending their
life eleven minutes earlier than if they would have not partaken in the behavior of smoking
(Shaw, Mitchell, & Dorling, 2000). If an individual participates in cessation of smoking, they are

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greatly reducing their chances for a variety of diseases along with premature death. The CDC
(2015) states that no matter what age an individual is, there are associated health benefits
regardless of age and some of these benefits include reduced heart disease, reduced respiratory
symptoms, and reduced threat of developing lung disease.
Suggestions for Intervention
Statistics show that individuals who are attempting to engage in cessation of smoking, almost
36% have used an intervention program consisting of behavioral treatments, pharmacologic
treatments, or both in combination (Shiffman, Brockwell, Pillitteri, & Gitchell, 2008). The most
common intervention program type was pharmacologic treatments which included over-the-
counter (OTC) nicotine replacement therapy (NRT), which entails that an individual uses a
transdermal nicotine patch, chews nicotine gum, or uses a nicotine lozenge (Shiffman et al.,
2008).
One type of intervention readily available to all individuals is self-help treatment. Self-help
treatment relies on the individual to take matters into their own hands and manage their own
program of cessation with no help from a professional or peer group. This type of treatment is
very low-cost, but comes with a trade-off because the effectiveness is not very significant
(Smoking Cessation, 2008). In some cases, group therapy and alternative therapies, which
include acupuncture and hypnosis, can become relatively expensive and are not readily available
to every individual. In response to high levels of smoking, more of these programs should be
made more affordable to those who are not of a higher socioeconomic status.
For interventions to be effective, individuals need to be aware of the different types and
programs that are made available to them. Physicians can ask patients about their smoking
history and then ask questions about whether they want to quit and if they do, physicians can
assess their willingness to quit by examining attitudes, self-efficacy, and perceived control
towards quitting (Smoking Cessation, 2008). After this is done, physicians can sit down with a
patient and create a plan of action that both are comfortable with.

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In trying to increase levels of cessation among individuals, new intervention programs are being
created and implemented by SAMHSA, the CDC, and Healthy People 2020. For example, one
study measured the effectiveness of a text message based intervention program for smoking
cessation. This study sent text messages to participants that were in the form of motivational
quotes along with informational messages that focused on increasing self-efficacy, which would
lead to an end in smoking (James, 2016). This type of intervention program would be highly
effective if promoted more throughout society because it would attract attention since it is a low-
cost program and allows exposed populations to be reached (James, 2016). It would also be
effective because if individuals are located in a sparse area then they might not have the means to
travel to a physician’s office or be able to see a counselor and this text message intervention
could reach them and be an effective means to get them to engage in cessation.
For any intervention program, there needs to be a surveillance system to monitor the effects of
the program and to evaluate the intervention’s effectiveness among different determinants such
as age group, gender, race/ethnicity, and geographical location. Surveillance systems are useful
in examining areas that need to be modified or changed within an intervention program to
betterment the program for individuals. In order for any intervention program to be reformed, a
surveillance system should be put into place and implemented so that researchers can better
understand how the program is working and how individuals are responding to it.

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