Cognitivebehavioural theories

The 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 theorize
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, 3 the health
beliefs model,4 the rational addiction model5 and the transtheoretical model.6
A second set of theories, of which the social cognitive theory of Bandura 7 is 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,8 which has not been applied to smoking as much as it could
have, and more recently the hugely influential PRIME theory of West 9 and temporal self-regulation
theory.10 These 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.

7.3.2 Behavioural theories

Behavioural 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 (See Section 7.13.)

7.3.3 Psychodynamic theories

Psychodynamic 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. 12 There 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 (See Section 7.15.3 for further information on individual counselling.)

7.3.4 Physiological models of addiction

Physiological 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. (See Chapter
6, Section 6.2 for 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. (See Section 7.16 for further
information on pharmacotherapies.)

7.3.5 Sociological theories

Sociological 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