Running Head: APPLICATION OF BEHAVIOR CHANGE MODELS TO CIGARETTE

SMOKING AND SMOKING CESSATION

Application of Behavior Change Models to Cigarette Smoking and Smoking Cessation

Nicole Wager
California State University Long Beach
HEALTH BEHAVIOR INTRODUCTION:

The smoke produced from the burning of tobacco is known as tobacco smoke, and one of

the most common ways to smoke tobacco is through cigarettes. Smoking is the inhalation of the

chemicals from cigarettes which are known to cause detrimental affects, small or large, on all

parts of the body’s organs, and can cause diseases such as cancer or cardiovascular disease

(Leone and Landini). This is smoking behavior. This behavior is significant to the health of the

public because it is the leading preventable cause of death in the United States. Smoking

cigarettes affects more than just those who smoke them. Family members, significant others, and

anyone in the vicinity of smokers are all affected by the harmful components of cigarettes and

cigarette smoke. ​The Transtheoretical Model and the Health Belief Model both demonstrate and

apply constructs that are beneficial to someone who is making an effort to change their behavior.

This paper will highlight the ways these models can be applied towards cigarette smoking and

smoking cessation to explain, predict, and modify the changing of one’s behavior of smoking

cigarettes.​ While both these models work, some models include useful constructs that others do

not. Each model is useful in its own way and may fit some situations better than others. Along

with the application of these models, professional research will be analyzed and examined to

show how the Health Belief Model and the Transtheoretical model have been used in practice to

explain the intentions of tobacco use and smoking behavior.

MAIN POINTS:

A. HEALTH BEHAVIOR BACKGROUND

 This health behavior significantly affects the health status of many people not just one

particular group of people. Yet, the major groups of people who are largely affected by cigarette

smoking are those with low socioeconomic status. Low socioeconomic status is a factor that

translates to the susceptibility one has to engaging in smoking behavior. Those who fall into the

low and middle income categories are more likely to smoke cigarettes and are predicted to be

impacted by the smoking of tobacco more than nonsmokers (Owusu, 2017). Another group that

is largely affected by cigarette smoking are those people affected by secondhand smoke. The

Center for Disease Control states that “Secondhand smoke exposure contributes to

approximately 41,000 deaths among nonsmoking adults and 400 deaths in infants each year.

Secondhand smoke causes stroke, lung cancer, and coronary heart disease in adults. Children

who are exposed to secondhand smoke are at increased risk for sudden infant death syndrome”

(CDC, 2017). With so many people affected by secondhand smoke each year, there should be

more anti-smoking campaigns, and ways to urge regular tobacco users that they need to quit

smoking.

Many different factors have been found to correlate with the start and continuation of

tobacco use. They range from social and environmental, to psychological and genetic. The

determinants of health for this specific behavior range from “Gender, race, ethnicity, age, income

level, educational attainment, geographic location, and disability” (Healthy People). The

determinants of health for this behavior also happen to affect adolescents and young adults more

often than older adults and children; older adults and children tend to be the one’s affected by

secondhand smoke exposure. According to Healthy People, the specific factors that influence

tobacco use among adolescents are: the approval and use of it from social peers, seeing their
parents smoke, the accessibility of cigarettes, the promotional campaigns they are exposed to,

and their own low self esteem problems (Healthy People). Healthy People express their concern

that understanding these factors is the key to helping reduce tobacco use and secondhand smoke

exposure.

B. HEALTH BEHAVIOR THEORIES AND MODELS

The Health Belief model was developed by Godfrey Hochbaum in the nineteen fifties

when he conducted a study to understand why people were not going for TB screening. The

model was created to help explain and predict preventative health behaviors. According to

ReCAPP (Resource Center for Adolescent Pregnancy Prevention), ​“the Health Belief Model is a

framework for motivating people to take positive health actions that uses the desire to avoid a

negative health consequence as the prime motivation” (Firpo-Triplett)​. ​As professor Guillam

discussed in lecture, the model was developed with five constructs. The five constructs include

perceived susceptibility, perceived seriousness, perceived benefits, perceived barriers and cues to

action. In recent years, self efficacy was added as a sixth construct to help personalize the model

and build confidence in those using it.

How does each construct structure a way to explain, predict, or modify behavior?

ReCAPP defines each construct where perceived susceptibility is for the purpose of assessing

one’s risk of having a certain health problem. Perceived seriousness is the thoughts and feelings

one has about how devastating the disease may be, including physical and social consequences.

Perceived benefits and barriers are all the actions that may help or prevent one from changing

their behavior. Cues to action, are all the factors, internal and external, that push a person to
change their behavior (Firpo-Triplett). With the addition of self efficacy to the model, now

people may also evaluate their attitude toward how confident they are in themselves that they can

successfully change their behavior. Understanding each construct is essential to understanding

how to achieve serious behavior changes in one’s life.

The Health Belief Model is a great model to show how cigarette smoking and smoking

cessation can utilize the framework to help change one’s behavior. Someone who is just starting

their effort to change may weigh the perceived susceptibility of the diseases and risks that are

commonly associated with smoking cigarettes. One may look at statistics for smokers and see

how common lung disease, cardiovascular disease, and cancers are among frequent cigarette

smokers. Tobacco smoke and “​cigarette smoking play a strong role in the development and

progression of cardiovascular damage, primarily atherosclerotic lesions” as reported for the

Fellow of the Royal Society for Promotion of Health, London, UK (Leone and Landini). ​After

discovering how susceptible one may be to all these disease, they may think about how serious

these threats are and how they may impact their life if they continue smoking.

After considering their susceptibility and the seriousness of the behavior, a person may

consider the benefits of quitting smoking. These benefits may include the risks for lung disease,

heart disease, and cancers all decreasing within the first year of smoking. The Center for Disease

Control and Prevention has reported that after five years of quitting smoking, a person’s risk for

cancers of the mouth, throat, and esophagus decrease by more than half (Smoking and Tobacco

Use). The barriers that are associated with smoking come from the difficult withdrawals users

experience when they begin their separation from nicotine. Withdrawals such as finger tapping,

stress, and the impairment of attentional and cognitive abilities can strain a person in their
everyday life. Other factors such as weight gain also happen when a person quits smoking. In his

report on the behavioral and cognitive effects of smoking, SJ Heishman states that smokers

typically weigh around three to four kilograms less than nonsmokers, and that after a person

begins quitting smoking, those three to four kilograms of weight reappear​. This is because

“changes in eating and energy expenditure are responsible for the body weight changes seen

during smoking cessation and relapse” (Heishman). After weighing all the benefits and barriers

that are associated with cigarette smoking, one may finally want to change because of cues to

action. These cues may be a close relative or someone they know becoming diagnosed with

esophageal cancer due to tobacco use. Seeing a close family member become ill because of the

same health behavior may awaken their cognitive thoughts about really seeking a change in their

negative smoking behavior.

The other model that has been used to help change behaviors is the Transtheoretical

model. The Transtheoretical model was initially developed while Dr. Prochaska was conducting

research on cigarette smokers. He began the development of this model in the late nineteen

seventies by “​examining the experiences of smokers who quit on their own with those requiring

further treatment to understand why some people were capable of quitting on their own”

(LaMorte, 2016)​. This model focuses on how change occurs, and involves the use of emotions,

cognitions, and behavior. The four constructs that make up the foundation of this model are:

stages of change, decisional balance, self efficacy, and processes of change. In the first construct,

there are six stages of change; precontemplation, contemplation, preparation, action,

maintenance, and termination. Wayne LaMorte explains how for each stage, many different
intervention strategies are used to push the person into the next stage of change, and ultimately to

the maintenance stage (LaMorte, 2016)​.

The other constructs, decisional balance, self-efficacy, and processes of change are all

supporting constructs to help a person move through the stages of change. With the information

provided from lecture, Professor Guilliaum explained that decisional balance happens during the

contemplation stage where a person weighs the pros and cons of changing their behavior and

makes a decision based off these factors. Self efficacy is important in the success of behavior

changes because it encourages the individual from their own thoughts and cognitions. It is

influential because they are being positively reinforced by themselves instead of hearing from

somebody else who does not struggle with their addictive behavior. LaMorte describes the

processes of change construct as a way “​To progress through the stages of change” and states

that “ten processes of change have been identified with some processes being more relevant to a

specific stage of change than other processes” (LaMorte, 2016).​ The transtheoretical model

provides clear, precise directions for a person who is seeking to change their behavior and can

provide stability and reassurance for those who are unsure whether they want to change or not.

The Transtheoretical Model is relevant to cigarette smoking and smoking cessation

because it was originally developed while studying cigarette smokers. This models structure

provides a pathway for positive intervention and overall success when it comes to changing the

behavior. Going through each of the steps is imperative for those who are trying to quit smoking

which is why the theory has been proven to work so successfully. Once a smoker realizes their

behavior is a problem, they move past the precontemplation stage and begin to enter the

contemplation stage. In this stage they are faced with a decisional balance of the pros and cons of
quitting, such as not being at risk for diseases, but also “withdrawal-induced negative moods”

and stress that may occur from quitting (Heishman). After deciding and mentally accepting the

intention to change, one then can move into the preparation stage and begin the process of

changing their behavior physically. In this stage, one may visit a doctor and ask about patches or

other ways to help reduce the urge to smoke. Here they prepare everything they will need to kick

the behavior. One they have prepared, typically this stage lasts around a month, the person then

goes through the action and maintenance stages. Here, a person will do everything they prepared

and maintain their actions, sometimes for a lifetime. According to the CDC, “​People who stop

smoking often start again because of withdrawal symptoms, stress, and weight gain”, which is

why it is important to maintain and remain in the maintenance stage as long as possible (CDC,

2017). ​All the while, as a person follows the model, their self efficacy, which started off very

low, increases with each stage until one has a high confidence that they can successfully quit

smoking cigarettes.

C. HEALTH BEHAVIOR THEORY/MODEL RESEARCH APPLICATION

In research conducted by Tara Mantler, the framework of the Health Belief Model was

used to review and appraise youths’ perceptions of their addictive behavior regarding smoking

and their view of the health risks associated with it. The research began by selecting articles that

related to youths, smoking, and risk perception from five electronic databases, resulting in ten

articles and over twenty five hundred participants. The articles were then appraised based on risk

perception using susceptibility, severity, benefits, and barriers. Among the data analyzed, it was

found that smoking youths had more optimistic views regarding risk perception, than older
smoking adults and non smoking youths had. They believed they had the ability to quit and

would not be affected by the mortality rate and diseases consistent with smoking and tobacco use

(Mantler, 2012).

Highlights from the study showed that youth perceived the barriers of quitting as more

relevant than the benefits of quitting. The study concluded that the appraisal system used

suggested that youth were quite optimistic towards their perception of cigarette addiction and

health risks, and they rationalized continuing to smoke because they felt that the barriers to

quitting outweighed the benefits they may gain. While those results are nowhere near

encouraging, it was found that “once the decision to quit was made, smokers were better able to

identify the benefits of cessation” (Mantler, 2012). Mantler showed how using the Health Belief

Model as the framework for this study provided an overarching umbrella for summarizing the

data as a whole. The results were analyzed based off the constructs of perceived susceptibility to

addiction, perceived severity of smoking risks, perceived barriers to cessation, and perceived

benefits to quitting.

Using the Transtheoretical Model, researchers studied the intentions to quit smoking in

fourteen low and middle income countries. The study evaluated factors associated with the first

three stage in the model; precontemplation, contemplation, and preparation. This study is

relevant to the content of this course because over eighty percent of the worlds tobacco smokers

reside in low and middle income countries (Owusu, 2017). The intention to quit smoking

parallels interventions and policy enactment, so the purpose of this study was to understand the

factors that promote the intention to quit cigarette smoking. Researchers collected data from

forty three thousand, five hundred and forty participants of the GATS, Global Adult Tobacco
Survey in fourteen LMICs, low and middle income countries. The responses from participants

were analyzed and organized into the three stages precontemplation, contemplation, and

preparation from the transtheoretical model. The findings of this study reported that

approximately eighty two percent of participants were in the precontemplation stage, fourteen

percent were in the contemplation stage, and four percent were in the preparation stage (Owusu,

2017).

The factors that they found to be consistent with smoking behavior and the first three

stages were location, smoke free homes, and anti-smoking messages. Residents who lived in

rural areas had increased odds of being in the contemplation stage versus residents who live in

urban areas. Those whose homes prohibited smoking had increased chance of being in the

contemplation or preparation stage, and those who has been exposed to anti-smoking messages

from more than one media channel also had increased odds of being in contemplation or

preparation stages, versus no exposure. This study was relevant to researchers because low and

middle income countries contain more than eighty percent of the billion tobacco smokers in the

world (Owusu, 2017). Researchers concluded at the end of their study that the factors that related

to the intention to quit smoking in LMICs were anti-smoking media campaigns and smoke-free

policies. These factors suggest that implementation of these campaigns and policies may

promote the intention to quit based on the responses from participants who fell into the

contemplation and preparation stages of the transtheoretical model.

CONCLUSION AND RECOMMENDATIONS FOR FURTHER STUDY

Looking at the consequences associated with smoking cigarettes, the amount of people
who still engage in the behavior brings about the question of how difficult it is to quit smoking.

Smoking cessation is a difficult behavior to change but with the use of behavior change models,

one can hope to see a difference. The Health Belief Model and the Transtheoretical Model are

two models that have been applied to the practice of changing cigarette smoking. Tobacco use

can impact the health status of any individual, even those who do not participate in the behavior

themselves. Secondhand smoke can cause diseases such as lung and heart disease and affects

everyone from infants to adults to senior citizens (CDC, 2017). The application of the Health

Belief Model and the Transtheoretical Model to cigarette smokers and their intentions to change

their behavior show how they can help explain, predict, and modify behaviors. Research for both

models examined how the models can be used in practice. In the first study, where the

framework from the health belief model was used, researchers looked at youths’ perceptions of

risk and addiction associated with tobacco use. The second study provided analytical evidence

that classified the responses of smokers from low and middle income countries into the three

stages of the transtheoretical model, and was used to evaluate the factors that were most

associated with intentions to change their behavior. Further research may be necessary to

discover if the factors associated with intentions to change behavior are similar or different in

upper income countries so this research can be generalizable for the whole population of tobacco

users and cigarette smokers. Other future studies could look at the application of other theoretical

perspectives to study perceptions of addiction to decrease potential biases in the perspectives

used in this paper.

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