Self-efficacy in treating tobacco use: A review article

Abstract

Globally, tobacco use continues to be a major health care concern. Despite strong recommendations to quit smoking, tobacco users are experiencing difficulties in quitting. The purpose of this integrative review is to discuss self-efficacy theory as an important behavioral therapy for treating tobacco use and nicotine dependence. Moreover, the paper proposes a literature-derived model that employs self-efficacy as a central component for treating tobacco use and nicotine dependence. Eleven relevant articles were included in this review. Self-efficacy has an important role in smoking cessation. Improving self-efficacy enhances the individual’s success in quitting tobacco use and preventing relapse. Moreover, incorporating self-efficacy as a cognitive behavioral intervention has shown various degrees of success for treating tobacco use and nicotine dependence. In order to offer guidance to health care providers assisting in quitting tobacco, a model that integrates self-efficacy as a central component of the quitting process is proposed.

Introduction

Tobacco use is one of the biggest public health problems the world has ever faced. It is one of the leading causes of preventable illness and death.^1,2 For example, tobacco causes many different cancers as well as chronic lung diseases, heart disease, and many other serious health problems. Globally, tobacco use-related diseases are estimated to kill one in six adults.^1–3 Out of 1.2 billion tobacco users in the world, nearly half of them will die from related diseases.^1,4 Assisting tobacco users to quit greatly reduces their risk for disease and death.^1,2

Despite the well-known health risks of tobacco, youth and adult tobacco use rates are increasing and large proportions of tobacco users are unable to successfully to quit.^2,5,6 In 2005, only 4–7% of 19 million American adults who made a serious attempt to stop tobacco use were able to successfully quit.^2,5 Unfortunately, 80% of smokers in the United States who attempted to quit tobacco use by themselves relapsed within the first month of abstinence. ⁷ Evidence shows that these tobacco cessation attempts fail due to tobacco addiction and/or insufficient motivating factors such as self-efficacy to quit.^2,6,8

For more than three decades, the self-efficacy theory has been used in health promotion in various health conditions such as changing behavior related to substances abuse, tobacco use cessation, and cancer prevention. ⁹ Evidence shows that high self-efficacy has an important role in improving an individual’s achievement and changing their undesirable behaviors. ⁹

The purpose of this paper is to review the literature that discusses Bandura’s self-efficacy theory as a cognitive behavioral therapy for treating tobacco use and nicotine dependence. Specifically, this review examines the influence of self-efficacy in tobacco cessation interventions and proposes a model to guide health care providers in tobacco cessation interventions. This paper consists of two parts. The first part presents an overview of self-efficacy theory and its role as a mediator for tobacco cessation and the second part proposes a model that could be utilized by health care providers dealing with treatment of tobacco use and nicotine dependence.

Methods of literature selection

A search in the Medline, PubMed, SCOPUS, and PsycINFO databases was conducted to identify articles related to utilization of self-efficacy in treating tobacco use and nicotine dependence. The following keywords “smoking” “treating tobacco use,” “treating nicotine dependence,” “smoking cessation,” “smoking abstinence,” or “relapse to smoke” were used in combination with “self-efficacy” or “self-confidence” in order to identify pertinent literature. The following criteria were used to select relevant studies: (1) peer-reviewed reports of original studies; (2) published in English language; (3) published between 2000 and 2015; and (4) studies describing predictors of high self-efficacy and its relationship with tobacco cessation. Non-English studies and articles that were not accessible were not included in the review. This search yielded 56 articles that were examined in accordance with inclusion and exclusion criteria. Only 17 articles were found to be relevant for the purpose of this paper and were considered for this review.

Self-efficacy and tobacco use cessation

Self-efficacy theory

Self-efficacy is a theoretical construct first postulated by Bandura in 1977 as a cognitive mechanism underlying behavioral change. ¹⁰ Self-efficacy is defined as “people’s judgments of their capabilities to organize and execute causes of action required to attain designated types of performances.” ¹⁰ Self-efficacy (also called self-confidence to refer to behaviors) is the self-perception of having the skills to perform a behavior.^10,11 An individual’s efficacy expectations determine whether coping behavior will be initiated and how long the effort will be sustained to face the obstacles. These self expectations can provide a measure of the amount of energy to be expended in coping efforts.^10,12

Self-efficacy theory is a construct derived from social cognitive theory. ¹⁰ Bandura conceptualized the interactions among person, behavior and environment as having triadic reciprocity. ¹⁰ These factors impact an individual’s self-confidence to resist an adverse behavior such as tobacco use. ¹² The theory of self-efficacy has become increasingly popular as a framework for predicting health behaviors and promoting human health, particularly for tobacco cessation, physical activity and weight control programs.^9,13

Bandura’s self-efficacy theory as well as numerous other cognitive and social-learning frameworks have received widespread acceptance from psychologists for understanding a varied range of human behavior. ¹⁴ Self-efficacy data appear in many diverse publications . ⁹ Self-efficacy has been measured and reported for a wide range of behaviors, including the traditional clinical areas, intellectual development, health-related activities, and sporting performance. ⁹ Many social-learning theorists have used the concept of self-efficacy in the development of complex models of the processes of behavioral change. ¹⁴

Factors affecting self-efficacy and source of self-efficacy judgment

Enactive attainment or “experience”

Enactive attainment, or the actual performance of a behavior, has been described as the most important source of self-efficacy information for enhancing self-efficacy.^9,10,12 Repeated failure will reduce perceived self-efficacy while success will increase it. ⁹ Despite the fact that enactive attainment results in greater strengthening of self-efficacy expectations than do other informational sources, the actual performance of an activity alone does not establish self-efficacy belief. ¹⁰ Other factors such as preconceptions of ability, perceived difficulty of the task, amount of effort expended, external aid received, and past successes and failure impact the individual’s cognitive appraisal of self-efficacy. ⁹

Vicarious experience or “modeling”

The second influence on self-efficacy expectations is seeing other similar people successfully doing the same activity. Exposing the individual to successful behavioral performances or gaining experience through practice is more likely to influence self-efficacy expectations. ⁹ For example, when smokers see their friends succeed in quitting smoking by getting tobacco treatments and/or attending tobacco cessation programs that raise the participants’ beliefs that they are able to quit, smokers believe they will succeed if they do the same.

Modeling influences provide the individuals with more than a social standard against which to judge their own capabilities. Through express ways of thinking, models transmit knowledge and teach observers effective skills and strategies for managing environmental demands. The acquisition of better ways to address problems raises perceived self-efficacy. ¹⁵

Verbal persuasion or “social persuasion”

Verbal persuasion is referred to as informing individuals of their capabilities of mastering the given behavior. Verbal persuasion is the influence of the suggestions of others on efficacy beliefs, in particular, persuasion given by those in authority who have special knowledge. ⁹ Verbal persuasion has proven to be effective in enhancing recovery from chronic diseases, improving health promotion, and influencing change in people’s adverse behaviors especially for high risk health problems such as tobacco users with acute coronary syndrome. ⁹ Verbal persuasion by health care providers has a significant impact on the self-efficacy expectations of these patients on quitting smoking.

Physiological feedback

People depend on information about their physiological status in order to judge their abilities, particularly in areas related to coping with stressors, physical accomplishments, and health functioning. ⁹ Sometimes an individual’s evaluation that they lack the physical capacity may inhibit their performance. For example, older adults may refuse to participate in rehabilitation activities because they are afraid of falling, suffering pain, or becoming short of breath. These potential complications and symptoms decrease the individual’s confidence in their ability to perform the activity. ⁹ Interventions that focus on mastery (eliminating the emotional reactions to a given situation) and alter the interpretation of body states can help individuals cope with physical sensations, enhance self-efficacy and improve performance. ⁹

In addition to physiological feedback assessment, mental feedback should be considered before providing treatment to tobacco users. Tobacco users are in need to address any emotional concerns before attempting to quit. This may include efforts to reduce stress and depression. ¹⁶ Motivational intervention is a useful aspect of the treatment model that could be applied in tobacco cessation. This intervention is based on the idea that most persons do not come prepared to change individual habits. Because of this, attempts to only give advice about what a smoker should and should not do, may have limited success in getting the desired change. Moreover, it might trigger resistance with the advice-giving approach. Statements of affirmation, encouragement and diplomacy could encourage those who are attempting to quit to express and explore thoughts both for and against behavioral change. ¹⁶

Conceptual framework of self-efficacy theory

Bandura described the self-system as a unifying central mediator that is dependent on performance accomplishments, vicarious experiences, verbal persuasion and physiological states. ¹² He also distinguished between efficacy expectations and outcome expectations. Efficacy expectation is the individual’s belief about whether he/she has the capability to perform certain actions. It is a major determinant of whether that person attempts those actions. Efficacy expectation can help individuals determine whether to engage in the behavior, how much effort will be expended, and how long the behavior will last despite possible obstacles.^10,12 In addition, the person can determine whether he/she will persist in the face of initial failure, the level of success eventually achieved, and the level of intrinsic interest developed. ¹⁰ On the other hand, outcome expectation is the belief that outcomes may result from engaging in certain behaviors.^10,12 Perceived self-efficacy is introduced as “an integrative theoretical framework to explain and predict psychological changes achieved by different modes of treatment.” ¹²

Utilization of self-efficacy theory in tobacco cessation

Tobacco users may need to repeat tobacco cessation attempts to successfully quit; this may require medical help.^1,2 Tobacco users face many obstacles and challenges to quit, maintain abstinence and to prevent relapse. ² For example, the craving for substance abuse is among influencing factors for relapse.^2,17,18 Self-efficacy beliefs help to achieve desired modifications through motivational, cognitive, and choice processes. Perceived self-efficacy is a helpful approach in each phase of personal change to achievement of desired changes. ¹⁷ Moreover, promoting perceived self-efficacy is an effective method for long term maintenance and preventing relapses of a drug or nicotine dependence. ¹⁷

Many studies showed that self-efficacy plays an important role as a mediator in cognitive behavioral change among tobacco users attempting to quit. Individuals who successfully quit tobacco by themselves had higher self-efficacy than those who were unwilling to quit or those who relapsed.^19–21 Self-efficacy was found to have a significant relationship with stopping tobacco use and preventing relapse.^2,6,18,22

Several reports have illustrated significant relationship between self-efficacy and successful tobacco cessation interventions. High perceived self-efficacy predicted the individual’s success in quitting tobacco use where self-efficacy predicted maintenance of tobacco cessation 6 and 12 months after quitting. ²³ Similarly, the role of self-efficacy was examined to predict contemplation and pre-contemplation for tobacco cessation among adult and adolescent smokers.^24,25 The data showed that self-efficacy was significantly associated with successful tobacco cessation. Moreover, a significant relationship between lower nicotine dependence and higher self-efficacy scores among individuals with chronic obstructive pulmonary disease was established after a three-year follow up. ²⁶ Conversely, low levels of self-efficacy after tobacco cessation attempts predicted relapse. ²⁷ Moreover, evidence shows that emotional factors can influence self-efficacy. Higher anxiety levels were found to have significant negative association with self-efficacy to resist tobacco use. ²⁸ Tobacco users with higher than normal anxiety levels are more vulnerable to relapse.

The role of self-efficacy as a mediator for tobacco cessation

Tobacco use behavior is a complex phenomenon and no single theory can cover all aspects of it. ²¹ Although, the available evidence suggests that self-efficacy as a motivation argument is valuable, other diverse sources of motivation to induce behavioral change require further evaluation. ²¹ Therefore, tobacco cessation intervention strategies depend on utilizing all of what is known about appropriate treatment. Using intensive and individualized education combined with emotional support and cognitive behavioral strategies delivered by health care providers are found to be effective interventions for tobacco cessation. ²¹

The Health Promotion Board of Singapore developed clinical practice guidelines based on comprehensive literature reviews on recent evidence on tobacco use and dependence treatments. ²⁹ These guidelines act as a resource for health professionals to identify and screen tobacco users and to deliver evidence-based tobacco use cessation treatments for individuals and specific population groups who use tobacco. The guidelines outlined person-to-person behavioral support (e.g. cognitive behavioral therapy) as an effective means to increase abstinence rates among tobacco quitters. Success for tobacco cessation is assured via trial of multi-components (skills training and self-efficacy) as well as persistence. ²⁹

The mediating effect of self-efficacy on the relationship between craving and tobacco abstinence among cardiac patients was reported in the literature. ¹⁹ The report indicated that craving reduced self-efficacy, which in turn reduced the likelihood of tobacco abstinence particularly among individuals with moderate anxiety levels. Moreover, interventions for cardiac patients who use tobacco should aim to reduce craving and to enhance patients’ self-efficacy in order to stop tobacco use after discharge from hospital. ¹⁹

Stead et al. evaluated the effect of increasing the intensity of behavioral support for individuals using tobacco cessation medications. ²⁰ The authors searched the Cochrane Tobacco Addiction Group Specialized Register for records for any mention of pharmacotherapy, including any type of nicotine replacement therapy (NRT), bupropion, nortriptyline, or varenicline. In this report, the authors evaluated the addition of personal support or compared two or more intensities of behavioral support. The authors reported the evidence of a small but statistically significant benefit for using more intensive support (RR 1.17, 95% CI, 1.11–1.24) for tobacco abstinence at the longest follow-up. The report emphasized the need for some form of personal support (personal contact, face-to-face or by telephone) for people attempting to quit using medication in order to increase their chances of success if they also have access to behavioral support. ²⁰

Clinical practice guidelines

Current clinical practice guidelines recommend strategies for the health care providers to improve an individual’s self-efficacy to quit smoking.^2,29 The suggested strategies include: (1) encourage tobacco users to determine personal abilities and offer help to quit smoking based on past successes; (2) offering applicable and reliable steps for changing tobacco use habits; (3) inform tobacco users about successful behavioral change techniques and strategies to quit tobacco; (4) encourage tobacco users to avail of resources related to tobacco cessation (e.g. quit helpline, individual-tailored web-based interventions); (5) inform tobacco users about the health benefits of tobacco use cessation; (6) provide motivational interviewing or cognitive behavioral therapy to help tobacco users quit; (7) encourage tobacco users to discuss and share their ideas about successful tobacco cessation strategies with other persons attempting to quit.^2,29

Proposed model for clinical practice

The aim of the proposed model is to provide an overview for health professionals to guide them in their clinical practice to assist individuals in quitting tobacco (Figure 1). The model highlights self-efficacy as a central concept of the quitting process. This model includes the risk factors that have negative influence on persons in developing nicotine dependence. Many influencing factors negatively affect initiation of tobacco use and the development of nicotine dependence. These influencing factors are divided into internal or external influencing factors. Internal factors include personality features, genetic properties, and co-morbid psychiatric disorders.^18,30 External or environmental influencing factors include social acceptability of tobacco, accessibility of tobacco products, cost of tobacco products, and bans on smoking.^18,30,31 The United States Department of Health and Health Services (2012) reported several risk factors for developing nicotine dependence. These factors can be: (1) genetic; (2) socioeconomic (e.g. ethnicity, gender, and socioeconomic status); (3) personal (e.g. knowledge of health hazards of tobacco use); (4) behavioral (e.g. academic achievement, and influence of friends and peer groups); and (5) environmental (e.g. acceptability of tobacco products). ¹⁸

Figure 1.

Proposed model in clinical practice to treat tobacco use and nicotine dependence.

The evidence shows that genetic factors and variation leads to differing patterns of tobacco use behaviors and tobacco cessation.^2,18,30,31 Hatsukami et al. reported that susceptibility to nicotine dependence is high in persons diagnosed with psychiatric disorders such as depression and schizophrenia. ³¹ Environmental factors, including influence of friends, peers smoking and family members and advertisements on social media, increase the risk of starting tobacco use and developing nicotine dependence.^6,18,30–32 Tobacco use is generally common among individuals with low level of education and socioeconomic status.^18,32

The proposed model integrates the “5 A’s” model to treat tobacco use and nicotine dependence. This model was developed by Fiore et al. and it emphasizes the process of screening tobacco users, advising for quitting, assessment for willingness to quit, assistance with quitting, and arrangement for follow up to prevent relapse. ⁶ The model recommends that health care providers assist tobacco users willing to quit, by providing pharmacological treatment, and improving self-efficacy, and arrange for follow up to prevent relapse. ²⁹ Improving self-efficacy through providing cognitive behavior therapy is well known to have a positive effect in quitting tobacco use. Many factors have positive effects to improve self-efficacy, including: (1) enactive attainment (providing person-to-person behavioral support); (2) vicarious experience (providing group support interventions and models of the targeted behavior); (3) verbal persuasion (providing social support, and encouragement and provide technological, and social media interventions); and (4) physiological and mental feedback (providing face-to-face individual support and personalized advice based on the subject’s physiological and mental feedback and readiness to quit).^29,33 These sources of self-efficacy judgment can positively influence self-efficacy and outcome expectations in interacting with characteristics of the persons and the environment. ⁹ The literature review showed that a consistently-positive significant relationship exists between high self-efficacy and health behavior change (tobacco cessation) to prevent relapse.^33–37 Moreover, the recent guidelines recommend that educating tobacco users about health hazards of tobacco use, benefits to quit, and successful methods to quit through interventional tobacco cessation programs, self-help materials, person-to-person, group and social support have positive influences to enhance efficacy expectations. These interventions improve tobacco cessation by directly targeting the enhancement of self-efficacy.^6,29

For tobacco users who are unwilling to quit, health care providers are encouraged to provide motivational intervention.^2,6 Motivational intervention encompasses: (1) expressing empathy (respecting individuals’ decisions and the use of skillful listening approach); (2) developing discrepancy (helping tobacco users to focus attention on how current behavior differs from those of set goals and values or desired behavior, and motivating them to quit); (3) rolling with resistance (avoiding arguing for change and provide personalized feedback); and (4) supporting self-efficacy (eliciting self-motivation to quit tobacco use by providing intensive behavioral support). ²⁹

Motivational interviewing interventions assist tobacco users to quit by helping them explore and resolve their uncertainties about tobacco cessation. Motivational interviewing works in partnership with the tobacco user, avoiding a confrontational approach. It has been shown to be effective when conducted by trained health care professional advisors, and interventional approaches using this tool have been used successfully to help tobacco users quit. ²⁹ A recent systemic review of the literature showed that those who received motivational interviewing interventions were about 1.5 times more likely to abstain from tobacco use compared to those who did not receive such interventions. ³⁸

Conclusion

This paper has reviewed published literature regarding the role of self-efficacy theory as a cognitive behavioral therapy and its mediating effect in the process of quitting tobacco and nicotine dependence. Self-efficacy is believed to play an essential role in tobacco cessation. Improving self-efficacy enhances the individual’s success in quitting tobacco and preventing relapse. Success for tobacco cessation is assured via trial of multiple-components (skills training and self-efficacy) as well as persistence. The proposed model in this paper illustrates that a combination of pharmacological and non-pharmacological treatments including cognitive behavioral therapy, counseling, motivational interviewing interventions and improving self-efficacy to quit smoking could be effective in the process of tobacco quitting and preventing relapse.