Smokers attributed continued smoking despite problems to addiction, habit and stress (Cunningham et al., 1994
; Eiser et al., 1977
; Balmford et al., 2008
). This suggests smokers see inability to stop as due to multiple different causes. In the study most similar to ours, done over 25 yrs ago, 71% of the general public stated tobacco use was an addiction (cf our 88% in our more recent sample of smokers only) and 75% stated it was a “habit, not disease” (cf. our 88%) (Cunningham et al., 1994
). Surprisingly, only a minority of smokers attributed the inability to quit to lack of willpower or motivation. In prior surveys, over 80% of smokers have said these were important (Balmford et al., 2008
). One possible reason for our different results is that we surveyed smokers, not the general public. Also, we used a concrete scenario that emphasized prior inability to stop and use of tobacco despite problems. Finally, we intentionally did not ask about the smokers' own smoking because smokers often believe they do not conform to the norm for smokers.(Weinstein et al., 2004
). Such differences in ratings for “actor/observer” scenarios are common (Malle, Knobe, & Nelson, 2007
). Nevertheless, our unexpected finding requires replication.
Few smokers endorsed face-valid causes of the inability to quit smoking such as disease, personality problems, weakness of character, family/upbringing, biological factors, and genetics. Some of this may have been due to the terms we used (e.g. “mental disease” vs “disease”) or due to a lack of knowledge; e.g. most smokers are not aware of genetic factors (Wright, Weinman, & Marteau, 2003
Habit and addiction endorsements were positively correlated. The one prior test of this relationship found a similar result (Cunningham et al., 1994
). In contrast, prior scientists have argued that endorsement of “habit” and “addiction” are mutually exclusive (Perkins, 1999
; Davis, 1992
) and, thus, should be negatively correlated. Clearly, further research is needed to determine whether use of the term habit implies non-addiction to the lay public.
Although scientists often link addiction to biological factors (Leshner, 1997
), smokers' endorsements of addiction were not related to endorsements of biological or genetic causes. Whether this is because smokers are unaware of the biological or genetic factors or whether they believe endorsement of addiction does not require endorsement of biological factors is unknown.
The central construct of scientific theories of addiction/dependence is that the disorder causes impaired control over drug use (Piper, McCarthy, & Baker, 2006
). If this is the case, then the more one believes inability to stop is an addiction, the less they should believe inability to stop is due to willpower and, in fact, this is what we and others (Cunningham et al., 1994
) have found. On the other hand, one would think the same relationship would occur between addiction and motivation but we did not find this. Clearly more research on how smokers perceive the relationships among addiction, willpower and motivation is needed.
Higher ratings of addiction were positively related to treatment seeking and higher ratings of willpower and motivation were related to endorsing quitting without treatment. This is consistent with findings for other behavioral problems. For example, when asked about substance-use and non-substance use psychological problems, those who conceptualize a problem as a bad habit/character flaw/personality problem/sin/moral failure rather than a medical/psychological disorder/disease/addiction are less likely to seek treatment (Cunningham et al., 1993
; Moyers & Miller, 1993
; West & Power, 1995a
; Varney et al., 1995
; cunningham, Blomqvist, & Cordingley, 2007
; Cunningham et al., 1996
). More specifically, those who believe biology causes a drug problem or mental illness have more favorable attitudes toward medication whereas those who believe environment causes mental illness have more favorable attitudes toward psychotherapy (Kuppi & Carpiano, 2006
; Iselin & Addis, 2003
; cunningham et al., 2007
; Cunningham et al., 1993
). However, the relationship between ratings of causes and endorsement of treatments in the current study was small, suggesting other factors are more important in determining treatment seeking.
As stated earlier, interpretations of comparisons across problem behaviors must be cautious because almost all the participants had had personal problems stopping smoking, but few had personal problems stopping problematic alcohol use or losing excessive weight. Even though participants were asked to rate a fictional other person, their own experiences of lack thereof may have influenced these ratings. Future studies could survey persons who have a history of problems changing two or three behaviors to provide a within-subject comparison that should be a more fair comparison.
As noted above, we failed to find several expected relationships and several unexpected ones occurred. One possible explanation for this is that, although our small pilot suggested little confusion about our “causes”, there is significant heterogeneity in how smokers interpret the 1-3 word causes we used. If so, then psychometrically-developed multi-item scales (Schaler, 1995
; Humphreys et al., 1996
; Luke et al., 2002
) may be necessary to find more valid results. Thus, qualitative studies to obtain a better understanding of smokers ideas, beliefs, attitudes and definitions of causes may be needed before further research is undertaken. In retrospect, we should have done such a study prior to undertaking the current study.
Another possible explanation for our unexpected results is that smokers really have not put much time into thinking about causes of the inability to stop smoking (Nisbett & Wilson, 1977
). If so, then their responses may be unreliable or reflect more what they believe is the norm rather than their own personal beliefs. Several lines of evidence suggest that often when participants are asked beliefs they are “telling more than they can know” and this clearly could be the case for our smokers (Nisbett et al., 1977
The major assets of the study were its focus on one group of substance users (i.e. tobacco smokers), the inclusion of a large number of different perceived causes, the use of concrete scenarios, the comparison groups of alcohol users and obese persons, and the randomization of participants to different scenarios. One possible limitation of the current study is that it recruited via internet and the response rate is unknown; however, the sample did not appear to be younger, more affluent, or more educated. Minorities were under-represented in the current study and, it is clearly possible they endorse concepts differently. However, this method did not allow us to ascertain the response rate or sample bias. Another limitation is that we used only current smokers; thus, our results may not generalize to ex smokers or never smokers. We did not vary the order of questions across participants and used only a single word or phrase to convey causes. Finally, as stated above, our use of brief phrases to define causes may have been too vague. A preliminary qualitative study to produce better descriptors of causes may be necessary to obtain more valid results.
In terms of significance, although scientists may argue that certain concepts are antithetical (e.g. addiction vs habit), many, if not most, smokers appear to not see contradictions in simultaneously endorsing what appear to be very different causes: i.e., addiction, habit, willpower and motivation, as causes of the inability to stop smoking. Thus, one implication of our results is that scientists cannot assume that smokers have the same network of concepts or the same denotative or connotative meanings of terms that scientists do.
Perceived causes were linked to treatment seeking; however, this relationship was weak. Thus, it is currently unclear whether changing perceptions about causes will change treatment seeking; e.g. a campaign to better convince smokers that smoking is an addiction and not due to low willpower may not necessarily increase treatment seeking.