Reducing Tobacco Use Among Adolescents Using Social Cognitive Theory and Social Network Theory

Running head: REDUCING TOBACCO USE USING SCT & SNT 1

Reducing Tobacco Use Among Adolescents Using

Social Cognitive Theory and Social Network Theory

Shauna Ayres

HBEH 730 - Theoretical Foundations of Behavioral and Social Science

The University of North Carolina at Chapel Hill

October 12, 2015

On my honor, I certify that no unauthorized assistance has been received or given in the completion of this

work and all outside sources have been cited appropriately.

REDUCING TOBACCO USE USING SCT & SNT 2

INTRODUCTION: Public health efforts to reduce tobacco use among adolescents started in the late

1980s (Wakefield, 2000) and continues to be a major public health goal. Research has demonstrated that

tobacco use at a young age leads to addiction and physical dependency for nicotine more quickly in

developing adolescent brains, as compared to adult brains, and permanently alters the composition of the

brain (Jacobsen, 2007). This is supported by the finding that approximately 9 out of 10 adult smokers report

smoking as adolescents (Towns, 2015; CDC, 2014). Additionally, it is estimated that 3,200-4,000 children

(<18 years old) smoke their first cigarette every day (CDC, 2010; 2014), of which about 1,000 children

become daily smokers (CDC, 2010). If current trends continue, estimates conclude that 5.6 million of

today’s youth will die prematurely from smoking-related illnesses (CDC, 2014).

Tobacco use is associated with a variety of negative health outcomes for young smokers. The short-

term effects include addiction to nicotine, reduced lung function, reduced lung growth, early cardiovascular

damage, shortness of breath, and reduced physical stamina (CDC, 2014). Long-term effects include, but

are not limited to, cardiovascular disease (CVD), cancer, chronic obstructive pulmonary disease,

emphysema, and diabetes (National Cancer Institute, 2014; CDC, 2014).

Aggregate data provided by Healthy People 2020 shows that smoking rates among children and

adolescents are declining with the exception of “smokeless tobacco use by adolescents in the past month”

(Office of Disease Prevention and Health Promotion, 2015). However, the trends are leveling off and many

Healthy People 2020 target goals associated with youth tobacco use and exposure will not be met in the

next five years. The increased advertising exposure, availability, and popularity of “safe” e-cigarettes and

other smokeless tobacco products among adolescents are concerning (Wang, 2014; Knorst, 2014). A major

fear is that more adolescents will initiate tobacco habits using these attractive alternative tobacco products

than would have otherwise initiated tobacco using traditional tobacco products. Consequently, more

adolescents may become nicotine dependent and increase their risk of tobacco-related health issues (Wang,

2014).

The purpose of this paper is to examine adolescent tobacco use through the theoretical lenses of the

Social Cognitive Theory (SCT) and the Social Network Theory (SNT). First, an explanation of the SCT


will be provided and accompanied by examples of how this theory has been applied to measuring adolescent

tobacco use and implementing successful health promotion programs. Next, an explanation of the SNT will

be outlined along with application and implementation examples. Possible effective strategies will then be

discussed for combining the theories along with key strengths and weaknesses. Finally, ideas for future

research directions will be considered.

SOCIAL COGNITIVE THEORY: Social Cognitive Theory determines motivating factors behind

health behaviors, provides understanding of those motivations, and then designs health interventions to

promote positive behavior change (Kelder, 2015). The concept model is comprised of a dynamic triad of

three factors: personal cognitive factors, socioenvironmental factors, and behavioral factors. Personal

cognitive factors can be broken down into four constructs that address personal abilities: self-efficacy,

collective efficacy, outcome expectations, and knowledge. Socioenvironmental factors can be broken down

into four constructs that address physical and social factors in the environment: observational learning,

normative beliefs, social support, and barriers and opportunities. Behavioral factors can be broken down

into three constructs that address health actions: behavioral skills, intentions, and reinforcement and

punishment (Kelder, 2015).

All 11 constructs in the SCT impact each other at different times and strengths and no construct is

considered more important or influential in determining a health behavior; however, certain constructs may

be more foundational and effective when designing a specific intervention for a certain behavior (tobacco

use) among an identified population (adolescents). By classifying intervention strategies into constructs,

program planners can provide a multifactor approach that will yield the greatest impact.

Because adolescents are in a period of self-identity, the emphasis on self-efficacy for this group is

critical when addressing any health behavior. A study conducted by Van Zundert in the Netherlands

attempted to determine if the cognitive factors of self-efficacy and outcome expectations and the behavioral

factor, intentions, could be used to predict adolescent smoking lapses and relapses. Self-efficacy was

defined as “the ability to resist smoking in tempting situations.” Outcome expectations were operationalized

as the “pros and cons of smoking” and the “pros of quitting.” Intentions were defined as “the motivation or


readiness to quit.” In the study, 135 daily smoking adolescents who were serious about quitting were

monitored three times per day for four weeks, and a two month follow-up was also administered. The

primary findings confirmed that adolescents who endorsed the pros of smoking (OR 1.24), had low self-

efficacy (OR 1.34), and smoked heavily at baseline (OR 1.05) predicted relapse within three weeks after

quitting (Van Zundert, 2009). This study highlights the importance of the cognitive factors of self-efficacy

and outcome expectations and stresses that more efforts should focus on increasing adolescent self-efficacy

and improving positive outcome expectations prior to their attempt to quit (Van Zundert, 2009).

However, a 1991 study by Hansen examined the effect of school-based programs stressing refusal

skills (behavioral skills) compared to programs correcting erroneous perspectives of prevalence and

acceptability (normative beliefs) for alcohol and marijuana use between grade seven and eight. The findings

suggest that programs focusing on normative beliefs were more effective at preventing adolescent substance

use (22.5% reduction rate for initial alcohol use and 64.5% reduction rate for marijuana incidence) (Hansen,

1991). This is not to say that behavioral skills, or in this case refusal skills, are not an important part to

adolescent tobacco abstinence, and in fact they may be instrumental for teens who have initiated tobacco

use and are trying to quit; however, an intervention based solely on teaching behavioral skills is not a

sufficient strategy. Further, a critique of 10 school-based health education programs that assessed 12

mediating factors of substance use among adolescents highlighted the need for a multi-strategy approach

and suggested that “at a minimum” correcting erroneous normative beliefs, having students commit to

abstinence (intention), educating students about consequences (knowledge), and having students identify

their ideal lifestyles and stressing how substances are incongruent with that lifestyle (outcome expectations)

should be incorporated in prevention programs to reduce substance use among adolescents (Wyrick, 2001).

An applied method for effecting normative beliefs and intentions was the enactment of the United

Kingdom’s Tobacco Advertising and Promotion Act (TAPA), which prohibited most tobacco marketing

from February 2003 to July 2005. Brown and Moodie used a cross-sectional study of over 1,100 adolescents

(11 to 16 years old) to measure changes in normative beliefs at various intervals: pre-ban, mid-ban, and

post-ban. The ban was successful in reducing teens’ intentions to smoke as well as shifting the normative


beliefs around smoking to be more socially unacceptable both during and after the marketing restrictions

(Brown, 2009). This strategy can also target outcome expectations if public health campaigns replace

tobacco ads with promotions that emphasize the health benefits of not using tobacco (physical outcome

expectation), portray smokers as uncool (social outcome expectation), and draw attention to personal

feelings about using tobacco (self-evaluative outcome expectation) (Kelder, 2015). Likewise, increasing

accurate knowledge about tobacco use can occur across a variety of mediums; however, widespread media

campaigns are instrumental when trying to reach large populations (Kelder, 2015).

A study conducted in the United Kingdom examined data from the 2007 and 2009 UK Office for

National Statistics Opinions and Lifestyle Survey to understand the characteristics shared among smokers

who have never tried to quit. They found that desire (intention) was the most predictive factor, followed by

health status, and also if smokers had received support or attention from someone to quit in the last year.

Those who had not received support were 1.57 times more likely to never have tried to quit as compared to

those who had received support. Also, smokers whose healthcare provider did not provide cessation advice

in the last five years were 2.69 times more likely to report never having tried to quit (Sharma, 2014).

Multiple web- or mobile-based cessation studies have found that interactive, tailored, and support-focused

interventions are linked to lowering cigarette consumption (Civljak, 2010; Haug, 2013; Shi, 2013). Social

support for asking questions, getting information, and quitting can be provided via quit lines, apps or

mHealth cessation programs, family and friends, school teachers and counselors, or social media platforms.

Related to social support, a key finding in a study of 3,473 youths with nonsmoking parents was that

the protective effects of increased perceived punishment and increased parental monitoring had on initiation

of smoking. Adolescents with higher parental monitoring were 33% less likely to start smoking while

decreased parental monitoring and decreased perceived punishment increase smoking initiation by 55%

and 17% respectively (Mahabee-Gittens, 2012). Interestingly however, another study found that a high-

school incentive-based cessation program was successful for short-term abstinence, but did not change

long-term abstinence rates (Krishnan-Sarin, 2013). Thus, reinforcements and punishments are highly


individualized and may be different for each person. Intervention designers should understand their target

population’s motivations in order to appropriately utilize this construct.

Reducing barriers and increasing opportunities for adolescents who have already started using tobacco

can be a challenge if other constructs are not being addressed. For example, lack of social support for

quitting or the perceived social benefit of smoking can both be barriers for abstinence. Several studies have

concluded that a primary action needed to reduce barriers for all smokers, including adolescents, is to create

or change policies (Rosenthal, 2013; Guiney, 2015; Levy 2012). This could transpire as mandating more

smoke-free zones, increasing tobacco taxes, increasing access to cessation treatment, or raising the

minimum age for tobacco sales (Levy, 2012; 2015; Bonnie, 2015). Due to the increasing prevalence of

smart phones, health professionals are becoming more interested in reducing barriers to access interventions

by developing health behavior apps and websites, which are relatively low-cost and accessible for both the

professional and the targeted individual. In addition, technology allows for unique tailoring of messages to

vast populations (Hall, 2015).

As demonstrated, aspects of the SCT are widely applied to adolescent tobacco use and often helpful

in reducing initiation rates or increasing cessation success; however, the theory in its entirety is too complex

for one study to address. This emphasizes the importance of the interactions between the various constructs

and acknowledges that there is not one formula for improving this health behavior. Some strategies are

foundational to success or have a greater individual impact on adolescent health outcomes such as self-

efficacy and social support, but nevertheless, incorporation of a variety of concepts into any intervention is

ideal so strengths of one construct overlap weaknesses of another.

SOCIAL NETWORK THEORY: Social Network Theory emphasizes understanding the connections

and relationships between and among individuals and groups to improve health (Valente, 2015). These

connections are often analyzed through mathematical algorithms and visually displayed as nodes/points

(people) and lines (connections). Unlike the SCT, the SNT does not have clearly defined constructs, but

rather three main components: network environment, position in a network, and structural or network

properties. The “network environment” component aims to understand the homophily, or the tendency for


like individuals to associate with one another. In the SNT, homophily is broken into two processes:

influence, or the degree to which individuals change their behaviors to match behaviors or beliefs; and

selection, or the degree to which they change their networks to match behaviors or beliefs. The “position

in a network” component identifies centrality of a social network, or the prominent people (opinion leaders)

with the greatest influence on the most people in the network. The “structural or network properties”

component seeks to explain the reciprocity in a social network, or the level of trust in a relationship;

transitivity, or the number of “friends who are friends with friends”; density, or number of interconnected

relationships; and the small-world property, or the distance between connections (Valente, 2015).

Essentially the SNT views the entire social network as one entity, not merely the sum of individuals, and

ultimately examines the encompassing network behavior. That network behavior is then the target for health

behavior change and improving network health.

The SNT is useful when trying to understand health beliefs and behaviors more today than ever before.

People are communicating ideas and beliefs much faster due to increased urbanization, improvements in

transportation, innovations in technology, accessibility to the internet, and the growth of social media.

Understanding these interactions is important when examining adolescent tobacco use because, as stated

before, adolescents are in a period of self-identity, and thus network-identity, and understanding the trends

in relationships between adolescents, their behaviors, and their networks becomes instrumental in

determining how to most effectively impact adolescents’ health beliefs and behaviors. The SNT theory is

particularly helpful because it provides tools to measure and understand adolescent social networks. By

identifying central positions in adolescent networks, intervention resources can be targeted to attain the

greatest impact within that particular network (Valente, 2015).

For example, during a three-year longitudinal study of 1,063 adolescents found that adolescents in

predominantly smoking peer groups were more likely to become smokers (40%) than those in

predominantly nonsmoking peer groups (27%) (Engels, 1997), demonstrating the SNT concept of influence

on homophily. This illustrates that tobacco use is a behavior that can be predicted by the friendship

connections adolescents have in their network. However, the researchers in this study also stress that other


determinants and social network connections are likely influencing adolescent behaviors simultaneously

and that peer connections should not be the only focus in any intervention (Engels, 1997). The same study

also found that smokers were more likely to become friends with other smokers (70%) as compared to

nonsmokers becoming friends with smokers (25%). This demonstrates the SNT concept of selection on

homophily such that adolescents tend to form network connections with peers that are similar to themselves

when it comes to smoking behavior. However, the research did not find that friendships were terminated

due to differing smoking behavior or habits (Engels, 1997).

Interventions for tobacco prevention among adolescents should be primarily focused on areas of

selection of new peer groups (Engles, 1997; Mercken, 2012). This could be achieved through media

campaigns or school-based programs that shift normative beliefs. If peers consider tobacco use to be

socially unacceptable and feel it will inhibit making friends, an adolescent may be less likely to initiate

tobacco use and will then be a positive influence on other individuals in the network. In time, nonsmoking

connections will become predominate, which will further perpetuate the shift in normative beliefs to

devalue tobacco use. This strategy can be particularly impactful when adolescents are transitioning from

junior high to high school—a time when many new connections develop.

Another network analysis conducted among 486 freshman students in Mexico found that students who

named more friends as being in their network had a protective factor for smoking (OR 0.89) while being

named a friend by peers increased probability of smoking (OR 1.10). It was theorized that these more

popular students (opinion leaders) had more pressure to smoke due to connections with other smokers

(influence). Due to their centrality in the student network, they would then be more influential in spreading

the norm that smoking is socially desirable (Ramirez-Ortiz, 2012). The study suggests future interventions

create a cultural climate where smoking is not valued by convincing popular students to support

antismoking norms and integrating these opinion leaders into prevention programs.

Identifying opinion leaders among adolescents in peer-led, school-based, antismoking health

promotion programs proved to be successful by reducing the odds of becoming a regular smoker by 22%

in a study conducted in England and Wales from 2001-2004. An in-depth network analysis was performed


on 10,730 students (12-13 years old) who were assigned to a control or intervention group. The control

group received normal smoking education—not peer-influenced—and the intervention group received

health programing supported by influential peers. Students were surveyed about their social networks and

the most frequently nominated students/friends in the intervention groups were trained as “peer supporters”

for a 10-week intervention period which focused on peer education and diffusing health promotion

messages (Starkey, 2009). This detailed examination of peer networks illustrates the SNT concept of

centrality in that among adolescents, popular peers (opinion leaders) are more influential than adult teachers

due to their central position in the network and can be utilized in health campaigns to influence the most

adolescents and alter the network behavior.

Although peer groups are important when considering tobacco use among adolescents, the family

structure is another critical network to understand when identifying risks for tobacco beliefs and behaviors.

A five-year longitudinal study of 406 adolescents (12-17 years old) found that adolescents with smoking

parents are 4.5 times more likely to experiment with tobacco and nearly 10 times more likely to become

regular users. Additionally, the risk of tobacco use increases with longer exposure to parental smoking.

However, former smokers or nonsmoking parents did not have a significant effect on adolescent tobacco

use (Mays, 2014). The study concluded that parents’ behaviors can unintentionally be passed to offspring;

and because duration of exposure to smoking is an additional variable predicting adolescent tobacco use,

parents who quit smoking as soon as possible can reduce their child’s risks of tobacco initiation and

dependency in the future. The SNT construct of structural or network properties is highlighted by the strong

reciprocity within a family unit and the profound effects it has on health behaviors such as tobacco use.

Likewise, a meta-analysis of 58 studies revealed that children with two parents who smoked had 2.73

times the risk of smoking. Increased risk of smoking was also linked if a sibling smoked (OR 2.30), the

mother smoked (OR 2.19), one parent smoked (OR 1.72), any household member smoked (OR 1.92), and

the father smoked (OR 1.66) (Leonardi-Bee, 2011). This highlights the small-world property of the SNT

by showing the strong ties among people living in the same household and the amount of influence these

people have on one another. Therefore, interventions combating adolescent tobacco beliefs and usage could


benefit from incorporating strategies to restructure the entire household network in respect to tobacco

exposure.

It is apparent that utilizing the SNT concepts can help understand the network complexities of

adolescents and how they relate to tobacco use. It is essential for health behavior interventions to identify

key opinion leaders and points of centrality among adolescent peer networks to effectively increase reach.

However, household networks and community networks are also important when influencing adolescent

behaviors and beliefs.

CONCLUSION: Both the Social Cognitive Theory and the Social Network Theory have proven to be

useful guides in understanding adolescent tobacco behavior. The SCT is more comprehensive and

comprised of a dynamic understanding of personal cognitive, socioenvironmental, and behavioral factors.

It is helpful in distinguishing strategies for interventions and correlations between constructs, variables, and

behavioral outcomes, but it lacks the insight into why those strategies are successful. Conversely, the SNT

does not provide concrete strategies like the SCT, but can examine evaluation gaps by describing networks

and why relationships exist and change. The SNT is also limited somewhat by measurement in that

qualitative data about relationships may not be accurately represented in a social network analysis or

quantitative data about relationships may not be that meaningful to the behavioral outcome. However, both

bring value and insight into finding best practices for improving current and creating new interventions to

prevent, reduce, and end adolescent tobacco use.

Personally, I think creating an anti-smoking program for adolescents will be most effective when it

classifies intervention strategies into all SCT constructs. For example, program planners would want to

ensure that they are providing a comprehensive, multifactorial approach by simultaneously addressing

personal cognitive, socioenvironmental, and behavioral factors. This is not to say that a program needs 11

different strategies; some activities, such as peer modeling, can be classified in any or all of the constructs

if well planned. For example, observing a respected peer refuse a cigarette during a role-playing exercise

can increase self-efficacy and collective efficacy by providing opportunities for mastery experiences,


develop behavior skills by suggesting refusal phrases, and shift social norms to support more anti-tobacco

attitudes.

The SNT can then be used to explain the success or failure of various strategies outlined in the SCT.

To continue with the peer-modeling example, SNT can provide insight into why this activity was successful

or not by answering questions related to the network environment, peer position in the network, and network

properties. SNT would examine the relationships the peer model had with others in the network and would

help to identify peers who will have the greatest impact on health behavior. Pinpointing the most influential

individuals is critical when designing an intervention to increase effectiveness and reduce wasted resources.

Most SCT studies utilize school-based interventions to reach adolescents; however, SNT studies

suggest adolescent anti-tobacco messaging that reaches outside the peer network and into wider familial

and community networks will have the greatest impact. The SNT not only focuses on message

dissemination, but also on how policies can influence a network. Large health campaigns, such as the Truth

and Campaign for Tobacco-Free Kids, provide examples of health strategies that not only promote

individual change to refuse or stop using tobacco, but also focus on anti-tobacco laws such as creating

smoke-free public spaces, raising the minimum age to purchase tobacco, and mandating regulations on

tobacco advertising (Campaign for Tobacco-Free Kids, 2014; Truth Initiative Foundation, 2015).

Future research is needed to determine the optimal combination of constructs within the SCT and the

most appropriate strategies to target today’s adolescents. These findings can then be analyzed with the SNT

to understand more effective methods for implementing these constructs to reduce tobacco use at the

individual and network level. I think this will be primarily done via technological platforms such as mobile

phones, video games, and mass media. Tobacco use among adolescents is a complex public health concern

that is continually evolving and there is no one simple solution. Nevertheless, understanding the SCT and

SNT and their applications to this health behavior can help public health professions better address the issue

now, and with reassessment, develop new strategies in the future.


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Health & Medicine

Reducing Tobacco Use Among Adolescents Using Social Cognitive Theory and Social Network Theory