Social support in smoking cessation: reconciling theory and evidence.

Abstract

INTRODUCTION: The majority of smokers attempt to quit smoking on their own, but in any given year, only 5% or less are successful. To improve cessation rates, tapping social networks for social support during quitting has been recommended or tested in some interventions. Prior reviews of this research, however, have concluded that there is little to no evidence that partner support interventions are effective. DISCUSSION: Given the theoretical importance of the concept of social support, its demonstrated value in treatments that are implicitly supportive (e.g., telephone counseling), and the general lack of a guiding conceptual framework for research on the effects of peer or partner support for cessation, we describe theoretical models that explicitly incorporate social support constructs in predicting motivation for and success in quitting. Conclusion: Better differentiation of support concepts and elucidating causal pathways will lead to studies that demonstrate the value of social relationships in improving smokers' likelihood of cessation.

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Nicotine & Tobacco Research, Volume 12, Number 7 (July 2010) 695–707
695
doi: 10.1093/ntr/ntq077
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sity of Web site use. Interventions have also been developed that
included training and materials for smokers on how to solicit
social support from network members or that assigned smokers
to “buddies” from inside or outside the network who they could
count on for ongoing support during their quit attempt (Kviz,
Crittenden, Madura, & Warnecke, 1994; Orleans et al., 1991).
Reviews of peer social support
for quitting
Meta-analyses of studies such as those described above led the
2000 U.S. Public Health Service–sponsored clinical practice
guideline Treating Tobacco Use and Dependence (Fiore, 2000)
to recommend that smokers be provided with social support as
part of treatment and that they should be helped in obtaining
support from others outside the treatment environment. Its
most recent updated guideline, however, excluded the latter
recommendation (Fiore et al., 2008). This action was a result of
recent literature questioning the research purporting to find
benefits of cessation programs that attempted to use smokers’
social networks to facilitate cessation. Piasecki and Baker (2001),
for example, pointed out that many interventions with socially
supportive treatments often included additional intervention
activities and were therefore not true tests of social support’s
effects. Other investigators have similarly pointed out that sup-
port programs involving peers were often adjuncts or supple-
ments to existing interventions, such as group-based or
telephone counseling (May & West, 2000; Park, Schultz, Tudiver,
Campbell, & Becker, 2004; Park, Tudiver, Schultz, & Campbell,
2004). May and West’s review, in particular, pointed out that of
all the studies they reviewed, only one examined the effects of
adding a buddy component to a self-help intervention (Orleans
et al., 1991). In that study, however, only 58% of subjects in the
support condition gave out support guides (as required) to bud-
dies. Moreover, there were no differences between groups in the
number of allies invited to help, in perceptions of support, or in
abstinence outcomes. In the Park, Tudiver et al. (2004) review,
which included several studies from the May and West paper,
five of the nine studies fitting their inclusion criteria tested
support interventions that were supplemental to the intratreat-
ment support provided through group treatment programs or
Abstract
Introduction: The majority of smokers attempt to quit smok-
ing on their own, but in any given year, only 5% or less are suc-
cessful. To improve cessation rates, tapping social networks for
social support during quitting has been recommended or tested
in some interventions. Prior reviews of this research, however,
have concluded that there is little to no evidence that partner
support interventions are effective.
Discussion: Given the theoretical importance of the concept of
social support, its demonstrated value in treatments that are im-
plicitly supportive (e.g., telephone counseling), and the general
lack of a guiding conceptual framework for research on the ef-
fects of peer or partner support for cessation, we describe theo-
retical models that explicitly incorporate social support
constructs in predicting motivation for and success in quitting.
Conclusion: Better differentiation of support concepts and
elucidating causal pathways will lead to studies that demonstrate
the value of social relationships in improving smokers’ likeli-
hood of cessation.
The majority of smokers attempt to quit smoking on their
own (Fiore et al., 2008) but most fail; abstinence rates among
self-quitters average 5% or less within 6–12 months of the at-
tempt (Hughes, Keely, & Naud, 2004). Using cessation medica-
tions such as nicotine replacement therapy (NRT) is one way
self-quitters can enhance their success, but additional tech-
niques to improve their ability to quit for good would be valu-
able. One possible strategy is to engage social networks to
provide social support for the quit attempt. Several studies have
provided evidence suggesting that support from others helps
smokers quit. For example, the greater the number of individ-
uals that smokers listed as being able to provide support when
quitting (using a web-based program), the more likely they were
to have quit at a 6-month follow-up, controlling for use of other
cessation products or services (Johnson et al., 2009). In another
study, Cobb, Graham, Bock, Papandonatos, and Abrams (2005)
found, in an evaluation of a web-based program for cessation,
that the use of peer-to-peer social support through forums,
E-mails, and/or chat rooms was associated with at least three
times greater odds of abstinence at 3 months, controlling for inten-
Review
Social support in smoking cessation:
Reconciling theory and evidence
J. Lee Westmaas, Ph.D., Jeuneviette Bontemps-Jones, M.P.H., C.H.E.S., & Joseph E. Bauer, Ph.D.
Behavioral Research Center, American Cancer Society, Atlanta, GA
Corresponding Author: J. Lee Westmaas, Ph.D., Behavioral Research Center, American Cancer Society, 250 Williams Street, NW,
Suite 6D.432, Atlanta, GA 30303, USA. Telephone: 404-329-7730; Fax: 404-929-6832; E-mail: lee.westmaas@cancer.org
Received November 23, 2009; accepted April 26, 2010
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Social support in smoking cessation
psychotherapy. The remaining studies were the Orleans et al.
investigation described above and three other studies that did
not find significant differences between the support interven-
tion and control groups (see Nyborg & Nevid, 1986; Powell &
McCann, 1981).
Limitations of investigations of
peer support for quitting
A problem with interventions designed to increase social sup-
port for quitting, but that is supplemental to an established and
efficacious treatment such as telephone counseling or group
programs, is that they may exhibit ceiling effects; the intratreat-
ment support may have adequately met smokers’ support needs
during and after quitting. Similarly, the extratreatment support
may not have been intense enough to influence quitting over
and above the intratreatment support (May & West, 2000).
A better test of the effects of peer or partner support for self-
quitters would be a randomized controlled trial (RCT) that
compared a peer or partner support program with a control
group that received minimal treatment (e.g., booklets).
The lack of a theoretical framework to guide interventions,
as well as methodological limitations, has also been noted in the
reviews of studies that investigated the effects of peer support
for quitting (Hogan, Linden, & Najarian, 2002; May & West).
These limitations include lack of differentiation among struc-
tural and functional support concepts, not randomizing partic-
ipants to conditions, failure to measure baseline support, using
only participants who had buddies available to help (and who
therefore might nevertheless provide support even if placed in
the control group), failure to verify participants’ engagement of
peer support, no measurement of perceived support, or if so,
only among participants who remained at the end of the treat-
ment, small samples, and an absence of biologically verified
abstinence.
May and West (2000) also pointed out that in studies that
assessed the supportiveness of a spouse or partner, the Partner
Interaction Questionnaire (Mermelstein, Cohen, Lichtenstein,
Baer, & Kamarck, 1986) was used. They noted a problem with
this scale in that “some of the negative ‘support’ behaviors are
only applicable if a person is still smoking,” for example,
“criticize your smoking” and “refuse to clean up your cigarette
butts,” whereas some positive partner behaviors are only appli-
cable when the smoker is abstaining, for example, “compli-
mented my not smoking” or “celebrated my quitting with me.”
As May and West stated, it would not be surprising to find neg-
ative behaviors to be more strongly associated with smoking
and positive ones with abstaining.
Intratreatment social support is
effective
Although the problems described above precluded conclusions
by prior reviews about the value of peer or partner support in
helping smokers quit, the updated Clinical Practice Guidelines
nevertheless emphasized the importance of support provided
by treatments for cessation (i.e., intratreatment support). This
endorsement implicitly acknowledges that behavioral treatments
for smokers shown to be effective in randomized clinical trials,
specifically individual or telephone counseling and group pro-
grams (Lancaster & Stead, 2008; Stead & Lancaster, 2009; Stead,
Perera, & Lancaster, 2009), provide high levels of informational,
instrumental, and in many cases emotional support for smokers.
Emotional support “involves the expression of empathy, caring,
reassurance, and trust and provides opportunities for emotional
expression and venting” (Cohen, 2004). Instrumental support
“involves the provision of material aid, for example, financial
assistance or help with daily tasks.” Informational support “re-
fers to the provision of relevant information intended to help
the individual cope with current difficulties and typically takes
the form of advice or guidance in dealing with one’s problems”
(Cohen). Telephone quitlines obviously provide emotional sup-
port for smokers (the California Helpline, e.g., instructs coun-
selors to acknowledge, discuss, and clarify smokers’ desire to
change and their related fears or ambivalence regarding quit-
ting; Zhu et al., 1996). Quitlines also provide information on
quitting strategies and cessation medications (i.e., information-
al support), and group therapy programs are a source of emo-
tional and informational support through “discussion and
sharing of experiences and problems” (Stead & Lancaster, p. 5).
An example of instrumental support provided by these effective
interventions would be the free NRT or cessation medications
that are sometimes available for qualified smokers.
While there may be factors that influence how effective pro-
fessional support would be compared with that from peers or
partners (e.g., smokers may be more motivated to please a pro-
fessional counselor or see them as more credible and objective
sources of information), only by investigating the extent to
which others can effectively provide these supportive functions
will the potential value of social networks in facilitating cessa-
tion become apparent. Understanding how social network
members can assist quitters would be useful because the major-
ity of adult smokers attempt to quit on their own (Larabie,
2005) because they do not have the inclination or time to par-
ticipate in behavioral treatment programs (indeed quitlines
reach only between 1% and 2% of smokers; North American
Quitline Consortium, 2009). Social network members can in-
fluence smokers to seek professional help such as from quitlines
(Muramoto, Wassum, Connolly, Matthews, & Floden, 2010;
Patten et al., 2008), but network members are also themselves
motivated to support smokers in their quit attempts in any way
they can (Thomas et al., 2008), especially judging from the
number of calls to quitlines by family members or friends of
smokers (Zhu, Nguyen, Cummins, Wong, & Wightman, 2006).
They are even willing to undergo training in order to better help
family members or friends quit (Campbell, Mays, Yuan, &
Muramoto, 2007). Using social networks to provide cessation
support for smokers is therefore a promising strategy for help-
ing smokers quit, whether or not smokers choose to use existing
treatments.
Using theory in research on
social support and quitting
As noted earlier, a significant gap in studies examining the effects
of peer or partner social support for smokers is the lack of a con-
ceptual or theoretical framework that explains how social support
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Nicotine & Tobacco Research, Volume 12, Number 7 (July 2010)
from others is supposed to operate in helping smokers quit. This
contrasts with interventions involving family members and peers
that have been developed for substance abusers (Fernandez,
Begley, & Marlatt, 2006; Litt, Kadden, Kabela-Cormier, & Petry,
2007). In a recent review of these programs, Fernandez et al.
found that newer interventions that included techniques from
Motivational Interviewing (Miller & Rollnick, 2002), that in-
cluded an optimal amount of social pressure and nonconfronta-
tional approaches and that were flexible, appeared to be the most
effective. Nonetheless, they noted that “research on these newer
interventions remains in its infancy” and that “further research
to examine mechanisms of action is needed” (p. 211).
Having a model or framework that specifies the mechanisms
of action of support from network members could potentially
help investigators designing support interventions determine
why an intervention was effective or not and what can be done
to improve it. For example, if the hypothesized effect of a sup-
port intervention targeting spouses of smokers is to increase
their self-competence for quitting, then repeatedly measuring
spouses’ provision of support, and the smoker’s self-competence
at baseline and during the treatment, would help determine if
the intervention indeed increased self-competence and whether
self-competence increased the likelihood of quitting.
Even for interventions established as effective, a theoretical
framework for how the support provided influences quitting is
often absent (exceptions, which are discussed below, are the au-
tonomous support model, Williams, Niemiec, Patrick, Ryan, &
Deci, 2009; Williams et al., 2006, and the family systems FAM-
CON approach; Rohrbaugh et al., 2001). For example, research
demonstrating the efficacy of quitlines typically has not assessed
potential mediators of their effects, for example, whether the
emotional support provided by trained counselors helped
smokers quit by reducing their anxiety about quitting, increas-
ing their self-efficacy in coping with withdrawal symptoms, in-
creasing their use of behavioral coping strategies, and/or helping
them cognitively reframe lapses. These effects are likely assumed
by investigators, but only by assessing these variables will it be
known which constructs are most important or whether they
are equally important in explaining the relationship between the
treatment support and abstinence. This knowledge could po-
tentially lead to more effective professionally led interventions.
In the present paper, we describe social support constructs
that we believe are important in determining how socially sup-
portive strategies help smokers quit, regardless of whether the
support is provided from health professionals or peers. We also
outline possible theoretical models that incorporate these con-
structs and that we believe can be used to guide subsequent re-
search examining the effects of peer or partner social support on
smoking cessation success.
Literature update
As described above, several comprehensive reviews have previ-
ously examined the extent to which peer or partner support in-
terventions helped smokers quit. We wanted to first determine if
subsequent to the last meta-analytic review in 2004 of partner
support interventions, additional RCTs had been conducted that
demonstrated benefits of social network support for smokers.
We thus conducted our own review that included published
studies and dissertations or theses from 2004 and later. We
searched for RCTs that compared smokers who received an in-
tervention to enhance peer or partner support with smokers who
did not receive the support intervention and in which abstinence
(however defined) at any timepoint following treatment was an
outcome variable. Searches were conducted using the PubMed,
PsycInfo, and Dissertation and Theses databases by pairing
smoking or tobacco with cessation or abstinence together with sup-
port, spouse, worksite, workplace, couples, buddy, partner(s), fam-
ily, friend, or coworker. Articles cited in reference sections of
these papers were also examined for possible inclusion.
Our literature search retrieved 186 records. These included
21 RCTs, 17 of which did not meet inclusion criteria. Specifical-
ly, in seven studies, the engagement of peer or partner support
was not a goal of the study; in six studies, the support was pro-
vided by health professionals such as nurses; in two studies, the
intervention group received both a standard cessation program
and a support but the control group did not receive the cessa-
tion program; one study combined data from three RCTs but
did not randomize to different levels of partner support; and in
another study, peer support was provided in both the interven-
tion and the control groups (see Table 1 for more specific de-
scriptions of excluded studies).
Of the four studies that met the inclusion criteria (Table 2),
two showed no difference in abstinence rates between the inter-
vention and control groups at any of the follow-ups (May, West,
Hajek, McEwen, & McRobbie, 2006; McBride et al., 2004). In
both of these studies, however, the peer support intervention
was in addition to an existing professionally led support pro-
gram found in previous research to be effective (e.g., group
therapy sessions or telephone counseling). Null effects could
therefore be attributed to ceiling effects as described earlier. In
contrast, the remaining two studies both found significant ad-
vantages of the peer support intervention at the end of treat-
ment and/or at a 3-month follow-up (Hennrikus et al., 2010;
Solomon et al., 2005). In one of these studies, pregnant smokers
identified a supporter from her social network and half of these
supporters received instructions from a counselor on how to be
supportive (intervention group), whereas the other half did not
(control group; Hennrikus et al.). In the second study, low-
income women receiving nicotine patches were randomized to
either receive telephone support from a peer who was an ex-
smoker who had received 8 hr of training for the intervention,
or to a control group that did not receive this peer support. In
addition to the significant difference in abstinence at the
3-month follow-up, this study also found a trend for the
6-month follow-up; the percent abstinent in the intervention
group (33%) was greater than in the control (26%), though the
difference was not statistically significant (Solomon et al.). These
studies suggest that at least for quitting in the short-term peers
trained to be supportive can increase abstinence rates.
In the two studies that obtained significant effects of sup-
port, a guiding conceptual framework for understanding the
positive effects obtained was not described, and thus, possible
mediators were not examined. Only by specifying and testing
models of how social support constructs influence quitting will
research and interventions targeting peer or partner support
elucidate why, when, and for whom peer or partner support
promotes the initiation and/or maintenance of quitting.
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Social support in smoking cessation
Modeling the role of social
support in smoking cessation
social support constructs and
models
As described previously, there are three generally accepted func-
tions of social support: emotional, informational, and instru-
mental. These support functions can be “abstinence specific” in
that they pertain to support specifically for the quit attempt, or
they can be more general. An example of abstinence-specific
emotional support would be providing a smoker the opportu-
nity to vent emotions about the difficulty of abstaining. More
generally, emotional support can contribute to a calm and secure
interpersonal environment that helps make the difficult task of
quitting more achievable (Mermelstein et al., 1986). Instrumen-
tal support that is abstinence specific would be providing NRT or
providing transportation for a smoker to attend a group therapy
cessation session. More general instrumental support would be
helping a partner with daily chores that might have the effect of
reducing feelings of stress or involving the partner in activities
that distract him or her from withdrawal symptoms.
Pathways in which these support functions can directly or
indirectly influence the likelihood of making a quit attempt
and/or achieving success in quitting are presented in Figure 1.
One perspective depicted is a stress-buffering model (also
known as the “stress and coping” model) of social support, as
described in the psychological literature (Cohen, Gottlieb, &
Underwood, 2000). According to this model, perceiving sup-
port to be available when needed minimizes the appraisal of
stressors as threatening, reduces the negative physiological
effects of stressors (i.e., stress responses such as increased heart
rate and blood pressure), and allows individuals to engage more
successfully in adaptive coping strategies (Paths 1–5 in Figure 1).
Adaptive coping (e.g., relaxation training, or exercising to cope
with cravings in the case of smoking cessation) would further
minimize the negative impact of the stressor. This model can be
applied to cessation because abstaining from smoking is arguably
stressful for many smokers and causes withdrawal symptoms,
including negative affect, that increase the likelihood of relapse
(Brandon, 1994; Kassel, Stroud, & Paronis, 2003; Perkins &
Grobe, 1992).
In coping with stress and negative affect during quitting,
emotional support, whether general or abstinence specific, may
be particularly helpful because of its potential for stress buffer-
ing (Lepore, 1998; Lepore, Allen, & Evans, 1993). For example,
a smoker who perceives that she or he can discuss daily hassles
with a spouse or friend, or who receives empathic responses and
validation for negative emotions experienced during a quit at-
tempt, may be better able to cope not only with daily hassles but
also the abstinence-specific consequences of quitting smoking,
namely withdrawal symptoms. Better coping with daily
stressors and with withdrawal symptoms should theoretically
Table 1. Randomized controlled trials excluded from consideration of effects of peer or
partner support on smoking cessation
StudyReason for exclusion
An et al. (2008) Intervention group received both Internet cessation program and peer E-mail support,
whereas control group received neither.
Health professionals (nurses) provided support during clinic visits or by telephone.
Tested effects of cessation advice and materials provided by trained midwives.
Intervention and control did not have goal of changing support mobilization of
pregnant women.
Support provided by midwives at medical practices in Netherlands
Examined effects of automated mobile phone support messages
Intervention group received both Internet cessation program and peer E-mail support,
whereas control group received neither.
Combined data from 3 randomized trials but did not randomize to compare levels of
partner or peer support among groups
Peer support provided in both intervention and control groups among high-school
students. Trained adult facilitators provided additional support for intervention group.
Randomized medical practices to intervention condition (consisting of providing
referrals for cessation treatment) or to a control condition (no referrals)
Randomized pharmacies to provide (or not provide) referrals to telephone quitline
counseling for smokers
Clinical hypnotherapists provided autonomy supportive or control treatments
Cessation intervention directed to smokers who are partners of pregnant women
(support between partners not investigated)
Compared nicotine replacement therapy with placebo
Worksite intervention did not include peer or partner support
Health professionals (nurses) provided support for cessation
Intervention delivered by physicians
Health professionals (nurses) provided individual support or through group sessions
Aveyard et al. (2007)
Aveyard, Lawrence, Evans, and Cheng (2005)
de Vries, Bakker, Mullen, and van Breukelen (2006)
Free et al. (2009)
Klatt et al. (2008)
Lawhon, Humfleet, Hall, Munoz, and Reus (2009)
Mermelstein and Turner (2006)
Murray et al. (2008)
Patwardhan (2009)
Solloway, Solloway, and Joseph (2006)
Stanton, Lowe, Moffatt, and Del Mar (2004)
Sun et al. (2009)
Tanaka et al. (2006)
Wiggers et al. (2006)
Williams et al. (2002)
Wilson, Fitzsimons, Bradbury, and Stuart Elborn (2008)
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Nicotine & Tobacco Research, Volume 12, Number 7 (July 2010)
increase the ability to abstain, at least in the short term. Research
addressing the validity of this model could also examine the rel-
ative importance of perceptions of the availability of emotional
or other support versus the amount of actual support received.
These could be evaluated for their ability to lower stress ap-
praisals and withdrawal symptoms and to increase adaptive
coping and the ability to quit. Informational support may be
less relevant to the stress-buffering perspective, however, and
more likely to have a direct effect on adaptive behavioral
responses (Path 6).
A theoretical model of the support process for smokers that
focuses on characteristics of how support is provided is the au-
tonomous support perspective of Williams et al. (Williams,
Gagne, Ryan, & Deci, 2002; Williams et al., 2009). They define
autonomous support as support that permits the receiver to ex-
perience a sense of volition, choice, and control. Based on pre-
cepts from self-determination theory (Deci, Eghrari, Patrick, &
Leone, 1994; Deci & Ryan, 1987, 1990), autonomous support is
hypothesized to increase (autonomous) motivation and self-
competence, which should make behavior change more likely
(Paths 9–15). In an intervention in which smokers received sup-
portive counseling sessions sensitive to their autonomy versus
receiving pamphlets and referrals, autonomous counseling was
associated with greater abstinence at 24 months compared with
the control group (Williams et al., 2009). A comparison of phy-
sicians’ use of an autonomous supportive style with that of a
controlling style, however, found that 7-day point prevalence
abstinence rates were greater for the controlling style, though
not statistically significantly so, at 6 months (13.0% vs. 7.8%),
12 months (13.0% vs. 11.2%), 30 months (20.3% vs. 18.1%),
and for abstinence at all timepoints as well (9.7% vs. 5.2%;
Williams et al., 2002). Structural equation modeling (SEM)
analyses nevertheless demonstrated that the intervention led to
smokers’ perceiving higher levels of autonomous support that
in turn predicted greater autonomous motivation. Autonomous
motivation, in turn, predicted continuous abstinence. Similar
SEM analyses using a different sample of smokers who received
autonomous support from professional counselors found that
autonomous motivation at 1 month predicted greater perceived
competence that in turn was associated with 6-month cessa-
tion (Williams et al., 2006). Although these autonomy sup-
portive interventions for cessation were provided by health
professionals, their results suggest that peers’ provision of
emotional, instrumental, or informational support should
also attempt to preserve the recipient’s sense of autonomy
and personal control.
The importance of the smoker maintaining a sense of con-
trol and freedom in response to others’ provision of support is
also emphasized in the family consultative (FAMCON) model
of smoking cessation (Rohrbaugh et al., 2001). According to
this perspective, partner behaviors such as pushing directly or
indirectly for change, nagging, or using other negative social in-
fluence tactics are evaluated in terms of whether they result in
resistance to change, also termed “ironic processes.” This per-
spective includes the concept of “symptom-system fit” whereby
the target behavior (e.g., smoking) serves communication and
emotion regulation functions in a relationship (e.g., to preserve
distance) that need to be identified. For example, if the partner’s
push for quitting results ironically in reduced change, the
recommended course of action would be to engage in less of
these behaviors, for example, by declaring helplessness, demon-
strating acceptance, or simply observing (Rohrbaugh et al.). The
FAMCON approach to cessation relies heavily on the profes-
sional support of a therapist and also includes standard effective
smoking cessation treatment (Shoham, Rohrbaugh, Trost, &
Muramoto, 2006). Nevertheless, it points out the potential
complexity of using peers, particularly romantic partners, to
provide support for smoking cessation.
Structural indices of network support such as social integra-
tion, or the proportion of smokers in a network, also have a role
to play in theoretical models of the support process for smokers
attempting to quit. Social integration refers to the existence and
strength of social bonds or the degree of involvement with social
ties in an individual’s network (Berkman, Glass, Brissette, &
Seeman, 2000). According to Brissette, Cohen, and Seeman
(2000), social integration “is a multidimensional construct
thought to include a behavioral component—active engagement
Table 2. Randomized controlled trials included in consideration of effects of peer or partner
support on smoking cessation
Study DescriptionOutcome
Hennrikus et al. (2010)Pregnant smokers (n = 82) identified supporter from social
network. Supporter in intervention group received
instructions from counselor; control group supporter did not
Smokers (n = 563) randomized to receive or not receive buddy
support from a participant in group smoking cessation program.
Intervention group more likely to quit at end of
pregnancy (13.0% vs. 3.6%) and 3 months
postpartum (9.3% vs. 0%)
No difference at 26 weeks postquit date between
experimental and control groups in continuous
abstinence using intent-to-treat (13% vs. 15%)
No difference in abstinence between groups at any
follow-up
May et al. (2006)
McBride et al. (2004)Pregnant smokers (n = 583) randomized to control group (provider
advice to quit and self-help guide); (b) control materials plus 6
telephone calls by health advisor; or (c) control materials,
telephone calls, and telephone counseling (and written guide) for
partners of women on how to support their quitting
Low-income women smokers (n = 330) receiving nicotine patches
randomized to (a) receive telephone support from a peer
(ex-smoker with 8-hr training) over a 4-month period or to (b)
control group with no telephone support
Solomon et al. (2005) Intervention group more likely to have quit at 3
months (43% vs. 26%) but not at 6 months
(33% vs. 26%)
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Social support in smoking cessation
in a wide range of social activities or relationships—and a
cognitive component—a sense of communality and identifica-
tion with one’s social roles.” The likelihood of a smoker solicit-
ing and/or receiving (or perceiving) emotional, instrumental, or
informational support from others for cessation will likely de-
pend on the smoker’s level of social integration, specifically
whether there are others who can be counted on to provide sup-
portive functions during quitting (Path 7). Social ties can be
characterized not only by number but also by their quality (sat-
isfaction) and type (intimate vs. more distant), which should
also influence how supportive they can be.
Assessing social integration might not seem to be impor-
tant for interventions in which the support person is a desig-
nated peer unknown to the smoker (as in some “buddy”
programs), but if the smoker already has network members to
whom he can turn for support, then enthusiasm and actual use
of an assigned buddy may be diminished. For those who lack
social ties that can serve supportive functions during quitting,
the reverse may be true (i.e., actual use of a buddy may be
greater and perceived as more beneficial). This was the case for
a support group intervention for breast cancer patients in
which only for women who reported lower levels of network
support was the intervention beneficial (Helgeson, Cohen,
Schulz, & Yasko, 2000). The strength or existence, quality, and
type of social bonds of smokers could thus also act as moderators
of the effects of socially supportive interventions involving
peers.
The proportion of smokers in the social network is an ad-
ditional structural support construct shown to be associated
with smoking cessation (Gulliver, Hughes, Solomon, & Dey,
1995). Knowing or seeing others who smoke can influence
norms about smoking, or act as triggers or cues for smoking.
Conversely, however, the proportion of nonsmokers or former
smokers in the social network can provide a form of social pres-
sure to quit. Christakis and Fowler (2008) found that stopping
smoking tended to spread within socially connected networks
such that “people appeared to act under collective pressures
within niches in the network” (p. 2256). It is possible that these
effects occurred as a result of feeling implicit pressure to quit
and/or as a result of smokers’ perceptions of norms about quit-
ting. Also possible, however, is that as the number of former
smokers in a social network grows, there is more dissemination
of knowledge within the network about how to quit (i.e., infor-
mational support). Former smokers may also be able to provide
more valuable emotional support to those considering quitting
or attempting to quit. Thus, the smoking status of social net-
work members may facilitate quitting through social pressure
and norms (Path 8) or by influencing the degree to which emo-
tional or informational support is provided to current smokers
(Path 7). These pathways, however, are only part of any theo-
retical model that attempts to understand how social influences
lead to actual cessation.
Other social influence constructs that overlap with social
support, and that would appear to be important in understanding
Figure 1. Pathways through which social support constructs can influence motivation for and success in quitting smoking.
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Nicotine & Tobacco Research, Volume 12, Number 7 (July 2010)
how others can assist smokers in cessation, are positive and neg-
ative social control. Social control refers to interactions in inter-
personal relationships that involve regulation of another’s
behavior (Umberson, 1987, 1992). Positive social control strat-
egies entail the provision of socially supportive behaviors such
as emotional support (Tucker & Mueller, 2000), rewarding
someone for changing a behavior, pointing to others who have
successfully changed their behavior, or offering to help (Lewis &
Rook, 1999; Tucker, Orlando, Elliott, & Klein, 2006). Negative
social control strategies involve direct pressuring of a person to
change their behavior or behaviors or statements that engender
negative feelings in the recipient such as guilt or anxiety. Re-
search on the effects of social control strategies consistently find
negative social control tactics to be unrelated to health behavior
change (including smoking cessation) and to predict negative
psychological reactions, such as hostility/irritation or sadness/
guilt (Lewis & Rook). The effects of positive social control strat-
egies, however, are less consistent, with studies showing either
positive (Lewis & Rook; Tucker et al.) or null effects on behavior
change (Helgeson, Novak, Lepore, & Eton, 2004; Thorpe, Lewis,
& Sterba, 2008). Although not depicted in Figure 1, positive and
negative social control tactics may influence quitting not only
through their effects on affect (as examined in prior research)
but possibly by influencing motivation to quit as well.
An additional aspect of social support that may be impor-
tant to consider in theoretical models is whether the support is
visible or invisible. Bolger, Zuckerman, and Kessler (2000) have
proposed that receiving support that is visible (or explicit)
threatens self-esteem and increases distress. In contrast, “invisible”
support is theorized to have positive effects on the mood of the
receiver. They provide evidence that “a supportive act is most
effective when it is accomplished either (a) outside of recipients’
awareness or (b) within their awareness but with sufficient sub-
tlety that they do not interpret it as support” (Bolger & Amarel,
2007). The effects of visible versus invisible support has never
been examined in relation to cessation ability but could be ac-
complished by assessing both support providers and smokers
about support provided and received, respectively, and examin-
ing their relationships to negative affect and abstinence. This
perspective may be important for improving predictions of ces-
sation by socially supportive network members as negative
mood is a significant precursor of lapsing (Kassel et al., 2003).
Piasecki and Baker (2001) also discuss the possibility that it
is smokers’ perceptions of support, rather than actual support
received, that predict abstinence (cf., Gulliver et al., 1995; Nides
et al., 1995). According to this view, perceived support may be a
marker of personal traits that allow these individuals to take ad-
vantage of, or benefit from, social ties. Assessing perceived sup-
port at baseline and at follow-ups, in addition to actual support
provided, would help to address this possibility.
The theoretical pathways described above are not meant
to be exhaustive, and some may be bidirectional. Moreover,
the importance of other variables in quitting is understood
though not depicted. For example, cognitive models of health
behavior change emphasize constructs that include the per-
ceived risks of smoking, benefits of quitting, costs or barriers
to quitting, cues to action, and expectations of success in quit-
ting (i.e., self-efficacy; Bandura, 1977). In the context of the
models diagrammed in Figure 1, these would likely influence
motivation to quit and whether an actual quit attempt is
subsequently made.
Moderators and mediators
Moderators or mediators should also be considered when
testing models of how social support influences quitting,
particularly gender. For example, Mermelstein, Hedeker, &
Wong (2003) found that subsequent to a group program for
cessation simply providing support and reinforcement by
telephone improved cessation for women compared with an
enhanced follow-up program. For men, however, the converse
was true. Gender is also relevant to a stress-buffering model of
support, as it is one of several factors that influence the degree to
which social support, specifically emotional support received,
attenuates the intensity of stress responses. For example, in
laboratory studies with nonsmokers, emotional support from
female partners decreases both men’s and women’s stress
responses (Glynn, Christenfeld, & Gerin, 1999; Kirschbaum,
Klauer, Filipp, & Hellhammer, 1995; Lepore et al., 1993), whereas
when the recipient is female and the support provider is male,
no benefits are realized (Glynn et al., 1999; Kirschbaum et al.).
These results suggest that the gender of a smoker and the person
providing support during a quit attempt could potentially influ-
ence perceived stress, coping, and cessation. Further investiga-
tions of this would have implications for buddy or “partner”
support interventions. One recent study in which 77% of sup-
port providers were female buddies who were enlisted to help
a sample of predominantly male smokers quit found that,
although not statistically significant, smokers receiving the
assistance of their female buddies made more quit attempts
and had higher 7-day point prevalence abstinence rates com-
pared with a control group of smokers (Patten et al., 2004).
This study and other research (Westmaas, Wild, & Ferrence,
2002) hint that in studies of self-quitters, female buddies might
be the most effective providers of support for male smokers
attempting to quit.
In addition to gender, other sociodemographic factors such
as race, ethnicity, or age should be considered as moderators in
determining what types of support, stressors, or coping behav-
iors may be most beneficial and for whom. For example, some
racial or ethnic groups might experience different types of stres-
sors more frequently (e.g., discrimination) and that might be
more resistant to the effects of socially supportive interactions.
Personality may be another factor that likely influences the
degree of stress-buffering effects of social support for smokers.
Westmaas and Jamner (2006) found that the higher participants
were in the personality trait of defensiveness, the greater their
blood pressure responses to emotional support provided by
a peer during a stressful task, even though they self-reported
lower negative affect. This indicates that for smokers higher in
defensiveness receiving support could paradoxically decrease
success in quitting if it elicits heightened physiological stress re-
sponses (which can potentially trigger urges and lapsing). Also,
autonomous individuals, because of their increased sensitivity
to potential threats to their autonomy (Clark, Steer, Beck, &
Ross, 1995), may be averse to seeking or receiving social support
and may prefer to rely on their own willpower to help them quit.
In contrast, women who are higher in sociotropy, a more inter-
personal orientation (Clark et al.), may be more accepting of
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Social support in smoking cessation
receiving social support. Social support may be more likely to
mitigate their physiological and emotional responses to inter-
personal stressors. Other individual difference variables have
been shown to moderate appraisals of the availability of sup-
port, the extent to which social support is perceived as benefi-
cial, or the actual effects of support on physiological responses.
These include hostility (Lepore, 1995), attachment style
(Mikulincer, Florian, & Weller, 1993; Mikulincer, Orbach, &
Iavnieli, 1998), or perceived similarity to a potential support
provider (Klohnen & Luo, 2003; Westmaas & Silver, 2006).
Genetic polymorphisms may also potentially identify indi-
viduals who are especially likely to benefit from socially sup-
portive interactions during quitting compared with others. One
possibility is a variant of the 5-HTTLPR genotype that is associ-
ated with both smoking cessation (Munafo, Clark, Johnstone,
Murphy, & Walton, 2004) and vulnerability to depression in
response to stressors (Hoefgen et al., 2005; Jacobs et al., 2006;
Otte, McCaffery, Ali, & Whooley, 2007; Zalsman et al., 2006).
There is also evidence, however, that social support for these
individuals is particularly beneficial (Kaufman et al., 2004).
Also potentially influencing the extent to which others’ sup-
portive behaviors influence variables in the model is the source
of support, for example, whether the supporter is a spouse ver-
sus an assigned buddy in an intervention for smokers. As May
and West (2000) point out, it may be more difficult to develop
or change established relationship patterns, whereas buddies
might benefit from a sense of “common adversity” and can both
be recipients and providers of support. Support provided by
preexisting social ties may persist for longer, however. Still, how
supportive these can be may depend on other aspects of the re-
lationship such as its quality or level of satisfaction.
The time course of support provided or perceived may also
be important (May & West, 2000). Actual support may be most
crucial in the early stages of a quit attempt, when smokers are
most vulnerable to relapse. In later stages, social support con-
cepts may diminish in importance or alternatively, other con-
structs in the model such as perceptions of support availability,
or the proportion of smokers in the network, may take on greater
importance.
Testing the validity of pathways
from social support to quitting
smoking
One approach to examining the validity of theoretical models of
support is to assess the targeted support constructs at appropri-
ate points during the cessation attempts of smokers quitting on
their own. As noted earlier, repeated measurement of support
constructs was absent in the majority of studies reviewed. To
determine for which pathways the evidence is strongest, smok-
ers planning to quit, and who vary in levels of perceived avail-
able support, could be assessed at baseline for their levels of
structural support indices, direct and indirect social control,
motivation to quit, and perceptions of available support (both
general and abstinence specific). Daily diary measures or
ecological momentary assessment (Shiffman, Stone, & Hufford,
2008) could be used to collect smokers’ reports of support re-
ceived from others (emotional, informational, and instrumen-
tal), how peers or a partner attempted to change the smoker’s
behavior, whether the provider’s behavior was perceived as con-
trolling versus autonomous, smokers’ solicitations of support,
perceptions of stress and daily hassles, withdrawal symptoms,
coping, and lapses. Providers’ reports of support delivered
would also help validate smokers’ reports of support received
and could determine whether the visible versus invisible sup-
port idea is relevant to smokers as well. Statistical analyses relat-
ing partner behaviors with actual smoking could also help
determine whether “ironic processes” are operating for some
smokers. Assessment of moderating factors should also be
considered, particularly if the stress-buffering model is being
tested.
Techniques such as SEM could then be used to examine
whether the data are consistent with the hypothesized pathways
of the model(s) being tested. Evidence for stress buffering would
be obtained if for smokers who reported lower levels of per-
ceived or received support, there is a positive association be-
tween stressors and stress responses, whereas for smokers who
reported higher levels of support, the relationship between
stressors and stress responses is lower or not significant. It would
also be potentially valuable to determine whether professional
support for quitting, such as that received from telephone coun-
selors, plays a stress-buffering role in helping smokers quit. Per-
ceiving that a counselor is only a phone call or E-mail away
could conceivably help smokers feel less daunted or stressed by
the difficulties they experience during a quit attempt, which in
turn could increase the likelihood of effective coping. If this
turns out to be the primary mechanism through which individ-
ual counseling increases cessation, then subsequent studies
could be conducted to determine if, for some smokers quitting
on their own, social network members can provide the same
function and produce the same effects on abstinence rates as
counselors (controlling for informational support).
Separately assessing emotional, informational, and instru-
mental support (both general and abstinence specific) could
also help to disentangle the relative effects of each. There is an
implicit assumption in the treatment literature that abstinence-
specific informational support is possibly the most important
aspect of treatment because it informs smokers about what they
need to do to quit. It is possible, however, that at least for some
smokers, emotional support received is equally important as, or
perhaps even more important than, advice received about what
needs to be done. In one study, Zelman, Brandon, Jorenby, and
Baker (1992) found that, for smokers higher in pretreatment
negative affect, social support counseling was superior to skills
training in helping them quit. The opposite was true for smok-
ers lower in pretreatment negative affect. Measuring the differ-
ent conceptions of support can help to disentangle their relative
effects, especially if they differ for different subpopulations of
smokers.
To assess support receipt or provision, some items from the
Partner Interaction Questionnaire, along with other measures
that have assessed what smokers find helpful and unhelpful
(e.g., Coppotelli & Orleans, 1985), could be used. A recent mea-
sure, the Support Interview (Thomas, Patten, Offord, & Decker,
2004), could be adapted for this purpose. The scale was designed
to assess a person’s provision of supportive behaviors to a
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smoker. The authors based their items on behaviors that smokers
perceived to be helpful in prior studies, specifically “praise for
the smoker’s efforts at quitting, encouraging rewards, minimizing
stress by avoiding interpersonal conflict and taking over some of
the smoker’s responsibilities, providing information, showing
empathy and concern, tolerating moodiness, and offering general
problem-solving advice.” These behaviors obviously encompass
all three functions of support and a measure that includes items
addressing each of them also has the potential to discern the rela-
tive importance of support functions in facilitating abstinence.
For measures of other support constructs such as social in-
tegration, and direct and indirect social control, investigators
could adapt measures used in other disciplines. For example,
there are several measures that assess structural features of so-
cial networks, such as size and density (Cohen et al., 2000).
Measures pertaining to social control of behaviors have also
been developed (Lewis, Butterfield, Darbes, & Johnston-Brooks,
2004). Including all these measures in social support studies
would help identify the most important support constructs for
understanding how others help smokers quit.
If the underlying mechanisms between social support
constructs and cessation are validated by research such as that
described above, interventions that aim to change levels of in-
tervening variables through social interactions can be designed.
Repeated measurements of variables relevant to the model, as
well as possible moderators, would help to determine why or
why not the intervention succeeded. The methodological limi-
tations inherent in prior studies of social support’s effects should
also be addressed. The results of such research may also point
to strategies that could be used to further enhance the efficacy of
cessation support provided by professionals such as quitline
counselors.
Conclusions
Although the ability of smokers to quit is undoubtedly influ-
enced to some degree by community-level or population-level
factors (e.g., smoking restrictions, advertising, culture), many
smokers have been helped in quitting by receiving social sup-
port through quitlines, group behavioral therapy, or individual
counseling. These treatments clearly provide high levels of emo-
tional, informational, and instrumental support even though
they are not explicitly referred to as socially supportive inter-
ventions. In apparent contradiction to these beneficial, support-
ive treatments are studies finding no differences in quit rates
between smokers in socially supportive-enhanced treatments.
The current paper argues that for research on the relevance of
peer or partner social support in smoking cessation to advance,
theoretical models need to be developed and tested. The roles
that social support constructs may play in facilitating cessation
were presented, including a stress-buffering perspective. Identi-
fying and assessing potential mediators and moderators of rela-
tionships specified in the models could provide an even more
informative account of why a particular function or dimension
of social support is effective and for whom it is effective.
Increasingly, social support for health behavior change is
being provided by Internet and electronic technologies (e.g.,
text messaging, E-mail, social networking; Portnoy, Scott-Sheldon,
Johnson, & Carey, 2008). Electronic technologies can also
increase assessment capabilities (e.g., ecological momentary
assessment), which can be used to validate theoretical models of
how social support constructs are involved in quitting smoking.
This can lead to further refining and testing of theories and the
ability to develop tailored cessation treatments based on a smok-
er’s personal profile. Tailored treatment would aim to provide the
optimal type, timing, and amount of social support for a particu-
lar individual. These treatments can easily be delivered at the
population level using the same advances in electronic technology
described above, particularly for young adults (Ling & Glantz,
2004). With new technologies and advances in understanding
how social support influences smoking cessation, the potential to
further reduce morbidity and mortality from smoking is great.
Funding
American Cancer Society.
Declaration of Interests
None declared.
Acknowledgments
The authors thank Dr. Peter S. Hendricks and anonymous
reviewers for their helpful comments on earlier drafts of this
manuscript.
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