Smokers’ Understandings of Addiction to Nicotine and Tobacco: A Systematic Review and Interpretive Synthesis of Quantitative and Qualitative Research

Daniel Pfeffer, Britta Wigginton, Coral Gartner, Kylie Morphett

Despite the centrality of addiction in academic accounts of smoking, there is little research on smokers' beliefs about addiction to smoking, and the role of nicotine in tobacco dependence. Smokers' perspectives on nicotine's role in addiction are important given the increasing prevalence of non-tobacco nicotine products such as e-cigarettes. We conducted a systematic review of studies investigating smokers' understandings and lay beliefs about addiction to smoking and nicotine. We searched PubMed, Embase, CINAHL and PsycINFO for studies investigating lay beliefs about addiction to smoking. Twenty two quantitative and 24 qualitative studies met inclusion criteria. Critical interpretive synthesis was used to analyse the results. Very few studies asked about addiction to nicotine. Quantitative studies that asked about addiction to smoking showed that most smokers believe that cigarettes are an addictive product, and that they are addicted to smoking. Across qualitative studies, nicotine was not often mentioned by participants. Addiction to smoking was most often characterised as a feeling of "need" for cigarettes resulting from an interplay between physical, mental and social processes. Overall, we found that understandings of smoking were more consistent with the biopsychosocial model of addiction than with more recent models that emphasise the biological aspects of addiction. Researchers should not treat perceptions of addiction to smoking interchangeably with perceptions of addiction to nicotine. More research on lay beliefs about nicotine is required, particularly considering the increasing use of e-cigarettes and their potential for long-term nicotine maintenance for harm reduction.