Treatment of people who use tobacco is different. Most treatments given to patients are reasonably successful, but cigarette smokers who are trying to quit will make multiple attempts before they remain abstinent, sometimes as many as twenty. Within hours of stopping, nicotine users can begin to experience withdrawal symptoms which include craving, anxiety, irritability, and restlessness that continue to increase and can rapidly be relieved by another cigarette.
Some people trying to quit use pharmacotherapy to reduce the withdrawal symptoms and allow them to learn how to cope without nicotine. Even then, the stress of major life events or even minor aggravations can induce the craving for a cigarette. The social use of cigarettes provides environmental cues that increase relapse risk. This cycle of quit attempts and relapses can weigh heavily on many individuals and instill a degree of pessimism toward future quit attempts.
Over successive attempts, a smoker may internalize the belief that “nothing I do changes the outcome.” This is the core principle of learned helplessness: withdrawal of effort following repeated experiences interpreted as failure.
The origins of learned helplessness
Martin Seligman developed the concept of learned helplessness, showing that animals exposed to inescapable stressors later failed to escape even when escape was possible; they had learned that their actions did not matter. Several foundational studies used canine models. (These studies would face substantial ethical scrutiny with today’s greater concern for animal welfare in scientific investigations.)
This framework was expanded to humans with the suggestion that people do not just learn that outcomes are uncontrollable; they develop explanatory styles, habitual ways of interpreting failure. When failures are attributed to causes that feel internal, helplessness and depressive affect are more likely to generalize across situations. Behaviorally, it presents as withdrawal and reduced effort; cognitively, as the belief that action will not alter outcomes; emotionally, as discouragement or loss of hope.
Seligman and colleagues observed the similarities between learned helplessness and depression. The animals exhibited passivity, reduced motivation, and cognitive deficits in acquiring new escape strategies. These behaviors resembled the psychomotor retardation seen in severe depression. Seligman then tested the effect of medications used for the treatment of depression. Animals treated with antidepressants were restored to near normal ability to escape.
Interestingly, the prevalence of tobacco use among people with depression is double that of the general population. The rate of relapse is also doubled, as some patients may find it easy to self-medicate with nicotine. It should come as no surprise that some antidepressant medications (bupropion and nortriptyline) have been approved for the treatment of tobacco.
The power of self-efficacy
The flip side of learned helplessness is self-efficacy. Self-efficacy is a psychological construct defined by Albert Bandura as: “An individual’s belief in their capability to organize and execute the actions required to manage prospective situations.” It is not a measure of general confidence or skill; rather, it is a task-specific belief about one’s ability to perform a behavior under particular conditions. In many ways, self-efficacy and learned helplessness are conceptual opposites:
| Learned helplessness | Self-efficacy |
|---|---|
| Actions do not matter | Actions influence outcomes |
| Stable, global failure attributions | Specific, controllable attributions |
| Passivity | Persistence |
| Avoidance of attempts | Increased initiation |
In tobacco treatment, repeated quit attempts without behavioral support lower self-efficacy. Treatment delivered by trained counselors in structured settings, combined with systematic follow-up, can enhance self-efficacy. Medications approved for the treatment of tobacco can double the success rate of such interventions. Many tobacco users have been able to stop for significant periods of time but can relapse after a major life stress event. They may need to be reminded that they have quit in the past and can quit again, but they need to learn how to prevent relapses.
Discussions of learned helplessness and self-efficacy do not fully explain all the challenges in treating tobacco, but they certainly provide a framework for understanding the role of repeated failure in the mind of the patient who continues to use nicotine.
Organizational self-efficacy and systemic change
The repeated failures also have an impact on clinicians. Only 8 percent of quit attempts each year are successful, which would mean that most patients treated for tobacco use will fail. Is it any wonder that studies of physician performance in tobacco treatment show many missed opportunities? Clinical practice guidelines for the treatment of tobacco were first issued in 1996 and updated in 2008 and have been widely endorsed by professional societies. They detail evidence-based interventions that can be provided to every tobacco user at every clinic visit. Studies of medical claims or electronic medical records show wide variation in treatment rates, but the overall performance remains poor.
The pessimism regarding treatment of tobacco extends to medical clinics, health systems, and even health insurers. Why should clinicians spend their valuable time providing treatment that fails most of the time? Extrapolating from the experience of their clinicians, medical group practices and health systems can develop low organizational self-efficacy regarding tobacco treatment. Few health systems and health insurers have prioritized tobacco treatment or even measure performance. The standout exception is Kaiser Permanente of Northern California.
In the initial studies of learned helplessness in dogs, the animals conditioned to helplessness had to be physically guided to the safe side of their cages when escape was possible. Learned helplessness can be unlearned. Just as counseling and medication can help a patient reframe their past quit attempts into successful quitting, the growing literature on systems change strategies can help clinicians and health systems develop a sense of self-efficacy.
Edward Anselm is a board-certified internist with a long-standing focus on public health, tobacco control, and preventive care. He earned his medical degree from the Chicago Medical School at Rosalind Franklin University and completed his internal medicine residency at Montefiore Medical Center in New York. Over the past three decades, Dr. Anselm has served in senior leadership roles across clinical, corporate, and managed-care settings, including chief medical officer positions at HIP Health Plan of New York, FidelisCare, and Health Republic Insurance of New York.
Recently retired from his role as medical director at Aetna, Dr. Anselm continues to teach at the Icahn School of Medicine at Mount Sinai as a clinical assistant professor. His current work focuses on strengthening reimbursement pathways for tobacco cessation and preventive services, helping clinicians integrate evidence-based care that improves patient outcomes while supporting practice sustainability. His research has been published in the American Journal of Accountable Care, the American Journal of Preventive Medicine, AJPM Focus, and Health Affairs Forefront, including articles on tobacco control in accountable care, underbilling of cessation services, and the financial and quality benefits of treating tobacco use as a clinical priority.
Dr. Anselm’s educational and policy work is shared through EdwardAnselmMD.com and The Anselm Nicotine Prescription, with professional updates available on LinkedIn.
