Risk Factors

Risk Factors and Social Determinants of Tobacco Use

The Three-Link Chain of Tobacco Dependence

The causes of tobacco dependence are complex, and differ from person to person. The Three-link Chain is a model that provides an understanding of the complex interplay of biological, psychological, and sociocultural factors that contribute to tobacco dependence.

Biological Factors:

  • Tobacco use results in drug dependence on nicotine, comparable to the dependence caused by heroin, speed, and cocaine.
  • Nicotine affects essential brain structures associated with reward and arousal, which persist long after an individual stops using tobacco.
  • The addictive powers of nicotine may strengthen the learned behaviors that form tobacco-use patterns and make users more resistant to change.
  • Withdrawal symptoms, including depressed mood, insomnia, irritability, anxiety, difficulty concentration, restlessness, decreased heart rate, and increased appetite or weight gain, are associated with both abrupt cessation and reduction in tobacco use. Withdrawal symptoms are severe within the first two weeks, but may recur in the form of cravings for months or even years.

Psychological Factors:

  • Reinforced conditioned drug-taking behavior is thought to be central to the concept of addiction.
  • Tobacco products are often used out of habit; lighting up or dipping may become an automatic behavior.
  • Tobacco is used as a coping mechanism to handle stress, loneliness, boredom, happiness, or anger.
  • Nicotine may be used to self-medicate underlying problems such as depression, anxiety, stress, or Attention Deficit Disorder.

Sociocultural Factors:

  • Tobacco may be a part of identifying with a group, or a regular part of social activities or cultural practices.
  • Tobacco use becomes a part of many daily activities and rituals.

Social Determinants of Tobacco Use

Tobacco use, like other risk factors for poor health and chronic diseases, is impacted by the social determinants of health. Population health outcomes related to tobacco use depend on improving many of the fundamental social determinants of health, including:

  1. Educational opportunities;
  2. Low income/poverty;
  3. Limited access to health services and supports, including insurance;
  4. Gender and gender identity;
  5. Sexual orientation;
  6. Racism and historical targeting;
  7. Culture and language;
  8. Physical environments, such as community, housing and work environments; and
  9. Social stressors and limited social support.

Understanding and addressing the nuances of how social determinants and social factors (as well as stigma) lead to the creation and persistence of tobacco use disparities is an important focus of tobacco prevention and control efforts.


Hawaii Department of Health and Hawaii Community Foundation (2006). Basic Tobacco Intervention Skills Certification Guidebook.

Tobacco Use Prevention & Control in Hawaii. A Strategic Plan for the State 2011-2016. Click Here.