Le tabagisme demeure la première cause évitable de mortalité prématurée dans le monde. Malgré des politiques publiques efficaces et la diffusion des traitements de substitution nicotinique, la prévalence du tabac se stabilise, notamment parmi les populations à vulnérabilité psychiatrique. Cette persistance traduit la complexité d’un comportement à la fois biologique, psychologique et social. Cet article propose une analyse intégrative des alternatives au tabac combustible (cigarettes électroniques, tabac chauffé, produits nicotiniques oraux) et des modèles de changement comportemental applicables au sevrage tabagique. En s’appuyant sur les données récentes de la littérature internationale, il discute la place des thérapies comportementales et cognitives (TCC), les mécanismes motivationnels et émotionnels du changement, et les perspectives d’une approche globale centrée sur l’engagement durable plutôt que sur le seul contrôle du comportement. Une attention particulière est accordée aux enjeux éthiques pour la psychiatrie contemporaine : concilier autonomie du patient, réduction des risques et responsabilité du clinicien. L’objectif est de replacer le fumeur au cœur du processus de soin, en favorisant la transformation du rapport à la dépendance dans une dynamique de sens et d’émancipation.

Tobacco use remains the leading preventable cause of premature mortality worldwide, accounting for more than eight million deaths annually, including over one million attributable to second-hand smoke exposure. Despite decades of public health policies, regulatory measures, taxation strategies, and the widespread availability of pharmacological nicotine replacement therapies, smoking prevalence has reached a plateau in many industrialized countries, particularly among socioeconomically disadvantaged groups and individuals with psychiatric comorbidities. This epidemiological stability highlights the limits of purely regulatory and biomedical approaches and calls for a deeper understanding of smoking as a complex biopsychosocial behavior embedded in cognitive, emotional, social, and identity-related processes. This article proposes an integrative and clinically oriented analysis of contemporary alternatives to combustible cigarettes – namely electronic cigarettes, heated tobacco products, and oral nicotine delivery systems – and examines their role within broader models of behavioral change applicable to smoking cessation. Rather than framing these alternatives exclusively as technological substitutes, the paper situates them within a harm-reduction and behavioral transition paradigm, where gradual disengagement from combustion may represent a pragmatic and clinically meaningful step for highly dependent smokers who repeatedly fail with traditional cessation strategies. Drawing on recent international literature, the article reviews evidence regarding the relative risks and cessation efficacy of alternative nicotine products. Electronic cigarettes, in particular, appear to significantly increase abstinence rates compared with conventional nicotine replacement therapies, largely due to their ability to address both pharmacological dependence and behavioral conditioning associated with smoking rituals. However, uncertainties remain regarding long-term safety, sustained nicotine dependence, and potential risks of initiation among non-smoking adolescents, emphasizing the need for careful clinical guidance and regulatory oversight. Heated tobacco products and oral nicotine pouches are also discussed as emerging tools whose risk profiles are lower than combustible tobacco but not negligible, and whose public health impact depends largely on patterns of use, substitution versus dual consumption, and accessibility among vulnerable populations. Beyond product-based considerations, the article focuses on psychological models of behavior change that help explain why smoking persists despite high levels of risk awareness. Classical rational decision-making models, such as the Health Belief Model and the Theory of Planned Behavior, are reviewed and contrasted with dual-process theories that distinguish reflective intentions from automatic habits driven by emotional and contextual cues. Smoking behavior is shown to rely heavily on conditioned responses, affect regulation, and environmental triggers, which limits the effectiveness of interventions based solely on information or fear-based messaging. The transtheoretical model of change is examined as an early attempt to conceptualize smoking cessation as a dynamic process rather than a single decision point. While useful for tailoring interventions to motivational stages, its predictive value remains limited. The paper therefore emphasizes more recent approaches derived from motivational psychology and social psychology, particularly self-determination theory and commitment theory, which highlight the central role of autonomy, perceived competence, and active engagement in sustaining long-term behavior change. Within this framework, Cognitive and Behavioral Therapies (CBT) are presented as a cornerstone of effective smoking cessation interventions. CBT conceptualizes tobacco dependence as a learned behavior maintained by dysfunctional beliefs, emotional regulation deficits, and maladaptive coping strategies. Interventions target automatic thoughts, core beliefs, and situational triggers while promoting alternative behavioral responses and strengthening self-efficacy. Empirical evidence indicates that CBT significantly improves long-term abstinence rates, especially when combined with pharmacological support and structured relapse prevention strategies. The article further integrates so-called “third-wave” CBT approaches, including mindfulness-based interventions and Acceptance and Commitment Therapy (ACT), which shift the therapeutic focus from symptom suppression to psychological flexibility and values-based action. These approaches help smokers develop tolerance to craving and negative affect without resorting to avoidance through smoking, thereby reducing relapse vulnerability. Acceptance of internal experiences, cognitive defusion, and commitment to personally meaningful goals emerge as key mechanisms supporting durable change. Emotional determinants of smoking behavior are analyzed in depth, particularly the role of negative reinforcement, stress reactivity, and affective dysregulation. Neurobiological models of addiction demonstrate that nicotine modulates reward and stress circuits, creating a strong association between smoking and emotional relief. During cessation attempts, heightened emotional reactivity and perceived stress frequently precipitate relapse. Consequently, emotional regulation skills, mindfulness practices, and stress-management techniques are presented as essential components of comprehensive cessation programs. Motivational processes are equally critical. External pressures such as medical advice or social stigma may trigger quit attempts but rarely sustain long-term abstinence unless internalized and aligned with personal values. The transition from extrinsic to intrinsic motivation is therefore considered a central therapeutic objective. Motivational interviewing techniques are highlighted for their ability to resolve ambivalence, enhance self-directed change talk, and support patients’ sense of agency. Ethical considerations are explicitly addressed, particularly within psychiatric populations where smoking prevalence is substantially higher and cessation is often deprioritized. Clinicians face the challenge of balancing harm reduction, patient autonomy, and professional responsibility. A rigid abstinence-only approach may inadvertently marginalize highly dependent smokers, whereas a guided transition using alternative nicotine products, embedded within a structured psychotherapeutic framework, may offer a more realistic and compassionate path toward reduced harm and eventual cessation. Ultimately, the article advocates for a shift from control-based public health paradigms toward engagement-based clinical strategies. Rather than viewing smoking cessation as a matter of compliance with medical advice, the proposed model emphasizes progressive self-engagement, identity transformation, and reconstruction of personal meaning. Behavioral micro-commitments, feedback mechanisms, social support, and digital monitoring tools are discussed as practical methods to reinforce engagement and consolidate new health-related identities. In conclusion, sustainable smoking cessation cannot be achieved through pharmacology or regulation alone. It requires an integrative clinical approach that addresses neurobiological dependence, cognitive distortions, emotional regulation, motivational dynamics, and social context. Alternatives to combustible tobacco may serve as transitional tools within this broader therapeutic process, but lasting change ultimately depends on psychological transformation and autonomous commitment. Psychiatry, situated at the intersection of behavioral science and clinical medicine, is uniquely positioned to lead this integrative model of tobacco dependence treatment, promoting not only abstinence but also long-term recovery of autonomy and well-being.