Theory and practice of helping people change their behaviour: the case of smoking cessation

Theory and practice of helping people change their behaviour: the case ofsmoking cessation Robert West University College London 2010

Outline • Behaviour as part of a system • Motivation and behaviour change • Helping smokers to stop

The ‘behaviour system’ Capability Behaviour Motivation Opportunity

The ‘behaviour system’ Capability Physical and mental ability: changeable by education, training, enablement/resources Behaviour Motivation Values, desires and habits: changeable by education, persuasion, inducement, punishment, stimulus control Opportunity Physical and psychological/social availability: changeable by restrictions, education, persuasion, enablement/resources

Policy options • Mass media communication • Environmental restructuring • Fiscal measures • Legislation • Service provision • Regulation • Guidelines

Physical Capability Emot/ Habit Psych Motivation Psych/social Rational d-m Physical Opportunity The Behaviour Change Wheel Behavioural targets Service provision Intervention Options Regulation Training Education Policy Options Fiscal Restriction Persuasion Environmental restructuring Coercion Inducement (incentives/rewards) Legislation Stimulus control Enablement/ resources Guidelines Mass media Michie & West, 2010

The structure of human motivation

The structure of human motivation Lighting up a cigarette Taking a puff on a cigarette Saying no to offer of a cigarette • Starting, stopping or modifying actions • Generated by the strongest of competing impulses and inhibitions at that moment

The structure of human motivation • Impulses and inhibitions: patterns of activation in CNS pathways that organise and impel or block specific actions • Formed from strongest of competing learned and unlearned stimulus-impulse associations • Motives are important triggering stimuli • Impulses are experienced as urges when blocked • Vary in strength Impulse to light up a cigarette Inhibition of impulse to light up

The structure of human motivation Want to smoke Need a cigarette Want to stop smoking • Feelings of desire or attraction or repulsion in relation to something that is imagined • Want: anticipated pleasure or satisfaction • Need: anticipated relief from mental or physical discomfort • Formed when stimulus generates image to which past experience has associated positive or negative feelings • Can vary in strength

The structure of human motivation • Beliefs (internalised statements) that something is good or bad • Formed from acceptance of communication or when stimulus triggers recall of plans, memory of beliefs, plans, wants and needs, or inference • Must generate motive (want or need) to influence behaviour • Can vary in strength of adherence, ambivalence, extremity, valence Smoking is harming my health and costing me a lot of money I ought to stop smoking

The structure of human motivation • Self-conscious intentions to behave in a particular way (personal rule) or perform an action (one-off plan) in the future • Formed when positive evaluation of action outweighs negative one • Must be remembered and generate positive evaluation to be enacted • Can vary in: commitment, starting conditions, specificity One off: I will stop smoking tomorrow Personal rule: I will not smoke

Controlling purposeful behaviour • We act in pursuit of what we most desire (want or need) at every moment • Beliefs about what is good or bad and prior intentions can only influence behaviour if they generate sufficiently strong desire at the key moments • Behaviour is under the continuous control of stimuli that generate desires which have been shaped by prior associations with positive and negative feelings • Control over behaviour involves making and breaking associations and controlling the triggering stimuli • This includes triggering plans and shaping plans so that they generate strong desires

Identity, rules and self-control • We can form mental representations of ourselves (identities) which are an important source of desires • A major part of our identity involves ‘personal rules’ (types of plan) • Self-control involves domination of desires arising from personal rules • Failure of self control arises when desires arising from personal rules (‘oughts’) are insufficient

Routes to behaviour change • Deliberate • change in personal rules • Non-deliberate • change in • opportunity • capability • emotional responses or habits

The process of deliberate behaviour change SNAP: 4 states based on the rules smokers apply to themselves • Starts with is a rule in which person defines him/herself as • attempting (‘I am trying to change’) • engaging in the new behaviour (‘I have changed’) • People plan a change attempt when • the feeling of ‘want’ or ‘need’ to change at a future date exceeds the desire to continue • People make a change attempt when • the want or need to change now exceeds the want or need to carry on • People lapse when • the want or need to revert at a given moment exceeds the want or need to stick to the rule • the rule is still in force • People relapse when • the want or need to abandon the change attempt exceeds the want or need to continue with it Stay with old beh Pre-quit Planning Attempting New behaviour Post-quit

SNAP versus ‘Stages of Change’

Features of smoking cessation • Smokers who seek help already want to stop and are mostly willing to set a quit date after which they will stop completely • The major barriers for them are probably: • powerful urges arising from the way nicotine acts on the motivational system • unpleasant mood and physical withdrawal symptoms • lack of alternative sources of reward • many opportunities for lapse • lack of immediate negative consequences of lapse

Helping smokers to stop • Combination of • behavioural support • medication • Together there is strong evidence that this increases chances of success by 300% • It is available throughout the UK, free on the NHS

Behavioural support • Advice, proposed activities, discussion and encouragement aimed at helping people to achieve lasting change in behaviour patterns • Includes a number of ‘behaviour change techniques’ (BCTs) aimed at • reducing the motivation to engage in undesired behaviour and increasing the motivation to engage in desired behaviour • increasing the capacity for self-regulation • increasing effective adoption of adjunctive activities • supporting the above

Classification of BCTs by function

Data from English Stop Smoking Services: West et al (In press) • 37 services provided treatment manuals and data • coded for number of times mentioned each of a number of behaviour change techniques (BCTs): using taxonomy developed by Susan Michie • likelihood of a smoker achieving 4-week CO-verified abstinence as recorded by the service was predicted by exposure to each of the BCTs using logistic regression • N=177,064 smokers • Looked at significant associations between number of time BCT cited in manual and 4-week success rate by both self-report only and CO-verified self-report

BCTs associated with higher success rates: motivation • Measure CO • Strengthen ex-smoker identity • Provide ‘rewards’ (usually praise or tokens of success) contingent on successfully stopping smoking

BCTs associated with higher success rates: self-regulation • Advise on changing routine • Facilitate relapse prevention and coping planning

BCTs associated with higher success rates: adjuvant activities • Advise on stop smoking medication • Ask about experiences of stop smoking medication that the smoker is taking • Give options of additional or later support

BCTs associated with higher success rates: supportive actions • Elicit client views

Summary • Behaviour can be usefully viewed as part of a system in which there are possibilities for change in: capability, motivation and opportunity • Intervention and policy options can be mapped on to this system • Motivation is particularly important in many areas and it is important to recognise that the target is typically control of momentary desires • Deliberate behaviour change involves establishing personal rules that generate momentary desires that have sufficient force to overcome strong competing desires • Analysis of the data from the English Stop Smoking Services suggests particular behaviour change techniques that, in that context, are associated with greater effectiveness

Theory and practice of helping people change their behaviour: the case of smoking cessation