Exploring Stupidity: Smoking and Human Behavior

1. Why do we do stupid things ... like smoking for example?And what's to be done about it? Robert West University College London September 2012

2. Aims To use observations on cigarette smoking to show how a ‘synthetic model’ (COM-B+PRIME) can explain diverse features of human behaviour and guide interventions to help us act more ‘rationally’

3. Outline • What is stupidity and in what way is smoking stupid? • Observations about cigarette smoking and models of behaviour • Application of the synthetic (COM-B+PRIME) model

4. Outline • What is stupidity and in what way is smoking stupid? • Observations about cigarette smoking and models of behaviour • Application of the synthetic (COM-B+PRIME) model

5. What is stupidity? • Acting • in a way that has a significant risk of causing harm or fails to take advantage of an opportunity • when an unbiased cost-benefit analysis taking account of the relevant information using one’s own values and preferences • leads, or would have led, to a different course of action

6. Put another way I wonder what would happen if I put my head in

7. Why is smoking mostly stupid? Most smokers ... • lose around 6 hours of life expectancy each day that they smoke • rate their health at a level equivalent to someone 10 years older • report that they do not enjoy smoking • report higher levels of stress than non-smokers and when they stop average stress levels reduce • want to stop and try many times • and carry on smoking

8. Outline • What is stupidity and in what way is smoking stupid? • Observations about cigarette smoking and models of behaviour • Application of the synthetic (COM-B+PRIME) model

9. Laws, models and theories • Laws express generalisations • E=mc2 • Thorndyke’s Law of Effect • Models represent structures and the relationships between their elements • The double helix structure of DNA • Theory of Planned Behaviour • Theories provide explanations for things • Atomic theory • Homeostatic drive theory

10. Observation and theory • With regard to explanation a theory can: • provide a simple or complex explanation • provide a coherent or incoherent explanation • fail to provide an explanation • With regard to prediction a theory can: • be agnostic • make an accurate or inaccurate prediction

11. In a given domain, a better theory ... • Explains more relevant observations • Uses fewer concepts • Gives a wider range of, and/or more accurate, predictions • Is easier to understand and use

12. In the field of behaviour change We want theories that: • explain patterns of behaviour and how these change in populations and individuals • help develop more effective intervention strategies and design more effective specific interventions than can be achieved using ‘common sense’

13. Ten theoretical traditions • Decision theory (e.g. Savage, Janis) • Learning theory (e.g. Skinner) • Habit theory (e.g. Hull) • Drive theory (e.g. Hull) • Personality theory (e.g. Eysenck) • Identity theory (e.g. Tajfel) • Marketing theory (e.g. Borden) • Imitation theory (e.g. Heyes) • Social influence theory (e.g. Moscovici) • Dual process models (e.g. Strack and Deutsch)

14. A primer on the psychopharmacology of smoking Rapid transport to the brain’s ventral tegmental area where nicotine attaches to acetylcholine receptors Nicotine absorbed through large surface area of the lungs Puff on cigarette This activates neural pathway leading to dopamine release in nucleus accumbens West (2009) COPD, 6, 277-283

15. Decision theory • Expectancy-value models: • e.g. Choose the option with the highest ‘expected utility’ • Multi-attribute utility models • e.g. Choose option with the best utility-weighted attributes • Procedural models • e.g. Choose option according to set of IF-THEN rules

16. Knowledge and smoking • Smoking prevalence declined steeply when smokers became aware of the health risks Royal College of Physicians Report

17. Price and smoking • Many smokers and potential-smokers choose not to smoke or smoke less when it becomes more costly

18. Predictors of quit attempts • Concern about cost and belief that one could be harmed, or are being harmed are important predictors of quit attempts1 1West et al (2012) www.smokinginengland.info

19. Learning theory • A given response is made more or less likely when it is followed by particular types of stimulus termed positive and negative reinforcers

20. Effectiveness of medications to aid cessation • Better pharmacological blockade of nicotine’s positive reinforcing value is associated with greater efficacy in aiding smoking cessation1 1West et al (2008) Psychopharmacology

21. Habit theory • Repeated enactment of a given behaviour in a given context increases the likelihood that the behaviour will occur in that context without the need for a consciously formulated goal

22. Habit and smoking • Many smokers ‘automatically’ light up a cigarette in response to particular situations without thinking about why they are doing it Automatic subscale of the SMQ1 I light up a cigarette without realising I still have one burning in the ashtray I smoke automatically without thinking about it I find myself smoking without remembering lighting up 1West et al (1985) Psychopharmacology

23. Dependence in non-daily smokers and cue driven urges • Even non-daily smokers experience ‘urges’ to smoke in particular situations and have a low probability of success when they try to stop1 65% failed in their most recent quit attempt within 6 months 1Kotz et al (2012) Addiction

24. Short-term effect of smoke-free legislation • Smoke-free legislation was followed by a sharp decline in smoking prevalence until the recession hit West et al (2012) www.smokinginengland.info

25. Smoke-free and quitting • It was not due to an increase in quit attempts West et al (2012) www.smokinginengland.info

26. Smoke-free and quitting • It appears to have been due to an increase in success of quit attempts West et al (2012) www.smokinginengland.info

27. Drive theory • The brain generates subjective needs in response to ‘biologically’ driven imperatives which then generate behaviours to reduce that need

28. The time course of urges to smoke • Urges to smoke increase during abstinence then decline logarithmically, consistent with an acquired drive1 1Ussher et al (In press) Psychopharmacology

29. Effect of glucose on urges to smoke • Glucose tablets reduce urges to smoke in abstaining smokers compared with low calorie sweet1 * Desire for a cigarette *p<0.001 for time x group interaction 1West et al (1999) Psychopharmacology

30. Effect of nicotine products on urges to smoke • Nicotine products reduce urges to smoke without providing positive pleasure or satisfaction1 1West et al (2001) Psychopharmacology

31. Effectiveness of different medication types West et al (In Preparation) Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

32. Effectiveness of different forms of NRT West et al (In Preparation) Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

33. Different ways of using NRT West et al (In Preparation) Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

34. Self-control theory • Self-conscious control of behaviour requires formulation of a plan or personal rule that has sufficient motivational force when relevant to overcome sources of motivation arising from habits, drives and emotion. This requires and depletes mental energy.

35. Breath-holding and success • Smokers who give in earlier when trying to hold their breath are less likely to succeed in stopping smoking1 Abstract A pre-treatment test of breath-holding endurance predicted end-of-treatment outcome in 56 Smokers Clinic clients (r = .44; p less than .001). The cut off points derived by discriminant analysis were 32 seconds for men and 20 seconds for women, which correctly classified 78.6% of cases ... 1Hajek et al (1987) Addictive Behaviors

36. Predictors of success • A cessation attempt made soon after a failed attempt is less likely to succeed1 N=9,847 1West et al (2012) www.smokinginengland.info

37. Predictors of success • Quit attempts made abruptly rather than gradually are more likely to be successful1 N=9,847 1West et al (2012) www.smokinginengland.info

38. Personality theory • Individuals differ in a number of relatively stable traits relating to their emotional reactions, thought processes and action tendencies and these differences account for a wide range of differences in behavioural responses

39. Personality factors and uptake and maintenance of smoking • Pre-disposition to sensation seeking, impulsivity and anti-social motivation are positively predictive of taking up smoking

40. Identity theory • We form thoughts, images and feelings relating to ourselves which shape our behaviour

41. Identity and smoking • Positive smoker identity is an important predictor of not trying to quit, over and above other smoking motives

42. Marketing theory: The marketing mix • Consumers will buy goods and services to the extent that, and at a time when, they feel they want or need them as long as it is easy and the price is right Product Promotion Place Price

43. Key events and cessation • Cessation attempts are triggered by significant event: New Year and No Smoking Day1 1Kotz et al (2012) Tobacco Control

44. Ad campaigns and cessation activity West et al (2010) All Party Parliamentary Group report

45. Imitation theory • We often imitate behaviours that we observe without necessarily realising that we are doing it

46. Imitation and smoking • Smokers tend to light up when others light up, other things being equal1 1Harakeh et al (2012) Drug and Alcohol Dependence

47. Social influence theory • Individuals influence each other’s behaviour reciprocally through a numbers of active and passive mechanisms, including identification, persuasion, and imitation.

48. Social influence theory and smoking cessation • Smokers tend to stop in clusters and continuing smokers find themselves in the periphery of social networks1 1Christiakis et al (2008) NEJM

49. Outline • What is stupidity and in what way is smoking stupid? • Observations about cigarette smoking and models of behaviour • Application of the synthetic (COM-B+PRIME) model

50. A synthetic model Aims to provide • a more comprehensive model of behaviour within which existing models can be understood and compared • a basis for improving existing models • a rational basis for the design of interventions to change behaviour