Behaviour change and tobacco use: from theory to practice

1. Behaviour change and tobacco use: from theory to practice Robert West University College London May 2012

2. Topics • 9:35-30:30 Understanding behaviour • COM-B and PRIME • 11:00-12:00 Helping people change • The BCW and BCTs • 12:00-12:30 Tobacco addiction • what it is and how to help people get over it • 13:30-16:00 Clinical experience • what is being done and how it can be improved • 16:00-16:30 Conclusions • key ‘take-home’ messages and evaluation

3. Topics • 9:35-30:30 Understanding behaviour • COM-B and PRIME • 11:00-12:00 Helping people change • The BCW and BCTs • 12:00-12:30 Tobacco addiction • what it is and how to help people get over it • 13:30-16:00 Clinical experience • what is being done and how it can be improved • 16:00-16:30 Conclusions • key ‘take-home’ messages and evaluation

4. Understanding behaviour For a behaviour to occur at a given time on a given occasion we must: • be able to do it • have the opportunity to do it • have stronger motivation to do it than not to, or to do something else

5. The COM-B Model Michie S, M van Stralen, West R(2011) The Behaviour Change Wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6, 42.

6. The COM-B Model Does the person have the physical or psychological ability to engage in the behaviour?

7. Capability • Physical • anatomy and physiology • physical skills, strength, speed and stamina (4Ss) • Psychological • knowledge and understanding • mental skills, strength, speed and stamina (4Ss)

8. The COM-B Model Does the person have the physical or social opportunity to engage in the behaviour?

9. Opportunity • Physical opportunity • physical and financial access • prompts and cues • Social opportunity • language and concepts • social rules and laws

10. The COM-B Model Will the person’s plans, beliefs, desires and impulses drive the behaviour more than a competing behaviour?

11. Motivation • Reflective • plans (self-conscious intentions) • evaluations (beliefs about what is good and bad) • Automatic • desires (wants and needs) • instincts and habits (unlearned and learned impulses)

12. Focus on motivation • All those brain processes that energise and direct our behaviour • Includes: • automatic impulses e.g. to puff on a cigarette • desires e.g. wanting to stop smoking • evaluations e.g. thinking that smoking is bad • plans e.g. to stop smoking

13. PRIME Theory: the structure of human motivation I will try not to smoke Smoking is bad for me Need a cigarette Urge to smoke www.primetheory.com

14. Motivation in the moment Want that bar of chocolate ‘Urge’ to reach for chocolate’ Need to eat: hunger Desires (wants and needs) Impulses/ inhibition Thoughts (plans and evaluations) I intend to eat healthily Need to stick to diet Inhibition of urge Eating healthily is a good idea

15. The ‘Law of Affect’ We want things that we imagine will give us pleasure or satisfaction We need things that we imagine will give us relief from mental or physical discomfort At every moment we act in pursuit of what we most want or need at that moment Identity (images, feelings and thoughts, about ourselves) is an important source of wants and needs Beliefs about what is good or bad, and prior intentions have to work through momentary wants and needs

16. Identity • Images • Feelings • Thoughts • Labels (e.g. I am an ex-smoker) • Attributes (e.g. I am healthy) • Rules (e.g. I do not smoke)

17. Why plans do not get implemented?

18. Why plans do not get implemented? Poorly formed plans lacking: a. clear boundaries b. specificity c. emotional force Poor recall of plans Inefficient processes for translating plans into motives Competing plans

19. Why plans do not get implemented? Evaluations that: a. are weak or incoherent b. fail to generate relevant imagery Inefficient processes for translating evaluations into motives Competing evaluations

20. Why plans do not get implemented? • Wants and needs arising • from the plan that are • too weak • Conflicting momentary • wants and needs

21. Why plans do not get implemented? • Conflicting learned and • unlearned impulses • Weak capacity for inhibition • Lack of energy for impulse • generation

22. Example • Choose a target behaviour pattern • What is driving that behaviour? • Capability • Physical • Psychological • Opportunity • Physical • Social • Motivation • Reflective • Automatic

23. Topics • 9:35-30:30 Understanding behaviour • COM-B and PRIME • 11:00-12:00 Helping people change • The BCW and BCTs • 12:00-12:30 Tobacco addiction • what it is and how to help people get over it • 13:30-16:00 Clinical experience • what is being done and how it can be improved • 16:00-16:30 Conclusions • key ‘take-home’ messages and evaluation

24. Common terms for methods for inducing behaviour change

25. Common terms for methods for inducing behaviour change

26. Common terms for methods for inducing behaviour change

27. Common terms for methods for inducing behaviour change

28. Behaviour Change Wheel Michie S, M van Stratten, West R(2011) The Behaviour Change Wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6, 42.

29. Behaviour Change Wheel Education Persuasion Incentivisation Coercion Taining Restriction Environmental restructuring Modelling Enablement

30. Behaviour Change Wheel Education Persuasion Incentivisation Coercion Taining Restriction Environmental restructuring Modelling Enablement Legislation Communication/marketing Service provision Guidelines Environmental/social planning Fiscal measures Regulation

31. Behaviour Change Techniques • Specific actions that aim to fulfil intervention functions: E.g. • Reward incompatible behaviour • Promote self monitoring • Promote anticipatory regret • Provide pharmacological support • Provide feedback on the target behaviour • Promote ‘self-talk’

32. Example • Choose a target behaviour change • What would need to be different for that behaviour to occur? • Capability • Physical • Psychological • Opportunity • Physical • Social • Motivation • Reflective • Automatic

33. Topics • 9:35-30:30 Understanding behaviour • COM-B and PRIME • 11:00-12:00 Helping people change • The BCW and BCTs • 12:00-12:30 Tobacco addiction • what it is and how to help people get over it • 13:30-16:00 Clinical experience • what is being done and how it can be improved • 16:00-16:30 Conclusions • key ‘take-home’ messages and evaluation

34. Addiction treatment is needed because unaided success rates are usually very low Estimated relapse curve from unpublished data

35. Urges to smoke are strongest in the first few weeks but can be present for at least a year Unpublished data

36. Urges to smoke Smoking triggers Reminders Urge to smoke Positive beliefs about smoking Want or need to smoke Want or need to smoke Nicotine ‘hunger’

37. Resolve note to smoke Resolve not to smoke Want or need not to smoke ‘Non smoking’ personal rule Ability to inhibit impulses

38. The battle over time between resolve and urge to smoke When the urge is stronger than resolve and cigarettes are available, a lapse will occur Urge to smoke Time Strength of urge Resolve

39. The role of treatment is to keep these lines as far apart as possible Urge to smoke Time Strength of urge Resolve

40. Aiding cessation

41. Behavioural support Drugs to reduce motivation to smoke

42. Pharmacological treatment Advice and support aimed at boosting motivation, helping with self-regulation, and promoting effective use of supporting activities

43. Behavioural support

44. Behavioural support Minimise motivation to smoke and maximise motivation not to smoke

45. Behavioural support Help to avoid and resist urges to smoke

46. Behavioural support Help smokers to make best use of medication and other aids to cessation

47. Behavioural support

48. Effectiveness of medication options: 12 months’ sustained abstinence Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

49. Effectiveness of medication options: 12 months’ sustained abstinence Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support

50. Effectiveness of medication options: 12 months’ sustained abstinence Derived 95% confidence interval from rate ratio in Cochrane reviews applied to 12m placebo continuous abstinence rates; all medications used with some behavioural support