Theories of Behavior Change for Tobacco Control

1. Theories of behaviour change and their applicability to tobacco control Ann Mcneill and Robert West

2. Outline • What is behaviour change? • What different levels of analysis are there? • What is a theory of behaviour change? • Examples of theories • General principles of behaviour change • Smoking cessation

3. What is behaviour change? • ‘Behaviour patterns’ are repeated activities or ways of engaging in particular activities • E.g. Smoking, driving fast, recycling, hand-washing • They arise from: • individual dispositions to respond to particular environmental stimuli • the presence or absence of those stimuli • ‘Behaviour change’ involves changes in behaviour patterns which can arise from either or both of: • changes in individual dispositions (e.g. attitude change) • changes in environmental stimuli (e.g. reduced availability)

4. A pragmatic analysis of behaviour change • Behaviour will generally occur: • more often if: • there are more opportunities or fewer restrictions • there are more reminders or prompts • it requires less time or effort • the capability to do it is greater • it is more attractive • the perceived need for it is increased • it is made more habitual • competition from alternatives is reduced • less often if the opposite happens

5. Levels of analysis • Population • the unit of analysis is a defined population • Eg: aggregate alcohol consumption, cigarette smoking prevalence • the models and theories refer to causal mechanisms linking population level variables • Eg price and aggregate consumption • Individual • the unit of analysis is individuals • Eg. daily alcohol intake, daily cigarette consumption • the models and theories refer to causal mechanisms linking individual level variables • Eg. number of friends who smoke and smoking behaviour

6. What is a theory of behaviour change? • Theories are statements about unobserved entities and/or cause-effect mechanisms that link two or more observable variables or types of event • Their goal is to explain and predict observations and provide a basis for developing ‘technologies’ (in the case of behaviour change we talk about ‘interventions’) • Theories of behaviour change seek to explain when, why and how behaviour change occurs with a view to developing improved interventions to promote desirable behaviour patterns

7. Examples of theories • Population level theories • Price-demand curves • functions relating the price of commodities such as tobacco and demand in terms of purchasing, smuggling, product substitution etc. • Social contagion theories • models of the way that behaviours spread in social groups • Individual level theories • Operant learning • functions relating the type, contingency and patterning of rewards and punishments to subsequent behaviours • Decision theories • functions relating perceived utilities of possible outcomes to choices

8. A very good source on theories • http://www.csupomona.edu/~jvgrizzell/best_practices/bctheory.html • Covers: • Learning theories • Health Belief Model • Social Learning/Social Cognitive Theory • Relapse Prevention Model • Transtheoretical Model • Ecological approaches • Social support

9. The process of behaviour change • Deliberate behaviour change • the individual makes a ‘rule’ regarding the new behaviour and tries to apply that rule • Eg. stopping smoking • Non-deliberate behaviour change • the individual behaves differently without consciously deciding to • Eg. increasing food consumption in response to increased availability of highly palatable food

10. Deliberate behaviour change PRIME Theory: • At every moment we are driven by what we most want or need at that moment; beliefs and plans can only influence behaviour through wants and needs • want: feeling of anticipated pleasure or satisfaction • need: feeling anticipated relief • When the moment comes that we most want or need to ‘decide to change’ we create the ‘rule’ defining that change (e.g. to stop smoking or to ‘cut down’) • This rule then generates additional wants or needs to engage in the new behaviour pattern • If at a later time we want or need to do something that violates the rule more than we want to adhere to the rule we break it or abandon it • Successful behaviour change involves avoiding that happening

11. Key implications • Focus and generating want and need to change now, not on beliefs and pros and cons • Repeat the message often • Provide a clear pathway to immediate action • Apply the message to everyone • Foster generation of a ‘change rule’ with clear boundaries (e.g. not a puff) backed up by a strong emotional commitment and rules regarding supportive activities (e.g. use of NRT, avoiding smoking cues)

12. The case of smoking • Many smokers enjoy smoking, believe it helps them cope and some like being a smoker, but most are also concerned about the harm it causes and the cost • Occasionally the negative feelings are strong enough or the positive ones weaken and a quit attempt is made • Once abstinence has started addiction to nicotine becomes a dominant factor determining whether they relapse • This addiction creates a need to smoke, experienced as powerful urges which undermine and overwhelm the want or need to stay with the non-smoking rule • This typically results in ‘lapses’ (the person smokes but has not abandoned the quit attempt) followed after days or weeks by ‘relapse’ (the quit attempt is abandoned) • The aftermath of the failed quit attempt is usually an attempt to ‘cut down’ and continued motivation to stop at a future time but reduced mental reserves necessary to enable a new quit attempt to succeed

13. ‘Oughts’ • We use the term ‘ought’ or ‘should’ to refer to actions that we do not want to do or feel a need to do but which we evaluate positively • According to PRIME Theory, ‘oughts’ will not lead to behaviour unless they can interact with identity (see later) to generate wants or needs

14. ‘Wants’ and ‘oughts’ to stop smoking • 3173 adult cigarette smokers in the Smoking Toolkit Study • Allowed to endorse either or both of • I want to stop smoking • I ought to stop smoking • Reports of ‘want’ to stop are lower than seen when asked on its own • In multiple logistic regression, only ‘want’ is associated with quit attempts • ‘Oughts’ do not relate to behaviour because they are just beliefs, not backed up by wants

15. Wanting and needing to smoke • Wanting to smoke appears to deter attempts to stop while needing to smoke leads to relapse once an attempt is made Data from 1479 smokers in Smoking Toolkit Study, followed up 6 months after ratings or enjoyment and urges were made to find out whether: had attempted to stop and if so had relapsed

16. Reading • NICE Guidance on behaviour change interventions • www.primetheory.com • http://www.csupomona.edu/~jvgrizzell/best_practices/bctheory.html

17. Quiz • What are behaviour patterns? • What is behaviour change? • What are the two levels of analysis of behaviour change? • Name three theories relevant to behaviour change? • Name 3 out of 8 changes that will tend to increase occurrence a behaviour • In deliberate behaviour change what is the typical sequence of events • How does this apply to smoking cessation?